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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 17  |  Issue : 3  |  Page : 226-228

COVID-Positive preterm neonate for emergency laparotomy: Anesthesia and management issues.


1 Department of Anaesthesiology and Critical Care, Indraprastha Apollo Hospital, New Delhi, India
2 Department of Paediatric Surgery, Indraprastha Apollo Hospital, New Delhi, India

Date of Submission30-Jun-2020
Date of Acceptance30-Jul-2020
Date of Web Publication07-Aug-2020

Correspondence Address:
Chetan Mehra
402, Chocolate Palm A, Omaxe Palm Greens, Sector Mu, Greater Noida - 201 310, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_70_20

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  Abstract 


Thirty weeks low-birth-weight preterm COVID-positive baby with anorectal malformation underwent emergency laparotomy in view of perforative peritonitis. Baby was assessed by a virtual telecommunication. Safety precautions were carried out for health-care workers during patient transit, aerosol-generating procedures, surgery, and postoperative care in COVID intensive care unit. Scarcity of evidence base for preterm neonates at that time made us design and efficiently conduct our own safety protocol. Interdepartmental team work was the key.

Keywords: Aerosol-generating procedure, COVID, personal-protective equipment, preterm neonate


How to cite this article:
Mehra C, Khan U, Chowdhary SK. COVID-Positive preterm neonate for emergency laparotomy: Anesthesia and management issues. Apollo Med 2020;17:226-8

How to cite this URL:
Mehra C, Khan U, Chowdhary SK. COVID-Positive preterm neonate for emergency laparotomy: Anesthesia and management issues. Apollo Med [serial online] 2020 [cited 2020 Sep 19];17:226-8. Available from: http://www.apollomedicine.org/text.asp?2020/17/3/226/291735


  Introduction Top


COVID-19 is an uncertain territory, where we are still navigating to provide correct management. Recommendations for the perioperative management of COVID-positive preterm neonate are sparse. We report successful management of COVID-affected neonate undergoing emergency laparotomy at the beginning of COVID saga (May 02, 2020). To our knowledge, this is the first case report of a preterm neonate undergoing surgery.


  Case Report Top


A preterm female baby delivered at 30 week of gestation, with birth weight of 1.69 kg, presented to our hospital at day 7 of life (Corrected Gestational Age 31 weeks), on May 02, 2020, with abdominal distension since day 3 of birth, with a history of passage of stools during micturition. Abdominal ultrasound study showed stool loaded bowel. Baby was scheduled for examination under anesthesia with check cystoscopy and sigmoid colostomy the next day.

She was second of the twins born out of surrogacy with an out-of-hospital birth status through lower segment cesarian section. She was found to have congenital anorectal malformation. Nasopharyngeal swab for reverse transcription polymerase chain reaction (RT-PCR) assessment for coronavirus was sent at admission i/v/o of her out-born-status.

In view of her worsening condition suggestive of perforative peritonitis, an emergency laparotomy was planned.

Preanaesthesia check (PAC) was carried telephonically with inputs from neonatologist and mother, who consented for surgery.

In the present COVID-19 crisis, our hospital has segregated neonatal intensive care unit (NICU) for in-born and out-of-hospital born babies, in order to prevent cross-infection, till the time their covid-19 status is confirmed. Hence, this neonate was nursed in a COVID suspect nursery.

Baby was taken up for surgery as a COVID-suspect as her RT-PCR report was awaited. Her covid-positive status was declared in the middle of surgery.

Operating room arrangements

Equipment for airway management, oxygen safety mechanism, hypothermia prevention, and necessary drugs were confirmed. A functional negative pressure in the operating room (OR) was rechecked.[1]

Donning and doffing by concerned staff members were carried out under supervision in a designated area. Personal protective equipment (PPE) included (1) filtering face-piece respirator (N95 mask), (2) fluid-resistant gown, (3) disposable double-layered gloves, (4) Goggles and face shield for eye/face protection, and (5) shoe cover. Thereafter, baby was transferred from NICU to OR in a transport incubator. Standard sign in protocol was followed before shifting baby to OR. Movement of personal from OR was kept to a minimum.[2],[3]

Conduct of anesthesia

Anesthesia-related interventions were carried out by consultant anesthesiologist. Oxygenation was carried out inside the incubator using a tight-fitting circular facemask and circle system and a total flow of 6 l/min for nearly a minute. Orogastric tube was gently suctioned. Anesthesia was induced with intravenous (IV) route using fentanyl 2 μg/kg (total 3.25 μg), followed by atracurium 2.0 mg (1.2 mg/kg). Trachea was intubated gently in the first attempt with 3.0 no uncuffed endotracheal tube (ETT) and confirmed by observing chest rise and ETCO2 trace. Baby's head and extremities were covered by sterile plastic drape to conductive heat loss.

