**7. Regional anesthesia**

Although some researchers have suggested that general anesthesia is safe for anesthesiologists and other HCWs, at this time of COVID-19, there is a clear tendency to use–whenever possible–the various regional anesthesia techniques [79–83].

The information available has focused on patients with active COVID-19 and post-COVID-19 syndrome. There is not enough information on the use of regional anesthesia in asymptomatic carriers, recently vaccinated and non-COVID-19 patients requiring anesthesia for surgery or any other medical procedures during this time of the pandemic. However, it is prudent to favor its use as a safe way to avoid possible infections in health personnel and to avoid complications for patients. A Turkish study [84] with 126 specialists in anesthesiology and resuscitation found that 42.6% had an increase in the use of regional anesthesia, compared to 57.3% who had no change. 74% were neuraxial anesthesia. The distribution of peripheral nerve blocks (PNBs) showed that upper extremity blocks were used at a rate of 64.9%, lower extremity blocks at 30.38%, and trunk blocks at 15%. Up to 44% of anesthesiologists used ultrasound guidance and 50% used both neurostimulation and ultrasound. An email survey of members of the American Society for Regional Anesthesia and Pain Medicine, UK Regional Anesthesia, and the European Society for Regional Anesthesia and Pain Therapy involving 729 anesthesiologists from 73 countries found that the use of regional anesthesia increased or remained the same, arguing that its use does not produce aerosols and reduces the risk of possible complications to patients. Only 2% of those surveyed decreased the use of regional anesthesia compared to the pre-pandemic period, being the most common reason for the possibility of urgent conversion to general anesthesia [85].

The following practical considerations are derived from the information available, the possibilities in the various clinical settings described above, the opinions of experts, and our experience.

#### **7.1 General recommendations in the operating room**

Before starting regional anesthesia, it is recommended to plan the available resources (staff, drugs, and equipment), appropriate clinical environment, suitable personal protective equipment for each case (in patients with active COVID-19 or carriers use PPE, goggles and N95 mask should be used throughout the perioperative period. In the other clinical scenarios described above, it is prudent to use minimal protective equipment that include goggles, N95 mask, face shield, surgical gown, and gloves), and evaluate meticulously the best regional anesthesia technique, as well as post-anesthetic care, always protecting patients and HCWs. All patients must be clinically monitored, in addition to being properly monitored with noninvasive blood pressure, electrocardiogram, respiratory rate, and pulse oximetry. If possible, carbon dioxide (CO2) monitoring is recommended. Intraoperative oxygen administration should be avoided, and only if pulse oximetry is 90% or less should be given at low flows (0.5 to 1 Lt/min). Oxygen must be administered with nasal prongs (cannula) with a surgical mask layered over it. It is advisable not to use sedatives during regional anesthesia. When the patient is restless, sedation should be minimal to avoid respiratory depression and the need to administer oxygen and thereby increasing aerosol production. Patients should always keep their N95 masks on to prevent droplet transmission, and preferably not speak during their surgery. The use of long-acting local anesthetic (bupivacaine, levobupivacaine, ropivacaine, and etidocaine) prolongs the anesthetic effect of regional anesthesia. In addition to a sufficient and safe dose, the addition of an additive such as dexmedetomidine, clonidine, morphine, or fentanyl prolongs its duration [86, 87]. Nerve blocks should always be performed in the operating room, and preferably recover in the operating room to limit contamination and contagion. It is mandatory to limit the number of personnel to the minimum necessary. An HCW must be available to bring the necessary supplies to the operating room if required. It has also been recommended by various authors that regional anesthesia should be administered by the most experienced anesthesiologist. However, this negatively interferes with the learning of residents [88–90], which is why we consider it correct that an expert anesthesiologist support colleague in training as long as they follow the guidelines to avoid contagion and with the proper PPE [87].

#### **7.2 Neuroaxial anesthesia**

Epidural, subarachnoid, and combined spinal-epidural anesthesia can be used in all types of patients with maximum safety and efficacy during this pandemic [73, 78–84, 86, 87]. Major et al. found that during this pandemic laparoscopic gynecological surgery under general anesthesia is associated with higher mortality and pulmonary complications. These authors recommend the use of neuraxial anesthesia with low-pressure pneumoperitoneum ≤8 and in pelvic surgery, the Trendelenburg position of as much as 30–45° is essential [91].

