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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 17  |  Issue : 3  |  Page : 224-225

Anesthetic management of a cesarean section in COVID-positive pregnant patient


Department of Anesthesiology and Critical Care, Indraprastha Apollo Hospital, New Delhi, India

Date of Submission24-Jun-2020
Date of Decision25-Jun-2020
Date of Acceptance02-Jul-2020
Date of Web Publication29-Jul-2020

Correspondence Address:
Ashish Malik
Department of Anesthesiology and Critical Care, Indraprastha Apollo Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_61_20

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  Abstract 


The novel coronavirus disease 2019 first emerged in Wuhan, China, and is now an emerging pandemic globally. This has strained health-care services leading to restrategizing anesthesia care and management of patients. We describe the anesthetic management of a 30-year-old COVID positive, multigravida, with term pregnancy taken up for elective cesarean section under the subarachnoid block in a dedicated operating room earmarked for COVID cases. For such a case, challenges in the modification of standard procedures to minimize exposure of the health-care professionals are delineated.

Keywords: Anesthesia, COVID positive, operating room, pandemic caesarian section, subarachnoid block


How to cite this article:
Malik A, Pallapotu B. Anesthetic management of a cesarean section in COVID-positive pregnant patient. Apollo Med 2020;17:224-5

How to cite this URL:
Malik A, Pallapotu B. Anesthetic management of a cesarean section in COVID-positive pregnant patient. Apollo Med [serial online] 2020 [cited 2020 Oct 29];17:224-5. Available from: https://www.apollomedicine.org/text.asp?2020/17/3/224/291125




  Introduction Top


The management of coronavirus disease 2019 (COVID-19) the positive patient is challenging as the virus is contagious endangering health-care professionals. It can cause life-threatening severe acute respiratory tract infections in 5% of the patients.[1],[2] However, the current evidence does not support that COVID-19 infection causes miscarriage or stillbirth. We describe the management of a COVID-19-positive parturient in the middle of this pandemic in India, which was done in a dedicated operating room (OR) having a separate air handling unit providing negative pressure.

Central neuraxial blockade is a preferred technique to reduce the chances of aerosol generation in such situations.[1],[2],[3] Hence, the above case is reported to understand the new normal anesthetic management of COVID-positive parturients.


  Case Report Top


A 30-year-old COVID-positive multigravida, with 38 weeks gestation, was admitted to the isolation room. In view of breech presentation with gestational diabetes, an elective lower segment caesarian section (LSCS) was planned. The couple were counseled about the implications of COVID 19 disease after which informed consent was taken.

The patient had gestational diabetes on diet control and no other comorbidities and weighted 88 kg with a body mass index of 32.3 kg/m2. Investigations revealed the haemoblogin level of 13.6 g/dl, total leukocyte count of 8000/mm3, platelet count of 20,000/mm3, glycosylated hemoglobin of 5.5%, International Normalized Ratio 1.1, and normal renal functions.

A separate OR, with a specific area for donning and doffing personal protective equipment (PPE) and having a clear exit path with a showering facility, was used. Along with anesthesia workstation, anesthetic and resuscitation drugs, spinal needles, video laryngoscope, stylets, and transparent sheets to cover patient, were arranged in case endotracheal intubation was required.[3],[4] Sodium hypochlorite disinfection was used for surface and floor decontamination.

Level 3 PPE consisting of N95 masks, impervious jumpsuits with hoods, goggles, face visor, shoe covers, and double medical gloves were worn by the entire team (anesthesiologists, obstetricians, neonatologists, nursing staff, and assistants).[5]

After the donning of the whole team, the patient was shifted wearing an N95 mask through a separate corridor after the stoppage of routine traffic of patients or personnel. One anesthesia technician and a nurse wearing PPE served as a runner in the OR with an assistant outside. Preanesthetic and airway examination were done through video calling 1 day before the surgery.

The patient was anxious, with a pulse rate of 110/min, blood pressure of 136/88 mm Hg, and SPO2 of 97%, with a mild dry cough on arrival to the OR. This could have been due to stringent contact and airborne precautions enforced, triggering adverse emotional responses in the patient.

After attaching routine monitors (electrocardiogram, SPO2 and noninvasive blood pressure), an 18 G intravenous cannula was secured, and the patient was preloaded with a 500 ml lactated ringer. Anti-aspiration prophylaxis was given. Subarachnoid block (SAB) was administered with a patient in sitting position in L3–L4 interspace using 27G whitacre needle and 2.2 ml of 0.5% bupivacaine with 20 μg fentanyl (2.6 ml). The level of block achieved was up to T5, and hemodynamics remained stable. The patient had an N95 mask with minimal oxygen supplementation until the baby delivery to limit aerosol generation with the face being covered by a transparent cover. The baby was delivered within 15 min of the block, cried immediately, and the APGAR score of 9 at 5 min. The surgery lasted for 74 min, and the estimated blood loss was 500–600 ml.

