Providing safe regional anaesthesia during the COVID-19 pandemic

Dr Stewart Southey looks at how the COVID-19 pandemic has challenged the very nature of how anaesthesia services can be delivered, and the need for increased attention on patient safety in regional anaesthesia during the COVID-19 crisis.

As we enter the sixth month since the World Health Organisation declared COVID-19 a pandemic, it remains unclear how long our ‘new normal’ will persist. With cases once again on the rise, it is perhaps prudent to reflect on the impact that SARS CoV-2 has had on the provision of anaesthesia services and the potential repercussions yet to come.

At its peak, the NHS broadly speaking was put on hold to accommodate the surge of coronavirus cases. It is true that the strategy did manage to prevent the NHS capacity from being overwhelmed, but as a consequence we now have an ever-increasing patient waiting list debt to repay. Given the possibility of a second wave, it is now even more urgent that we strike a balance between contingency planning for COVID Armageddon and ensuring that the UK population continues to receive care as usual.

Staff redeployment and fully occupied intensive care units are not the only reasons that elective care came grinding to a halt. The evidence that Aerosol Generating Procedures (AGP), such as tracheal intubation, increase the odds of transmission of acute respiratory infection 6.6 times compared with those who are not exposed¹ and that postoperative pulmonary complications after elective surgery in COVID positive patients is significantly higher,² is compelling enough. Not surprisingly, therefore, the advice to default to Regional Anaesthesia rather than General Anaesthesia has been advocated in a recent joint statement from the American Society of Regional Anesthesia and Pain Medicine (ASRA) and European Society of Regional Anaesthesia and Pain Therapy (ESRA)³ – the key message reading:

“Regional anesthesia should be preferred for providing anesthesia care wherever possible. Careful consideration should be given to allow the surgery to be performed entirely under regional anesthesia. An unplanned need for intraoperative conversion to GA is least desirable. If the duration or complexity of surgery means a high probability of conversion to GA, it is better to start with GA. This requires good communication between the anesthesia and surgical teams”.

While the debate as to the relative merits of RA over GA continues in the literature, a 2018 article in BJA Education⁴ provided a broad and balanced overview of the available evidence for a variety of outcomes relevant to the patient, the surgeon, and the institution. Though not all studies examined in that paper conclusively favoured one technique over the other, there appears to be some clear advantages for RA in certain use cases. Certainly, for improved postoperative pain management, reduced opioid use and lower post-operative nausea and vomiting, RA has the upper hand. Patient satisfaction scores are higher too, and early mobilisation and reduced length of stay bring institutional benefits as well as clinical ones.

More recently⁵, one of the authors revitalised the discussion, concluding that in the context of SARS CoV-2, “the scales that balance risk and benefit in the perennial regional vs general anaesthesia debate have tipped slightly more towards regional anaesthesia”.

Apart from the opportunity to preserve key drugs required during the critical care of COVID-19 patients, the perceived advantages of RA include a reduction in AGPs, preservation of immune function when compared with general anaesthesia, a less labour-intensive postoperative pain management process, and earlier discharge.

Importantly, McFarlane et. al. postulate whether Regional Anaesthesia is safer than AGPs, asking:

 “Is it possible that an awake patient anaesthetised with a regional technique, for whom staff are appropriately wearing droplet precaution PPE, poses a greater risk than a well-managed general anaesthetic in a patient who neither coughs on tracheal intubation or extubation nor requires suctioning when staff are wearing AGP PPE? Could some staff be more complacent during non-AGPs such as regional anaesthesia?”.

Much depends on the likelihood of SARS CoV-2 aerosolisation occurring during normal breathing and talking, and thus being the cause of subsequent transmission of infection.

Given that the studies are inconclusive, it appears sensible that anaesthetists should still consider RA where possible and maintain high levels of vigilance. It remains prudent to limit the period of close proximity between patient and healthcare worker during regional anaesthesia, place a surgical mask (rather than nasal prongs) on the patient and minimise manipulation of oxygen therapy devices. The flow of supplemental oxygen should be kept to the minimum (preferably < 5 l.min⁻¹) needed to maintain arterial oxygen saturation to reduce the risk of aerosolization.⁶

A degree of pragmatism is required in the absence of high-grade evidence. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) has provided recommendations according to best available evidence⁷.