Iliolinguinal/iliohypogastric nerve block was performed by surgeon with 1.5 ml of 0.125% bupivacaine. Laparotomy was performed using Rutherford Morrison incision, colonic perforation identified, peritoneal contamination cleaned, and a loop sigmoid colostomy performed. Anesthesia was maintained with sevoflurane in oxygen and air mixture (FiO2 40%) using controlled ventilation with circle system and a total flow of 0.4 l/min and tidal volume of 6 ml/kg. Surgical time was nearly 35 min and 30 ml of fresh-frozen plasma was transfused. Surgical nurse was the only one assisting the surgeon throughout the surgery.

Extubation and recovery

Baby was then covered in toto with a C-arm cover. A functional yankauer suction device and oxygen supply tubing were placed inside the cover. Muscle relaxation was reversed and baby extubated in lateral decubitus position inside the cover, with oxygen flowing @ 10 L/min and suction device left on to suck out expired air.

Baby was then transferred back to incubator after confirmation of adequate recovery and was observed inside the OR for the next 2 h.

Baby was then transferred to neonatal arrangement in adult covid intensive care unit (ICU) by NICU nurse, and postoperative care was provided by surgical team.


  Discussion Top


The objectives of this case report are to understand anesthesia management of covid-positive preterm neonate, strategies involved in maximizing safety of health-care workers, and preparation of a designated covid OR and postoperative ICU care.

Standard operating procedures for neonatal surgery had not yet been established at the time of this surgery; hence, inputs from various departments helped us sail through smoothly.

Management issues

  1. Case detection: RT-PCR test (computed tomography chest/lung ultrasonography) to be carried out for operating patients (emergency/elective)
  2. Coordination between surgical, neonatology, anesthesia team, staff involved in in-hospital transfer, supply of protection gear, and house-keeping staff involved in disinfection and disposal of infected material is crucial
  3. Telecommunication for the assessment and sharing information
  4. Isolation of covid-positive neonate from other healthy babies
  5. Doffing and Donning PPE:


    1. Time-consuming process – Shift patient after donning of OR personnel
    2. Availability of anteroom for donning and doffing
    3. Guided by a trained helper.


  6. Planning:[1]


    1. Availability of negative pressure OR with air exchange capacity of 15–20 air exchanges/30 min
    2. Outside high-traffic areas of hospital
    3. Completely emptied of nonessential materials
    4. Runner/support staff outside OR, to unnecessary movement in and out of OR
    5. Deep cleaning of OR after surgery.


Anesthesia-related concerns during covid pandemic

  1. Role of tele-consultation:[4],[5]


    1. Preanesthesia Check Up (PAC): Assess history, airway, spine, and investigations
    2. Identification of clinical features of COVID: Fever, shortness of breath, tachycardia, nausea/vomiting, diarrhoea, etc.


  2. Arrangement for virtual postoperative visits in ICU
  3. No evidence of contraindication of central neuraxial block in covid patients
  4. Anesthetic and emergency drugs should be preloaded according to body weight, to avoid struggle in the midst of surgery
  5. Prefer IV induction
  6. Local anesthesia should be used as a part of multimodal analgesia.


