Right Case, Right Patient, Right Place- A Case Report Applying the Office-Based Anesthesia Curriculum in a Complex Patient during the COVID-19 Crisis

Disclaimer: We aim to present letters from our readership that may generate further discussion on managing patients with COVID-19. Given the novelty of COVID-19, best-available clinical evidence is limited and supported from anecdotal reports from China, South Korea, Italy and other sites, and from studies of previous epidemics like SARS and MERS. The opinions expressed are those of the authors and not the APSF. These materials are presented for informational and educational purposes only and do not establish a standard of care or constitute medical or legal advice. The APSF does not support or endorse any specific idea, product, equipment, or trademarked technique. We strongly promote consistency with your governing bodies and organizations such as the CDC, WHO, ASA, AANA, and AAAA. Readers are reminded to consult with their institutions and medical/legal advisors regarding any of the views and opinions expressed by the authors.

Introduction

One of the primary factors for improved safety of office-based anesthesia is the clinical decision-making to determine appropriate selection of patient, procedure, anesthetic and personnel for each specific location.¹ The COVID-19 epidemic has made determining the right anesthetic plan much more difficult as new factors such as minimizing aerosolizing procedures have become new concerns. This case report exemplifies the application of the Society for Ambulatory Anesthesia’s (SAMBA) OBA 2020 Curriculum to a socially complex ambulatory patient who presented to our hospital during the COVID-19 pandemic.²

Case Summary/Discussion

A 49-year-old male with history of recurrent left forearm abscesses secondary to active intravenous heroin drug abuse presented to our emergency department (ED) with left forearm abscesses requiring incision and debridement. In our institution, this procedure would typically occur in the outpatient setting, with a local or regional anesthetic and minimal sedation. However, due to the urgency, the orthopedic hand surgery team attempted to do a bedside debridement, but the patient refused, stating clearly that he desired sedation. Given his multiple social and medical complexities, he was found to be a more suitable candidate for a general anesthetic in the operating room (OR) with a potential need for overnight monitoring available at a hospital compared to an ambulatory setting.

The patient endorsed significant COVID-19 risk factors upon initial screening at our institution, but his initial COVID-19 test was negative. According to our hospital’s protocol, this patient would technically be managed as a low-risk patient not under investigation. However, given his risk factors of inadequate social distancing, homelessness and IV drug abuse, we proceeded as if he was still potentially COVID-19 positive adhering to maximum PPE precautions and COVID-19 specific intubation, extubation and patient recovery protocols.

The initial anesthetic plan for this patient was to provide a left-sided supraclavicular block along with a general anesthetic with a supraglottic airway (SGA). The block would serve as part of a multimodal pain management technique as supported by ERAS (Table 1).³

Table 1⁷: Non-opioid pharmacologic agents used in multimodal analgesia. Adapted from: Graff V, Grosh T. Multimodal Analgesia and Alternatives to Opioids for Postoperative Analgesia. Newsl – Off J APSF. 2018;33(2):46-47.

Class	Drug Dosing
Anti-Convulsants	Gabapentin PO: 300-1200 mg TID
	Pregabalin PO: 150-600 mg per day in 2-3 divided doses
Alpha-2-agonists	Dexmedetomidine IV loading dose: 0.5-1 mcg/kg over 10 minsInfusion: 0.2-1.7 mcg/kg/hr
NMDA Anatagonist	Ketamine IV bolus: 0.3-0.5 mg/kgInfusion: start at 0.1-0.2 mg/kg/hr
Local Anesthetics	Lidocaine Bolus: 1.5 mg/kg Infusion: 1-2 mg/kg/h
Acetaminophen	PO: 325-650 mg every 4-6 hr IV: 1000 mg q6 hr IV if >50 kg; if < 50 kg, 15 mg/kg q6 hr
NSAIDs	Ketorolac IM or IV: 15-30 mg every 4-6 hrs PO: 10 mg every 4-6 hrs

Once induction started in the OR, the surgical team expressed surprise that the patient was undergoing a general anesthetic. They had assumed that the patient’s regional block implied that a general anesthetic would not be necessary and thus avoid an aerosol-generating procedure. Before COVID-19, this concern would not have been present from the staff. Given their concerns along with the patient’s desire to be asleep, we pursued MAC with intravenous propofol infusion for sedation. When propofol was administered through the 22-gauge IV in his hand, his only access, the patient could not tolerate the pain on injection due to this side effect of propofol coupled with his hyperalgesia from chronic opioid use.⁴ Once he was reassured, a new induction plan was initiated.

