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Table of Contents
Year : 2020  |  Volume : 4  |  Issue : 5  |  Page : 8-12

Perioperative safety during Covid-19 pandemic: A review article

Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia

Date of Submission12-May-2020
Date of Decision29-May-2020
Date of Acceptance04-Jun-2020
Date of Web Publication13-Jul-2020

Correspondence Address:
Dr. Christopher Ryalino
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Jl. PB Sudirman, Denpasar 80232, Bali
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/BJOA.BJOA_83_20

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Introduction: Coronavirus disease 2019 (Covid-19) has become a pandemic all over the world. Despite our familiarity with various protection devices, the high incidence among medical personnel is still worrisome. In this review, we provide several perioperative strategies regarding the management of daily cases in the Covid-19 pandemic setting. Methods: We used keywords (((((coronavirus[Title/Abstract]) OR (covid-19[Title/Abstract])) OR (ncov-19[Title/Abstract])) OR (SARS-cov-2[Title/Abstract]))) AND (perioperative[Title/Abstract]) in the National Library of Medicine (NLM) database to find eligible reports. Results: We found 32 articles from the NLM database. After eligibility screening, we found 25 eligible articles describing perioperative management during the Covid-19 pandemic that relates to the staff's safety. All eligible articles stress the importance of the negative-pressurized environment to deal with perioperative care of Covid-19 patients. In general, the use of personal protective equipment (PPE) and video laryngoscopy is also essential. Conclusion: The best protective suit to avoid health-care personnel from getting Covid-19 infection is proper training and self-discipline. This combined with cooperative, honest patients and proper PPE supply is vital in efforts to reduce the spread of the disease. Negative-pressure chambers, both in operating rooms and intensive care units, are essential in this pandemic. Unfortunately, they are not easily available in underdeveloped and developing countries.

Keywords: Negative pressure, novel coronavirus, severe acute respiratory syndrome coronavirus 2, staff management

How to cite this article:
Agung Senapathi TG, Ryalino C, Wiryana M, Gede Utara Hartawan I G, Pradhana AP. Perioperative safety during Covid-19 pandemic: A review article. Bali J Anaesthesiol 2020;4, Suppl S1:8-12

How to cite this URL:
Agung Senapathi TG, Ryalino C, Wiryana M, Gede Utara Hartawan I G, Pradhana AP. Perioperative safety during Covid-19 pandemic: A review article. Bali J Anaesthesiol [serial online] 2020 [cited 2023 Mar 22];4, Suppl S1:8-12. Available from: https://www.bjoaonline.com/text.asp?2020/4/5/8/289552

  Introduction Top

The novel coronavirus disease 2019 (Covid-19) pandemic started as 44 cases of pneumonia of unknown origin in Wuhan, Hubei Province of China.[1],[2] As of May 7, 2020, there were 3,672,238 confirmed cases worldwide, with the global death toll reached 254,045.[3] The virus was named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by the International Committee on Taxonomy of Viruses due to its genome similarities with the SARS virus.[4]

The common principles in preventing and controlling infectious diseases are to eradicate the infection source, to cut transmission route, and to protect the susceptible population. Despite our familiarity with the knowledge and various protection devices, the high incidence among medical personnel is still worrisome.

There were 3300 health-care workers in China infected by early March 2020.[5] The same report mentioned that 20% of health-care workers in Italy responding to the Covid-19 outbreak were also infected. Health-care workers who show respiratory symptoms should not be involved in patient care. When proper screening and vaccination become available in the future, the health-care workforce should be prioritized for evaluation and treatment.[6] In this review, we provide several perioperative recommendations regarding the management of daily cases in the Covid-19 pandemic setting.

  Methods Top

Search methods

This is a review that includes all studies and reports describing various perioperative anesthesia management during coronavirus pandemic. We applied no restrictions regarding the language and the year of the publication. Non-English articles were translated using Google translate to review the content of the article. We used keywords (((((coronavirus[Title/Abstract]) OR (covid-19[Title/Abstract])) OR (ncov-19[Title/Abstract])) OR (SARS-cov-2[Title/Abstract]))) AND (perioperative[Title/Abstract]) in the National Library of Medicine (NLM) database to find eligible reports.

Selection criteria

Each article was reviewed by two different authors to minimize the unintended discard of relevant reports. Whenever a discrepancy occurred, we used a decision by the third author. We reviewed all titles and abstracts from the search results and removed irrelevant studies that did not comply with our objectives. We further evaluated the reports for quality before including them in this review. We used an electronic data collection form to collect data from each author. We utilized the Review Manager (RevMan) [Computer program]. Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014 to merge and manage the collected data.

