HOT TOPICS: COVID AND BEYOND IMPLICATIONS FOR ANESTHESIA

PRACTICEKIMBERLY WESTRA DNP, MSN, CRNA, MBA

COVID 19….20….21?

• What is COVID 19? • A contagious disease caused by SARS-CoV-2• First cases in Wuhan, China approximately December 2019• Ongoing World Wide Pandemic• Primary Symptoms: Fever, Cough, Fatigue, Shortness of Breath, Kidney

Failure, Cytokine Release Syndrome, Respiratory Failure, Pulmonary Fibrosis, Multisystem organ failure (pediatric or adult), Chronic symptom issues: “Long Haulers”

COVID 19

COVID 19 ONSET, DURATION, DIAGNOSIS

• Usual Onset 2-14 days (average 5 days)• Duration: 5 days to chronic • Diagnosis: RT-PCR testing, CT Scan, Rapid Antigen Test• Prevention: Quarantine, Face coverings, social/physical distancing, hand

washing, improved ventilation in closed areas• Vaccines• Variants now developing: Variants will remain the greatest challenge to

stopping the spread of the virus***

COVID SYMPTOMS: IF YOU HAVE THEM…..

• Loss of smell or taste

• Cough

• Sore throat

• Fever

• Fatigue

• Muscle Aches

• Chills

• Headache

• Runny nose

• Congestion

• Diarrhea

• Nausea, Vomiting

• Shortness of Breath, pallor

• Hypoxia, Tachycardia

COVID 19 TEST TYPES

• Viral test identifies if there if a current infection: Two Types Nucleic Acid Amplification Test (NAATs) or Antigen Test.

• Antibody test (Serology test) identifies if you have had COVID 19 in the past. Antibody test should not be used for suspected current infections

COVID RAPID ANTIGEN TESTS

• Rapid Antigen tests can be done with patients with or without symptoms & involve looking for the Protein Fragments specific to the COVID 19 Virus

• Rapid Antigen test can be faster but often are considered to be less accurate than PCR tests• Rapid Antigen may

demonstrate a higher false positive rate as compared to other test modalities.

COVID TESTS FOR CURRENT SUSPECTED COVID INFECTION

• COVID 19 PCR Test: this is a molecular test which detects genetic material of the virus using a technique called polymerase chain reaction (PCR) when taken within 5 days of initial infection can be up to 90% accurate but variation occurs with “early” and “late” tests accuracy varies.

• PCR Tests are considered the “Gold Standard” and are required by many countries, screening processes prior to admission

• Timing of test & timeline of infection may impact accuracy thus early & late testing may result in accuracy as low as 70%

RAPID PCR COVID 19 TESTS

• PCR tests involve a swab of the nose & throat• Home Self Tests, Testing Sites

can also offer the PCR test however accuracy may be impacted by the quality of technique used for obtaining the sample

COVID 19 TESTS

COVID 19

• What makes COVID so dangerous? COVID is coronavirus with spike proteins that latch onto ACE2 Human cells allowing the virus to enter the cell.

• Once COVID enters the human cell is takes over the “machinery” of the cells replication it begins to churn out copies of itself and see new cells to infect

• COVID moves forward with the one goal of replicating and taking over the body

• COVID can be asymptomatic in many cases and up to 50% of cases have NO SYMPTOMS thus promoting spread to others

COVID 19: DAMAGE TO THE BODY

• COVID 19 makes its way into the body then begins to make copies of itself

• The coronavirus COVID 19 latches its spiky surface proteins to the receptors of the healthy cells especially the cells in the LUNGS

• COVID 19 viral cells bust in through ACE2 Receptors

• The lower airways have more ACE2 Receptors thus more likely to penetrate deeply into the respiratory tree (as compared to other viruses)

COVID REPLICATION & MUTATION

• Covid hijacks the host cells and begins to replicate however each time this occurs there is a chance of error….mutation.• Mutations open the door for variants of COVID 19• Errors in replication during the RNA “hijacking” are the

pathway for COVID 19 Variant (mutations)

COVID 19 AEROSOLS VERSUS DROPLETS

STOPPING THE SPREAD OF COVID 19

COVID 19 VACCINE

• RNA Vaccine for COVID 19: Moderna, Johnson & Johnson, Pfizer

• Vaccine versus Natural Immunity from COVID 19 Infection

• Vaccine Response to Variants (mutations of original virus)