The options before COVID-19 would have included attempting a MAC again with a different agent, deepening to a general anesthetic or a volatile induction. Volatile induction would be avoided given the risk of coughing, aerosolization and increased excitatory behavior. Ultimately, we decided to avoid an aerosol-generating procedure and pursue a MAC using non-opiates for sedation and anxiolysis including intravenous midazolam and dexmedetomidine.⁵ After 20 minutes, the patient was adequately sedated and the case was complete after 15 minutes without any sequelae in the perioperative period.

Conclusion

This case highlights the additional clinical decision-making needed to safely execute an otherwise straightforward procedure typically performed in an ambulatory setting that was ultimately complicated by multiple factors in a challenging patient. His initial presentation to the ED would likely have prevented him from having it performed in an office-based setting. The clinical decision-making was made more difficult due to the challenging, high-risk patient factors for COVID-19, COVID-19’s impact on airway management and staff concerns and a difficult regional anesthetic for an active IV drug abuser with hyperalgesia and high opiate tolerance (Table 2). Considering the OBA curriculum and following the provided ERAS protocols, we were able to supply an evidence-based anesthetic that not only provided the patient with a safe and satisfactory experience, but also allowed for a rapid recovery that is key to OBA. Ultimately, the patient and surgical staff had a positive outcome through careful, conscientious assessment of each challenge and remaining flexible in a high-stress environment.

Table 2: Impact of COVID-19 on Anesthetic Decision-Making for Regional Cases at our Institution

Factors	Pre-COVID-19	With COVID-19
Primary Regional Anesthetic	Preferred in most cases when possible to avoid GA and improve perioperative pain outcomes6	Still preferred for COVID-19 with additional benefit of potentially avoiding an aerosolizing procedure6
With:
MAC	Preferred for those who could tolerate it	Concerns over possible need to urgently convert to GA
GA-SGA	Preferred if patient was unable to tolerate MAC and there was no need for paralysis and no increased aspiration risk	Unsecured airway, can lead to aerosolization of particles with leak and positive pressure ventilation
GA-ETT	Secured airway, no concern over aerosolization, preferred when paralysis required or risk of aspiration	High-risk aerosolizing procedure, potential coughing on wake up
MAC Sedation	Agents were typically chosen based on provider preference and safety profile	Additional preference for sedative combinations that maintain spontaneous respiration, limit coughing/obstruction
Surgeon/ Perioperative Staff	Selective involvement by certain specialties (i.e. interventional pulmonology, ENT, OMFS); otherwise minimal involvement	More vested interest in limiting aerosolization during procedures
Patient’s Social History	Dealt with on case-by-case basis with patient-only focus	Now, provider and patient safety during intubation and extubation considered
Patient Preference	Would be accommodated as much as the patient’s health status would allow	May be deferred in preference for safer practices that minimize aerosolization

 

Nadim Choudhury, MD, MBA
Department of Anesthesia, Critical Care and Pain Medicine.
Beth Israel Deaconess Medical Center,
Harvard Medical School,
One Deaconess Road,
Boston, MA

Fred E. Shapiro, DO, FASA
Department of Anesthesia, Critical Care and Pain Medicine.
Beth Israel Deaconess Medical Center,
Harvard Medical School,
One Deaconess Road,
Boston, MA

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Neither author has any conflicts of interest to disclose.

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References

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3. Pollard RJ, Young S, Answine J, Shapiro F. What Can ERAS Programs Teach Us About Opioid Usage? ASA Monit. 2020;84(2):12-14.
4. Higgins C, Smith BH, Matthews K. Evidence of opioid-induced hyperalgesia in clinical populations after chronic opioid exposure: a systematic review and meta-analysis. Br J Anaesth. 2019;122(6):e114-e126. doi:10.1016/j.bja.2018.09.019
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6. Lie SA, Wong SW, Wong LT, Wong TGL, Chong SY. Practical considerations for performing regional anesthesia: lessons learned from the COVID-19 pandemic. Can J Anesth. Published online 2020. doi:10.1007/s12630-020-01637-0
7. Graff V, Grosh T. Multimodal Analgesia and Alternatives to Opioids for Postoperative Analgesia. Newsl – Off J APSF. 2018;33(2):46-47. https://dev2.apsf.org/article/successful-implementation-of-a-two-hour-emergency-manual-em-simulation-instructor-training-course-for-anesthesia-professionals-in-china/