They suggest that procedures ideally be performed in negative pressure rooms but that standard operating rooms with at least 15 air exchanges per hour (removing 99.9% of airborne contaminants within 28 mins) are preferable to block rooms where cross infection is a risk.

Standard precautions all continue to be applicable, with a pre-anaesthetic checklist, good anatomical knowledge, patient selection, and technical skill seen as variables that can prevent adverse events. The use of ultrasound (with or without nerve stimulators) helps reduce complications compared with blind techniques, and this is now considered by many to be standard practice.

It makes sense to only have essential staff present, and to maintain a safe distance of 2m from the patient where possible⁵. The use of assistants for Regional Anaesthetic procedures is common and thus increases the number of staff at risk. Careful planning and preparation may help minimise the potential points of contact.

A device recently launched by a UK-based company, Medovate (SAFIRA®: SAFer Injection for Regional Anesthesia) may be an interesting safety addition given that it enables RA to become a single operator process, with the assistant able to maintain at a safe distance. The  device has European CE Mark approval and makes use of a foot operator which controls a syringe driver to either aspirate or inject the local anaesthetic drug.

An additional (and seemingly attractive feature) is that the injecting pressure is limited to 20psi which is likely to reduce the risk of nerve injury – animal studies⁸ indicating that pressures above 25psi suggest an intra-fascicular needle tip. By automating the process in a more objective way, Anaesthetists are more likely to have confidence that risk is being minimised.

Nerve damage risk is not insignificant. The incidence of transient injury has been quoted as being as high as 8% of cases, with severe or permanent peripheral nerve injury, quoted as three in 10,000⁹. It goes without saying that the consequences for patients and doctors can be incredibly profound and should be minimized wherever possible.

In a study at Health Enterprise East, 23 out of the 30 Anaesthetists interviewed commented that they were confident the SAFIRA®device would allow them to save five or more minutes per procedure. The company claims that SAFIRA®also saves time and reduces costs by up to £40 per patient.¹⁰

This is clearly of importance in a COVID-19 world where RA is the preferred anesthetic technique. With an estimate across the NHS of circa 400 000 procedures backlogging per month¹¹, every inch of efficiency that can be gained is certainly welcome.

As we approach a possible second wave of COVID-19 infections, we remain obliged to provide the best care to the most patients possible. Regional Anaesthesia appears to help facilitate that goal and perhaps will help streamline services to ensure the deficit does not become too great.

References:

1. [Tran K, Cimon K, Severn M, Pessoa‐Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One 2012; 7: e35797.
2. (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31182-X/fulltext)
3. American Society of Regional Anesthesia and Pain Medicine (ASRA) and European Society of Regional Anaesthesia and Pain Therapy (ESRA). Practice recommendations on neuraxial anesthesia and peripheral nerve blocks during the COVID-19 pandemic. Available from: https://www.asra.com/page/2905/practice-recommendations-on-neuraxial-anesthesia-and-peripheral-nerve-blocks-dur (Accessed May 18th).  
4. [Hutton M, Brull R, Macfarlane AJR. Regional anaesthesia and outcomes. BJAE 2017:18(2):52-56]
5. [Br J Anaesth. 2020 Sep; 125(3): 243–247.Published online 2020 May 28. doi: 10.1016/j.bja.2020.05.016]
6. Cook TM, El‐Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID‐ 19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia 2020; 75:785‐99.
7. Neuraxial anaesthesia and peripheral nerve blocks during the COVID‐19 pandemic: a literature review and practice recommendations V. Uppal  R. V. Sondekoppam  R. Landau  K. El‐Boghdadly  S. Narouze  H. K. P. Kalagara First published: 28 April 2020.          https://associationofanaesthetists-publications.onlinelibrary.wiley.com/action/doSearch?ContribAuthorStored=Kalagara%2C+H+K+P
8. Hewson DW, Bedforth NM, Hardman JG. Peripheral nerve injury arising in anaesthesia practice. Anae 2018:73:51-60
9. O’Flaherty D, McCartney CJL, Ng SC. Nerve injury after peripheral nerve blockage – current understanding and guidelines. BJAE 2018:18(12):384-390
10. SAFIRA® Budget Impact Analysis for UK, France, Germany, Italy & Spain by Health Enterprise East (Sept 2020)) 
11. The building backlog of NHS elective cases post Covid‐19 N. Macdonald C. Clements A. Sobti D. Rossiter A. Unnithan N. Bosanquet