Data collection and analysis

Two authors were assigned independently to each article to assess the validity and reliability of the studies using the Joanna Briggs Institute's critical appraisal tool. Again, the decision of the third author was used whenever a discrepancy occurred. The cutoff point for inclusion was 50% of the total checkmarks in each critical appraisal checklist. The result was synthesized narratively to provide a guideline in perioperative management during coronavirus pandemic.

  Results and Discussion Top

We found 32 articles from the NLM database based on keywords described above. After eligibility screening, we found 25 eligible articles describing perioperative management during the Covid-19 pandemic that relates to the staff's safety [Table 1]. We analyzed all eligible articles to sum up the following recommendations.
Table 1: List of eligible articles used in this review

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General preoperative preparation

We believe that all health-care employees should obtain training on inhospital infection control and implement prevention protocol. Medical workers need constant updating regarding the Covid-19.[7]

All patients should be screened for Covid-19 using a combination of history, chest computed tomography (CT) scan, and real-time quantitative polymerase chain reaction testing based on the institutional or national policy. The preexamination should include an epidemiologic investigation for all preoperative patients. This should include details of travel history to the epidemic zone or had an adjacent contact with individuals from the epidemic area within the past 14 days.[8] Patients undergoing emergent neurosurgical procedures could be presumed to have Covid-19 until further information is available.[9]

Recommended personal protective equipment (PPE) for health-care workers in the anesthesia preoperative evaluation clinic should include white medical gowns, medical gloves, eye protection shields, disposable surgical caps, and surgical masks or test-fit N95 masks or respirators.[7] All involved health-care providers should wear biosafety level-3 protective measurements.[10],[11]

Contaminated, semi-contaminated, and clean zones must be visibly distinct. Protective gear should be put on and removed in the correct sequence according to the hospital guidelines.[12] All operating room (OR) staffs, including surgeons and anesthesiologists, have to work with fewer assistants in the OR.[13] Be sure to allocate sufficient time for all staff involved to put on the PPEs. It may take several minutes to wear PPE properly.

Arterial and central venous catheterization is recommended to be performed under ultrasound guidance to improve the success rate and reduce procedure time. Avoid unnecessary traffic (both entry and exit) of the staff, so necessary materials should be stored inside before the surgery started.[14] Limiting the number of unnecessary personnel during intubation is recommended.[15]

Suspected or confirmed Covid-19 patients undergoing surgery

Elective surgical procedures should be postponed. Emergency surgery must be arranged in a negative pressure OR.[7],[8],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29] If it is determined that the degree of negative pressure in the environment is not sufficient, the additional application of a portable high-efficiency particulate air filter should be considered.[16]

Hospitals that do not have an advanced facility for isolation and quarantine care should consider transferring to other hospitals with proper facilities.[22] A single OR would be assigned for only Covid-19 patients, preferably located in the corner of the OR complex with separate access.[25] For suspected patients, the endotracheal tube (ET) should be used to collect the respiratory tract secretions. The specimens should be sent as soon as possible for further examination.

Intubation procedure

Regional anesthesia should be considered for a suspect or confirmed Covid-19 patient or any patient who poses an infection risk to avoid any airway manipulation. Regional anesthesia preserves respiratory function, evades aerosolization and hence reduces viral transmission.[18] Unless an ET or a laryngeal mask airway is placed, a surgical mask or N95 mask must be applied to the patient throughout the length of stay in the OR complex.[7],[11]

All awake intubation, with or without topical airway anesthesia, should be avoided because coughing and nebulization may cause aerosol and virus spread.[13] Local anesthetics sprays can aerosolize the virus and should be avoided. Rapid sequence induction with adequate muscle relaxation is endorsed to prevent coughing.[13] Fast-acting muscle relaxants, such as rocuronium or succinylcholine, are preferred. The sequence of drugs administration should be a muscle relaxant and general anesthetic drugs, followed by opioids to avoid coughing. We highly suggest the use of video laryngoscopes to increase the likelihood of successful intubation.[15],[16],[24]

Mask ventilation with 100% oxygen can be employed to patients with a poor oxygen reservoir. With PPEs and hazmat put on, it is difficult to perform auscultation to confirm the placement of the ET, so the use of end-tidal carbon dioxide (EtCO2) monitor is essential. This does not mean other classic methods are not useful, such as symmetrical chest rise observation, pulse oximetry, and the depth of the ET. Electrostatic heat and moisture exchange filters should be used in the anesthesia circuit throughout the intubation process, as its virus filtration efficiency reaches 99.9995%.[12]The administration of high-flow nasal cannula devices should be avoided as these can also aerosolize the virus.[24] Leakages, manipulation, or adjustment of ETs may cause aerosolization and should be avoided unless essential.[19],[24]

Mechanical ventilation strategy

Sedatives should be used with caution in Covid-19 patients. As always, both ventilation and oxygenation should be thoroughly observed if the patient is sedated. Although the EtCO2 monitor is recommended, we should avoid connecting the CO2 sampling line directly to prevent contamination of the patient monitor.[18]

A small tidal volume (4–8 mL/kg) in the lung-protective strategy should be adopted to reduce ventilator-related lung injury. The inspiratory plateau pressure should be <30 cmH2O and the PEEP level should be <8 cmH2O. These parameters must be adjusted by blood gas analysis during a surgery.