COVID 19 VACCINE

• COVID 19 Infection & Vaccine: Can you get the vaccine for if you are infected with COVID 19? CDC recommends waiting until fully recovered from illness & have completed their quarantine

• Recommended for patients 12 yrs. or older at this time

• COVID 19 vaccine can be given with other vaccines at same time

• Severely immunocompromised patients may require an additional booster vaccine after to standard COVID 19 two dose vaccine is delivered

• Side effects of COVID 19 Vaccine: fatigue, myalgias, low grade fever, soreness at injection site, myocarditis/pericarditis (more often after second dose)

COVID 19 BOOSTER VACCINE: CONTROVERSY CONTINUES

• Penn Study August 2021 demonstrates the need to examine T cell levels NOT just antibodies

• Much controversy over the need for additional booster or 2 shot vaccines versus one dose vaccines (Johnson & Johnson)

• Stay tuned for new studies as the data continues to compile

• Much controversy & discussion on booster vaccines for population at large

• Controversy over name of booster: 3rd dose or “booster”

• FDA September 2021 authorized a “booster” shot for higher risk individuals (immunocompromised, 65 years or older, comorbid health status

COVID 19 VARIANTS

• Virologists study new variants (strains) of COVID 19 to examine changes in characteristics:

• Viral load• Transmissibility• Symptomology • Virulence• Convalescence Response to Vaccine

COVID 19 & IMMUNITY

Immune Systems of more than 95% of patients recovering from COVID19 had durable “memories” humeral immunity up to 6-8 months after COVID 19 infectionHybrid Immunity: Patients who were both infected by COVID 19 & have been vaccinated Hybrid Immunity to COVID 19 have highest level of antibodies…”Super Human Immunity”. New evidence suggest these Hybrid Immune Individuals antibodies demonstrate a higher level of flexibility to adapt & attack the Variants

COVID 19 HYBRID IMMUNITY

COVID 19 VIRUS MUTATION BASICS

VARIANTS, NAMES, PANGO LINEAGESOURCE COUNTRIES

SUPER MUTANT COVID VARIANTS

• Variants can combine for example Delta Variant (India) and Mu (Columbia) are now being watched closely

• Convalescence Evolution for variants combining although less common than global evolution of variants: Combination variants could prove most challenging

• Mu Variant seems to be most Immune Evasive (Vaccine resistant)

SCIENTISTS TRACKING VARIANTS & NEUTRALIZATION EFFECT

COVID 19 VARIANTS OF INTEREST

• https://www.who.int/en/activities/tracking-SARS-CoV-2-variants/

INFORMATION SOURCES: ANESTHESIA PROVIDERS CAN TRACK THE DATAhttps://covid.cdc.gov/covid-data-tracker/#datatracker-home

https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html

“PANGOLIN”PANGO NOMENCLATURE `

• Phylogenetic Assignment of Named Global Outbreaks • Purpose to implement a dynamic nomenclature to

classify genetic lineages to compare with other genome sequences of COVID 19

PANGO LINEAGE IMAGE

COVID 19 & ANESTHESIA

• COVID 19 has impacted perioperative care and anesthesia in a magnitude of ways since the beginning of the Pandemic• March 2020 saw the halt of most elective surgery with the

transformation of anesthesia teams into many dynamic roles: Intubation Teams, Critical Care Teams, Dynamic Roles for Anesthesia Providers which continue to evolve as the Pandemic evolves

MOVING FORWARD IN HEALTHCARE & PERIOPERATIVE SERVICES

• Moving forward healthcare organizations are working with moving data, targets & CDC guidelines to determine how to manage hospital services in the face of the continued COVID 19 Pandemic

• Perioperative Services represents a large portion of hospital revenue often 50-55%

• Elective Inpatient procedures are most at risk of being impacted: Orthopedics, Structural Heart Programs, Cardiac Procedures, Bariatrics

COVID 19 & ANESTHESIA

• Elective Surgery • Emergent Surgery • Intubations: Patients Under Investigation (PUI), Known

Positives, Unknown Patients across hospital services• Transmission across Healthcare Workers & Patients

COVID 19 & ANESTHESIA

• Infection Control & Prevention in the face of continuing COVID 19 Pandemic •COVID 19 Specific OR’s versus Integration• Infection Control Key Concepts for Safe

