Impact of Coronavirus and Covid-19 on Present and Future Anesthesiology Practices

Abstract

The Covid-19 pandemic has swept the world in fewer than 3 months, and there remains no end in sight. Approximately 6.1% of Covid-19 cases were classified as critical—defined as respiratory failure, shock, and multiple organ dysfunction or failure (1). Among the critically ill Covid-19 patients, ~6–47% of them were intubated in China (2–7), 71–75% were intubated in the United States (8, 9), and 88% were intubated in Italy (10). The sheer volume of patients who require invasive mechanical ventilation support entails that anesthesia professionals have been put under significant pressure during this pandemic. This pressure is exacerbated by the fact that many urgent and emergent surgeries must proceed, even in situations in which patients have confirmed or suspected Covid-19. Clearly, anesthesia providers are playing a fundamental role in the frontline efforts to fight against this formidable pandemic. This paper discusses the impact Covid-19 is having on contemporary anesthesia practice through different phases and highlights some of the lessons we can learn to inform future practice (Figure 1). Figure 1. Impact of the Covid-19 pandemic on anesthesia practice through different phases. Be it as a measure of precaution, resource-saving, better manpower allocation, or ensuring availability of hospital beds, many hospitals throughout the world have canceled or postponed elective and semi-elective surgeries amid the current pandemic. While the reduction in the volume of surgical procedures being performed varies across different hospitals, it can be as high as 70–90%. This move suddenly relieves most anesthesia providers from perioperative care, with only a small portion being deployed to provide anesthesia for urgent or emergent surgeries. At the same time, as a result of the rapidly expanding number of patients admitted to hospitals and intensive care units (ICUs), anesthesiologists are being mobilized and re-deployed to serve outside the perioperative setting. During this pandemic, anesthesia providers are typically being asked to provide the following services: (1) to intubate critically ill patients who require invasive mechanical ventilatory support; (2) to work in the ICU in the roles of intensivists, respiratory therapists, or nurses; (3) to place intra-arterial catheters and peripheral or central intravenous catheters; and (4) to work in the emergency departments or fever clinics to ensure the gaps in resources created by the sudden increase in symptomatic patients are filled (11). This is the overall global picture; however, the type and load of the work assigned to anesthesia providers outside the perioperative environment primarily depend on the number of cases encountered by individual hospitals and vary by country. Various issues that directly impact anesthesia providers have arisen in the midst of providing care to critically ill Covid-19 patients. These issues are related to self-protection, best practices of intubation and ventilation, and professional liability in delivering care to patients outside any specialist scope of practice. In mid-March 2020, an article was published documenting the intubation and ventilation experiences in one of the epicenters—Wuhan, China (11). In this paper, the authors described the personal protective equipment (PPE) used by the Chinese healthcare workers. Of note, when performing invasive procedures in Covid-19 patients, including intubation and ventilation, all healthcare workers in China were required to follow Level III protective measures. Put simply, this mandates coverage of the entire body (11). This practice has caused a wide-range discussion outside China. In comparison, in the United States, standard protective practice does not involve covering the neck or leg below the knee. Although we agree that neither under-protection nor over-protection are warranted, the most ideal approach to self-protection is unclear. We hope this information will come to light with future analyses of worldwide practice data. Regardless of what level of protection is most efficient, the shortage of PPE has caused some significant concerns. Especially at the early stage of the pandemic, there is a global shortage of almost every piece of PPE that is deemed necessary when performing invasive procedures in Covid-19 patients. Many medical practitioners are scrambling to identify methods of sterilizing and reusing N95 masks and/or making their own face shields. Reports of doctors and nurses using unconventional self-protection innovations, such as transparent plastic bags to cover the head and neck, have flooded social media and newspapers. The shortage of PPE and the difference in the availability of self-protection resources across different hospitals, regions, and countries have caused concern and confusion, and this has even resulted in some providers refraining from attending work (12). Moving forward, ensuring adequate PPE supply at all times with a robust production and supply chain capability is a priority. In regards to the best practice when intubating and ventilating Covid-19 patients, there is no universal agreement, but the experiences of different countries should be considered (11, 13–16). Most anesthesia providers typically perform the following steps during intubation: (1) maintain the oxygenation and ventilatory support that has already been used in the patient; (2) avoid bag-mask ventilation if possible; (3) use 100% oxygen for 5 min during pre-oxygenation; (4) cover the patient's nose, mouth, and face; (5) perform rapid sequence induction; (6) aim for complete muscle relaxation; (7) avoid coughing and bucking; (8) perform video laryngoscope guided intubation; and (9) avoid chest auscultation. When delivering ventilatory support, most providers adhere to the following processes. They should avoid non-invasive ventilation, including continuous positive airway pressure and bilevel...