Extubation strategy

Anesthesiologists must implement “cough-free extubation” procedures to reduce the spread of aerosols and respiratory drops.[13] Some useful strategies can be useful in this area, such as deep extubation with spontaneous ventilation and the use of lidocaine, dexmedetomidine, remifentanil, or fentanyl, just before extubation.[8]

We advise clamping the orotracheal tube before removing it from the patient. These protocols can be useful in lowering the contagious risk to health-care personnel, and they should be used, especially in patients with suspected or confirmed Covid-19.[30]

Postoperative precaution

Disinfection protocol must be employed in the OR after the surgery. Previously used airway kits must be placed in sealed plastic bags and removed for disposal. Follow the proper procedure to remove the hazmat kit. Wash hands properly after removing PPEs. Avoid touching body parts, in particular the hair and face, until hands are washed.[16] For Covid-19 positive patients, do not send patients to postanesthesia care unit, instead send them to a single, negative-pressure room in the intensive care unit (ICU) or wards.[25]

If OR personnel develop symptoms of 2019-nCoV infection after contact with suspected or confirmed cases, advanced investigations such as blood test, C-reactive protein, and pulmonary imaging should be acquired as soon as possible, followed by self or inhospital isolation.[21]

Parturient patients

The choice of modes of delivery should always be based on obstetric indications. The safety of vaginal birth versus cesarean section in Covid-19 infection has yet been established.[17] Intrathecal anesthesia is still recommended as the major anesthesia method for patients undergoing cesarean section, and patients should wear medical protective masks to reduce cross-infection by aerosol or droplets.[22]

Chen et al.[7] reported 17 Covid-19 patients who underwent cesarean sections. They reported no fatality in the patients, although three of them are still under close observation at the hospital by March 1, 2020. There were no neonates or medical personnel, from the study, reported positive for Covid-19 after the surgery. The Apgar score for the neonates was 7–9 at 1 min and 9–10 at 5 min.

In parturients with confirmed Covid-19 with desaturation (oxygen saturation decreases to ≤93%) present for emergency cesarean delivery, general anesthesia should be considered as a primary option.[20] Avoiding urgent cesarean delivery is essential to reduce the risk for general anesthesia and provider exposure during uncontrolled transfers to the OR. Therefore, ongoing assessment of both maternal and fetal status is the key to balance risks of prolonged labor versus cesarean delivery.[23]

