COVID-19 and Clinical Care

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1. Is ASA advocating use of a video laryngoscope as first line for intubation? We have a very limited supply of sleeves at my institution.

We recommend that providers perform intubations with the greatest chances of success on the first attempt. This must be balanced with the supply chain availability. We also recommend close collaboration with your healthcare system to closely monitor the supply chain and determine how best to utilize limited resources.

2. Does ASA recommend a specific course of action or treatment for COVID-19 patients in the Intensive Care Unit?

As a medical association, we cannot make specific medical recommendations for patients. We likewise do not track how physicians treat or may have treated individual patients.

3. Where can I find ASA Critical Care education and training resources?

In collaboration with the SOCCA, SCCM and APSF, a number of educational and training resources are available for members to use. This material is known as the COVID Activated Emergency Scaling of Anesthesiology Responsibilities (CAESAR) ICU Project.

4. How do we assess drug supplies during the use for ventilated COVID patients?

Assessment of drug supplies requires close coordination with your pharmacy and pharmaceutical distributers to identify current rates of medication utilization with days of supply on hand. The ASA Committee on Critical Care Medicine has published drug recommendations for COVID-19 during times of drug shortages.

5. How long are you able to keep a patient continuously ventilated on an anesthesia machine without disconnecting to change circuit, run machine check, change the filters?

Since there are numerous makes and models of anesthesia machines, ASA recommends discussing these concerns with the manufacturer’s technical services. Anesthesiologists are well-trained to balance the risks and benefits on an individual basis for patients under their care.

6. What are some elements of patient blood management that I should consider?

The ASA Committee on Patient Blood Management has developed a resource for anesthesiologists with regard to pandemics and patient blood management. The resource also includes references and links to relevant literature.

7. Are there specific recommendations for EGD procedures and other procedures with a high risk of aerosolization?

Decisions need to be based on an understanding of your local COVID-19 risk profile for community spread in your area in consultation with your local infectious disease and infection control experts. This information will help inform your own risk assessment development considering the patient, skill sets of the endoscopists and local resources. ETTs provide the most secure airway. Airway masks with apertures for gastroscopes such as a POM (Procedural Oxygen Mask by Curaplex) or similar masks may limit dispersion as an alternative when supplies of N95 are low. ASA has also released guidance for procedures where there is a high probability of aerosolization. Physicians may wish to consult recent gastroenterology consensus documents or conduct an independent literature review for more information.

8. What is the recommendation for LMA usage or MAC anesthesia? Should we presume all patients are carriers and therefore LMA usage and MAC anesthesia be minimized?

Since March 2020, anesthesiologist experiences in treating COVID-19+, COVID-19 negative, PUI and asymptomatic patients have increased and standard operating procedures have been reevaluated at local facilities. When considering LMA use, we recommend a risk assessment be performed based on the COVID community-wide transmission. We also recommend that anesthesiologists, when determining airway techniques and anesthetic choices, take into consideration the results of a patient’s COVID-19 test, including the sensitivity and specificity of tests being used, and balance testing and community spread with choosing the appropriate PPE to use. Anesthesiologists may wish to discuss policies with local infection prevention experts.
PPE for aerosol-generating procedures should be worn. Airway cases, upper endoscopy, bronchoscopy, and situations that induce cough or sneeze should be considered as high risk for aerosol production. There is potential risk for other providers who are present near the oropharyngeal airway as well, and gastroenterologist society recommendations warn of risk with upper and lower GI endoscopy.
For anesthesia professionals, an additional consideration is that a failed MAC case may need to be transitioned rapidly to tracheal intubation that likely bears higher risk for suboptimal conditions.

9. What should we do about “MAC” cases, with an open airway?

If dispersion of potentially contaminated exhaled gases from an open airway (e.g. “MAC”) in a patient with COVID-19 is a risk, consider alternate anesthesia plans. Potential contamination of your workspace and the room should also be considered. The safety of you and your colleagues is paramount.