The patient was then transferred to the recovery area in the same OR facility monitored by the same nursing staff and shifted to her room after the Bromage score was 3. No adverse events associated with anesthesia and surgery occurred. All team members exited after proper doffing of PPE under guidance. The baby was kept in the neonatal intensive care unit. He tested COVID negative on the 1st and 3rd days. The mother tested negative on days 14 and 21, after which she was discharged.


  Discussion Top


Our institution has been earmarked as a COVID hospital with a standalone OR facility. This has a separate OR, recovery with adequate space for donning and doffing of PPE. Negative pressure venting of air to prevent virus dissemination[6] is present with protocols to enhance adherence to infection prevention and control.

An elective LSCS was considered to be the safest option in breech presentation as induction of labor could lead to excessive aerosol production due to hyperventilation during bearing down with patients remaining in the facility for a long time increasing the risk of exposure to health-care professionals. Vaginal delivery could also lead to vertical transmission. Elective procedures also avoid the need of general anesthesia and tracheal intubation.

The Society of Obstetric Anesthesiology and Perinatology has recommended avoidance of emergency deliveries in COVID-19 parturients as much as possible.[7] To minimize transmission of the virus, preanesthetic assessment was made through video calling and transfer of the patient was done through a dedicated corridor after donning of the complete team.

Recent articles have described the safety of central neuraxial blocks for COVID positive obstetric patients requiring LSCS.[5] Anesthesiologists are deemed at significant risk of viral exposure during endotracheal intubations of COVID-19-positive patients and all strategies should be applied to avoid general anesthesia. SAB was given to reduce the chances of aerosol generation during preoxygenation, ventilation, endotracheal intubation, oral or tracheal suction, and extubation. Operational difficulties were due to the fogging and triple layer of gloves diminishing tactile perception. Electronic recording of data should be available to complete anesthesia charts later, which we did not have. Level 3 PPE was used as it is recommended. It is reported that 2.7% anesthetists with level 3 PPE developed polymerase chain reaction confirmed COVID-19 infection versus 57.1% anesthetists who had Level 1 protection.[8]

To conclude, the new normal anesthetic management is a modification of the routine practices to ensure the safety of both health-care workers and patients with the optimal use of resources at hand.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sorbello M, El-Boghdadly K, Di Giacinto I, Cataldo R, Esposito C, Falcetta S, et al. The Italian coronavirus disease 2019 outbreak: Recommendations from clinical practice. Anaesthesia 2020;75:724-32.  Back to cited text no. 1
    
2.
World Health Organization, Clinical Management of Severe Acute Respiratory Infection (SARI) when COVID-19 Disease is Suspected; 2020. Available from: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is suspected. [Last accessed on 2020 Apr 06].  Back to cited text no. 2
    
3.
Malhotra N, Bajwa SJ, Joshi M, Mehdiratta L, Trikha A. ISA advisory: COVID operation theatre-advisory and position statement of Indian Society of Anaesthesiologists (ISA National). Indian J Anaesth 2020;64:355-62.  Back to cited text no. 3
  [Full text]  
4.
Malhotra N, Joshi M, Datta R, Bajwa SJ, 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. 4
  [Full text]  
5.
Chen R, Zhang Y, Huang L, Cheng BH, Xia ZY, Meng QT. Safety and efficacy of different anaesthetic regimens for parturients with COVID-19 undergoing Caesrean delivery: A case series of 17 patients. Can J Anaesth 2020;67:655-63.  Back to cited text no. 5
    
6.
Fornari F. Vertical transmission of Covid-19: A systematic review. J Pediatr Perinatol Child Health 2020;4:7-13.  Back to cited text no. 6
    
7.
Podovei M, Bernstein K, George R, Habib A, Kacmar R, Bateman B, et al. Society for Obstetrics Anaesthesia & Perinatology (SOAP) Interim Considerations for Obstetric Anaesthesia Care Related to COVID-19. Available from: https://www.wfsahq.org/images/SOAP_COVID-19_Obstetric_Anesthesia_Care_031620-2_.pdf. [Last accessed on 2020 May 12].  Back to cited text no. 7
    
8.
Zhong Q, Liu YY, Luo Q, Zou YF, Jiang HX, Li H, et al. Spinal anaesthesia for patients with coronavirus disease 2019 and possible transmission rates in anaesthetists: Retrospective, single-centre, observational cohort study. Br J Anaesth 2020;124:670-5.  Back to cited text no. 8
    




 

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