Issues related to a covid-positive preterm baby

  1. Evidence base for neonatal surgery during covid pandemic was sparse.[6] So one had to rely on recommendations for adults or parturients
  2. Covid infection predisposes a patient for respiratory complications/pneumonia
  3. Adult Covid patients are more prone to resistant hypotension, therefore may require vasopressor support more often. It is not clear whether this can be extrapolated to neonatal population
  4. Extreme difficulty in securing vascular access with double layering of gloves. Hence, prefer to shift neonate with an in situ IV access
  5. Aerosol-generating procedures (AGP) during airway management.[2],[4],[5]


    1. All AGP should ideally be carried out in airborne infection isolation rooms – not available in our set up
    2. Preoxygenation with 100% oxygen is a must as covid patients are most likely to have lower respiratory tract infection. Physiological changes in neonates account for higher oxygen demand and rapid desaturation. A tight-sealing facemask should be used to prevent dissemination of infective aerosols
    3. Rapid intubation with videolaryngoscope by experienced anesthesiologist improves success to secure airway in the first attempt
    4. Avoid using Jackson Ree's circuit due to high flow of gases required
    5. Use circle system at time of induction and extubation. Use low gas flows for the maintenance of anesthesia
    6. Avoid ventilation till ETT cuff in inflated
    7. HEPA filters should be applied at ETT end or at expiratory end of circuit. Avoid accidental disconnections
    8. Use of PPE
    9. PLAN B: 2nd-generation supraglottic airway device (I-Gel/proseal laryngeal mask airways) should be preferred with a higher sealing pressure
    10. Anesthetist performing intubation wears double gloves and removes the outer one after handling patient's airway and avoid touching anesthesia workstation with soiled gloves. It has to be replaced by a new pair of gloves, thereafter
    11. Extubation: Increase the chances of AGP. Attempt to suppress cough reflex and plan for extubation in deeper planes of anesthesia if possible.[5]


  6. Confirmation of tracheal intubation by observing chest rise and ETCO2, rather than auscultation[5]
  7. Clear communication between OR personnel should be strictly followed as communication with PPE seems to be difficult
  8. Ventilatory parameters: Low tidal volume with positive end-expiratory pressure
  9. Extubate baby in a relatively closed compartment (e.g., C-arm cover as used by us). Oxygen source and a suction device (for scavenging expired gas, as higher flows of oxygen will be needed) can be kept inside the cover in the recovery phase of anesthesia
  10. Nurse baby in OR itself, with monitors and a nurse trained in neonatal care
  11. Anesthesia consultant should stay in constant contact and easily reachable in case of emergency.


Surgery-related issues

  1. Surgeon should attempt to complete surgery quickly and safely!! It seems to be quite a challenge operating once a person is donned PPE suit
  2. Limited surgical assistance may be available. In our case, scrub nurse was the only surgical assistant available.



  Conclusion Top


Our case brings forward the challenges faced in the perioperative management of a COVID-positive low-birth weight, preterm neonate. Multidisciplinary approach for this emergency surgery was the need of the hour. Preventive strategies to limit exposure of health-care workers should be stressed upon. Rapid dissemination of research and scaring of experiences can help build evidence base.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We would thank and acknowledge nursing staff, technical and housekeeping staff for their help in smooth conduct of this case and hospital management for timely arrangement of Covid-designated operating room and intensive care unit.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ti LK, Ang LS, Foong TW, Ng BSW. What we do when a COVID-19 patient needs an operation: Operating room preparation and guidance. Can J Anaesth 2020;67:756-8.  Back to cited text no. 1
    
2.
Wax RS, Christian MD. Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Can J Anaesth 2020;67:568-76.  Back to cited text no. 2
    
3.
Cook TM. Personal protective equipment during the COVID-19 pandemic – A narrative review. Anaesthesia 2020. Available from: https://doi. org/10.1111/anae.15071. [Last cited on 2020 Apr 30].  Back to cited text no. 3
    
4.
London MJ. Coronavirus Disease 2019 (COVID-19) Patients: Airway Management, Anesthesia Machine Ventilation, and Anesthetic Care. UpToDate; 2020. [Last updated on 2020 Apr 28].  Back to cited text no. 4
    
5.
Malhotra N, Joshi M, Datta R, Bajwa SJS, Mehdiratta L. Indian Society of Anaesthesiologists (ISA National) Advisory and Position Statement regarding COVID-19. Indian J Anaesth 2020;64:259-63.  Back to cited text no. 5
  [Full text]  
6.
COVID 19 Containment, Standard Operating Procedures, Advanced Pediatrics Centre, PGIMER, Chandigarh, India. Available from: http://pgimer.edu.in/PGIMER_PORTAL/PGIMERPORTAL/covid19/index. html. [Last cited on 2020 May 04].  Back to cited text no. 6
    




 

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