10. What contingencies should an anesthesia professional use when considering using an LMA with positive pressure ventilation versus an endotracheal tube in a standard operating room (positive pressure room)?

We recommend that anesthesiologists and anesthesia professionals, when determining airway techniques and anesthetic choices, take into consideration results of a patient’s COVID-19 test, the sensitivity and specificity of testing being used, and community spread. Based upon these criteria, anesthesiologists and other anesthesia professionals can determine whether a conservative or more liberal approach is necessary, especially if there is high community spread. In assessing risk of exposure, anesthesiologists should also consider whether individual LMA, MAC and regional cases would have a risk for general anesthesia conversion.

11. How should I deliver supplemental oxygen to a COVID+ or PUI patient who is wearing a mask?

If a patient has or is likely to have COVID-19, the first consideration is for your safety and the safety of everyone in the room. It is important that you wear appropriate PPE. Being at the COVID-positive patient’s head, there is always risk of coughing and of needing to physically support the airway with jaw thrusts or intermittent positive pressure ventilation by face mask. Therefore, PPE for aerosol-generating procedures should be worn. There will be insufficient time to garb if there is an urgent clinical development. For the patient, nasal prongs under surgical mask with low-flow oxygen or simple face mask over surgical mask might suffice. However, if patient oxygenation is not maintained on low-flow oxygen, higher oxygen flows may be unexpectedly needed that might increase aerosolization of COVID-containing respiratory secretions. Each patient will need to be evaluated on a case-by-case basis to consider the balance of aerosolization at the oxygen flow needed to maintain a satisfactory oxygen saturation, and whether to convert to a more closed airway system (LMA or ETT).

12. Does ASA have any guidance on the treatment of stroke patients during the COVID-19 pandemic?

The Society for Neuroscience in Anesthesiology and Critical Care has released several documents for consideration, including the “Anesthetic management of Endovascular Treatment of Acute Ischemic Stroke During COIVD-19 Pandemic” and a decision tree for “Endovascular Therapy for Acute Ischemic Stroke.”

13. Does ASA have any recommendations for overall obstetric care and specifically epidurals and spinals?

ASA members are encouraged to review the recent statement published by the Society for Obstetric Anesthesia and Perinatology (SOAP). regarding obstetric care. In general, we are unaware that coronavirus is a contraindication to a neuraxial block. Spinals and epidurals should take into consideration appropriate precautions, especially regarding COVID-19 patients or those suspected of having COVID-19. Such precautions may include isolating the infected or suspected patient and placing them in rooms identified for that purpose as well as having a dedicated operating room. Ideally, these operating rooms would be negative pressure rooms. We also recommend the use of N95 masks, double gloves, gowns and protective eyewear as appropriate.

14. Does ASA have any recommendations regarding pediatric airway management?

ASA does not have specific recommendations, but the Society for Pediatric Anesthesia’s Pediatric Difficult Intubation Collaborative and the Canadian Pediatric Anesthesia Society have published "Pediatric Airway Management in COVID-19 Patients – Consensus Guidelines."

15. Does ASA have any clinical recommendations on anesthetizing a patient who previously had COVID-19?

In general, all non-urgent procedures should be delayed until the patient has met criteria for discontinuing isolation and COVID-19 transmission precautions and has entered the recovery phase. Elective surgeries should be performed for patients who have recovered from COVID-19 infection only when the anesthesiologist and surgeon or proceduralist agree jointly to proceed. We recommend that anesthesiologists remain vigilant for ongoing physiologic changes that may have occurred with COVID exposure including, but not limited to, hypercoagulability and cardiopulmonary changes.

Additional Information

Disclaimer

Viewers of this material should review these FAQs with appropriate medical and legal counsel and make their own determinations as to relevance to their particular practice setting and compliance with state and federal laws and regulations. The ASA has used its best efforts to provide accurate information. However, this material is provided only for informational purposes and does not constitute medical or legal advice. This response also should not be construed as representing ASA policy (unless otherwise stated), making clinical recommendations, dictating payment policy, or substituting for the judgment of a physician and consultation with independent legal counsel.