  Conclusion Top

The best protective suit to avoid health-care personnel from getting Covid-19 infection is proper training and self-discipline. This combined with cooperative, honest patients and proper PPEs supply is vital in efforts to reduce the spread of the disease. Negative-pressure chambers, both in ORs and ICUs, are essential in this pandemic. Unfortunately, they are not readily available in underdeveloped and developing countries.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020;382:1199-207.  Back to cited text no. 1
Ryalino C. Covid-19: What we know so far. Bali J Anesthesiol 2020;4:1-2.  Back to cited text no. 2
World Health Organization. Coronavirus Disease (COVID-19) Situation Report 108. World Health Organization; 2020. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019. [Last accessed on 2020May 08].  Back to cited text no. 3
Yang P, Wang X. COVID-19: A new challenge for human beings. Cell Mol Immunol 2020;17:555-7.  Back to cited text no. 4
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Adams JG, Walls RM. Supporting the health care workforce during the COVID-19 global epidemic. JAMA 2020.  Back to cited text no. 6
Chen X, Liu Y, Gong Y, Guo X, Zuo M, Li J, et al. Perioperative management of patients infected with the novel coronavirus. Anesthesiology 2020;132:1307-16.  Back to cited text no. 7
Wen X, Li Y. Anesthesia procedure of emergency operation for patients with suspected or confirmed COVID-19. Surg Infect (Larchmt) 2020;21:299.  Back to cited text no. 8
Flexman AM, Abcejo A, Avitisian R, De Sloovere V, Highton D, Juul N, et al. Neuroanesthesia practice during the COVID-19 pandemic: Recommendations from society for neuroscience in anesthesiology & critical care (SNACC). J Neurosurg Anesthesiol 2020.  Back to cited text no. 9
Chen R, Zhang Y, Huang L, Cheng BH, Xia ZY, Meng QT. Safety and efficacy of different anesthetic regimens for parturients with COVID-19 undergoing Cesarean delivery: A case series of 17 patients. Can J Anaesth 2020;67:655-63.  Back to cited text no. 10
Kowalski LP, Sanabria A, Ridge JA, Ng WT, de Bree R, Rinaldo A, et al. COVID-19 pandemic: Effects and evidence-based recommendations for otolaryngology and head and neck surgery practice. Head Neck 2020:1-9.  Back to cited text no. 11
He Y, Wei J, Bian J, Guo K, Lu J, Mei W, et al. Chinese society of anesthesiology expert consensus on anesthetic management of cardiac surgical patients with suspected or confirmed coronavirus disease 2019. J Cardiothorac Vasc Anesth 2020;34:1397-401.  Back to cited text no. 12
Tan Z, Phoon PHY, Zeng LA, Fu J, Lim XT, Tan TE, et al. Response and operating room preparation for the COVID-19 outbreak: A perspective from the national heart centre Singapore. J Cardiothorac Vasc Anesth 2020. pii: S1053-0770 (20) 30300-1.  Back to cited text no. 13
Tarantini G, Fraccaro C, Chieffo A, Marchese A, Tarantino FF, Rigattieri S, et al. Italian Society of Interventional Cardiology (GISE) position paper for Cath lab-specific preparedness recommendations for healthcare providers in case of suspected, probable or confirmed cases of COVID-19. Catheter Cardiovasc Interv 2020.  Back to cited text no. 14
Coimbra R, Edwards S, Kurihara H, Bass GA, Balogh ZJ, Tilsed J, et al. European society of trauma and emergency surgery (ESTES) recommendations for trauma and emergency surgery preparation during times of COVID-19 infection. Eur J Trauma Emerg Surg 2020.  Back to cited text no. 15
Kim HJ, Ko JS, Kim TY. Recommendations for anesthesia in patients suspected of COVID-19 Coronavirus infection. Korean J Anesthesiol 2020;73:89-91.  Back to cited text no. 16
Qi H, Luo X, Zheng Y, Zhang H, Li J, Zou L, et al. Safe delivery for COVID-19 infected pregnancies. BJOG 2020.  Back to cited text no. 17
Lie SA, Wong SW, Wong LT, Wong TG, Chong SY. Practical considerations for performing regional anesthesia: Lessons learned from the COVID-19 pandemic. Can J Anaesth 2020.  Back to cited text no. 18
Sharma D, Rasmussen M, Han R, Whalin M, Davis M, Kofke WA, et al. Anesthetic management of endovascular treatment of acute ischemic stroke during COVID-19 pandemic: Consensus statement from society for neuroscience in anesthesiology & critical care (SNACC). Endorsed by Society of Vascular & Interventional Neurology (SVIN), Society of NeuroInterventional Surgery (SNIS), Neurocritical Care Society (NCS), and European Society of Minimally Invasive Neurological Therapy (ESMINT). J Neurosurg Anesthesiol 2020.  Back to cited text no. 19
Ashokka B, Loh MH, Tan CH, Su LL, Young BE, Lye DC, et al. Care of the pregnant woman with COVID-19 in labor and delivery: Anesthesia, emergency cesarean delivery, differential diagnosis in the acutely ill parturient, Care of the newborn, and Protection of the healthcare personnel. Am J Obstet Gynecol 2020. pii: S0002-9378(20)30430-0.  Back to cited text no. 20
Zhao S, Ling K, Yan H, Zhong L, Peng X, Yao S, et al. Anesthetic management of patients with COVID 19 infections during emergency procedures. J Cardiothorac Vasc Anesth 2020;34:1125-31.  Back to cited text no. 21
Li W, Huang J. Anesthesia management and perioperative infection control in patients with the novel coronavirus. J Cardiothorac Vasc Anesth 2020:1-6. [doi: 10.1053/j.jvca. 2020.03.035].  Back to cited text no. 22
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Matava CT, Kovatsis PG, Summers JL, Castro P, Denning S, Yu J, et al. Pediatric airway management in COVID-19 patients – Consensus guidelines from the Society for Pediatric Anesthesia's Pediatric Difficult Intubation Collaborative and the Canadian Pediatric Anesthesia Society. Anesth Analg 2020. [doi: 10.1213/ANE.0000000000004872].  Back to cited text no. 24
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Zangrillo A, Beretta L, Silvani P, Colombo S, Scandroglio AM, Dell'Acqua A, et al. Fast reshaping of intensive care unit facilities in a large metropolitan hospital in Milan, Italy: Facing the COVID-19 pandemic emergency Crit Care Resusc 2020.  Back to cited text no. 27
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