Perioperative Care Environments

OPERATING ROOM MANAGEMENT & COVID 19 EVIDENCE BASED APPROACH

• Confirmed transmission modes include aerosolization and contaminated environmental surfaces • Implementation of evidence based practices to attenuate

residual environmental contamination of COVID 19• Introduction of evidence based infection control techniques

at all levels of perioperative care using a multimodal approach for infection control

ANESTHESIA, COVID 19, INFECTION CONTROL

• Deep cleaning surfaces with surface disinfectants & ultraviolet light (UV-C)

• Placement of alcohol based hand rubs in immediate proximity to care station, placement of all contaminated instruments into designated dirty bag/area

• After induction of anesthesia, wipe down of all equipment using a top down sequence of disinfection of surfaces of anesthesia care station to reduce bioburden

COVID 19 CLEAN & DISINFECT

COVID 19 & ANESTHESIA MACHINE

ANESTHESIA & COVID 19

• Screening versus Preoperative Testing Debate• Decolonization of patients using Chlorohexidine wipes &

nasal povidone-iodine within 1 hour of incision, plus chlorohexidine oral rinse• Spacing of procedures to allow for OR room air exchange

with OR doors closed (typically 25 minutes) using signage

ANESTHESIA STAFFING PATTERNS & CONTROVERSY

• Staffing patterns promoting longer shifts and cohorting of staff to reduce cross transmission of care providers• Reduction in relief during surgical procedures to limit

cross contamination & transmission COVID 19• Care Provider fatigue concerns & increased error risk• Provider burn out & increased compassion fatigue

COVID 19 & UNDERSTANDING PARTICLE MOTION THOROUGH AREAS

• Understanding COVID 19 respiratory particle size & particle motion to understand transmission attenuation in healthcare• COVID 19 respiratory particle size is approximately is

0.06 microns to 0.14 microns• N95 Mask filter down to 0.03 micron filtration particle size

BROWNIAN MOTION & COVID 19 RESPIRATORY FLUID PARTICLE SIZE

COVID 19 DROPLETS & AEROSOLIZATION

AEROSOL GENERATING PROCEDURE& COVID 19

•Medical or health care procedures that is designated as increased risk of transmission of an aerosol borne contagious disease such as COVID 19• AGP should include require the use of Personal

Protective Equipment (PPE) to attenuate the risk of transmission

SHADOW GRAPHIC OF HUMAN AIRFLOWCOVID 19

AEROSOLIZING PROCEDURES EXAMPLES

• Intubation• Suction• Mechanical ventilation of various types including CPAP, BIPAP,

oscillators• Dental procedures, bronchoscopy, chest physiotherapy, nebulized

medication administration, nasal & oral gastric tube insertion• Many other examples exist, no all inclusive

AGP, COVID 19, ANESTHESIA

• Protection of anesthesia machine via use of protective filters• Viral Filtration Efficacy (VFE) type filter• Use of physical distancing for AGP examining evolving

literature for distance from AGP and distance of aerosolized particles (large & smaller)

AEROSOLIZATION & ANESTHESIA CONSIDERATIONS

• Masking patients• Limit open suctioning • Shielding particle disbursement (Brownian Particle Motion)• Intubation techniques: Video laryngoscopy versus open intubation

techniques• Extubation techniques: Domes versus distance, domes with air

evacuation devices (plume evacuation device)

STANDARDIZED COVID SCREENING TOOLSPREPROCEDURAL COVID SCREENING

• Ticket to OR for emergency procedures that details screening tool for COVID 19 & variant exposure risk such as travel, contact with known or suspected COVID positive persons, symptom based screening

• COVID rapid screen for Perioperative Cases rely on self quarantine• Test and Filter Resource limitations, time limitations for both elective

& emergency cases• True stat emergency assume patients to be positive and follow PPE

protocols, protect anesthesia machine, care stations equipment

COVID 19 & FUTURE CONSIDERATIONS

• COVID 19 & Variants continue to be a challenge to healthcare providers & organizations• COVID 19 infection controls procedures will continue to

evolve as the literature continues to advance our understanding of best practices and techniques to reduce spread….bloodborne training now standard of care, airborne training now likely to become next standard of care

COVID 19 & HEALTHCARE FUTURE?