Two years after the onset of the pandemic, there are many enigmas about the impact of the coronavirus 2019 on pregnant women, which have been considered at high risk due to the physiological changes of pregnancy and the effects on implantation, fetal growth and development, as well as the risk of infection in the newborn [92]. Anesthetic management guidelines for the mother-fetus-HCWs trinomial have been developed to reduce the possibility of contagion and complications of COVID-19 [93–95]. The available studies support the use of neuraxial anesthesia for labor, vaginal or cesarean delivery section, although the use of general anesthesia in urgent cesarean section continues to be the choice. Chen's retrospective study of 17 pregnant women found significant intraoperative arterial hypotension in 12 of 14 patients who received epidural anesthesia. Three patients were managed under general anesthesia. No newborns or HCWs were infected with COVID-19 [96]. Early epidural block minimizes the need for general anesthesia for urgent cesarean delivery. Depending on the hemodynamic status of each patient, a choice must be made between spinal, epidural, or combined spinal-epidural anesthesia, the latter with a very low spinal dose. Before doing a neuraxial procedure in these patients, it would be advisable to review the platelet count given that one-third of patients with COVID-19 infection have been reported to have thrombocytopenia compared with 7–12% of patients during pregnancy alone.

The possibility of neuroinfections (meningitis or encephalitis) after neuraxial analgesia/anesthesia is an unresolved topic, although it has been mentioned that this possibility is extremely low and there are no published cases with this complication [97]. At present, postdural puncture headache in patients with COVID-19, the epidural blood patch should be avoided [98], instead, regional analgesia can be used with peripheral blocks (greater occipital nerve block, lesser occipital nerve block, sphenopalatine ganglion block, and/or trigger point injections) [99, 100].

#### **7.3 Peripheral nerve blocks**

The introduction of ultrasound guidance has facilitated the development of new regional blocks with safe and effective results, for example, the erector spinae plane block, quadratus lumbar block, injection between the popliteal artery and the posterior knee capsule, pectoral nerve blocks, the transverse plane of the abdomen

#### *Regional Anesthesia in Times of COVID-19 DOI: http://dx.doi.org/10.5772/intechopen.104977*

and many more [101]. The use of ultrasound guidance in peripheral nerve blocks performed by an expert anesthesiologist reduces the incidence of failure and complications. The ultrasound machine and all the accessories used must be properly protected with disposable plastic and be sanitized at the end of each nerve block. Murata et al. published some recommendations when using ultrasound-guided regional anesthesia [102] since the gel, the transducer, as well as the ultrasound machine used, are vectors that can transmit pathogens, including SARS-CoV2. Devices that only have contact with intact patient skin are classified as non-critical and can be sanitized with 70–90% alcohol, aldehyde, phenolic and quaternary ammoniumbased disinfectants, and be used in conjunction with a single-use sterile transducer cover during the procedure. Needle guidance aids that are affixed to the transducer must be sterilized if re-used, but sterile and disposable attachments may be better suited for use in a pandemic. At the end of each regional block, the gel residues must


*Patient with N95 mask at all times, nasal O2 only if necessary. RA = Regional anesthesia. PPE = Personal protective equipment. MPPE = Minimum personal protective equipment.*

#### **Table 4.**

*Recommendations for the management of regional anesthesia in the era of COVID-19.*

#### *Topics in Regional Anesthesia*

be cleaned. If there are blood or body fluids on the transducer or its cable, they must also be decontaminated because they can be a vector for viral transmission.

A study to retrospectively analyze two cohorts of pre-pandemic vs. intrapandemic patients undergoing breast cancer surgery compared general anesthesia vs. paravertebral blocks and found that regional anesthesia significantly reduced hospital discharge time, the need for postoperative analgesics, time in the PACU, and the incidence of postoperative nausea and vomiting, concluding that this type of block offers safe anesthesia for patients and HCWs are not exposed to aerosols produced by general anesthesia, especially anesthesiologists [102].

Some nerve blocks can affect pulmonary function due to paralysis of the diaphragm or incidental pneumothorax. Brachial plexus block, stellate ganglion block, cervical epidural block, and thoracic subarachnoid anesthesia are procedures that could worsen borderline lung function in some patients with severe COVID-19 pneumonia, so these types of regional anesthesia should be avoided in these patients o meticulously adopt the recommendations to avoid these incidents.

There is always the possibility that regional anesthesia could fail. Before starting the surgery, it should be tested whether the dermatomes where the surgery will be performed have been adequately anesthetized. When the surgery is prolonged, conversion to general anesthesia is necessary. In both situations, the anesthesiologist must protect himself according to the established guidelines depending on whether it is a patient with active COVID-19 or one of the other scenarios described above, minimizing the production of aerosols. The possibility of systemic toxicity due to local anesthetics is remote, but if it develops it represents a true emergency that occasionally requires tracheal intubation. This emergency must be resolved in accordance with the established treatment protocols and the personnel must be properly protected to avoid becoming infected during the management of the airway [87].

**Table 4** lists updated recommendations on the study, evaluation, and management of regional anesthesia in the various intrapandemic clinical scenarios. These are suggestions, which can be adapted to local needs and capabilities.

#### **8. Conclusions**

SARS-CoV-2 is the third coronavirus producing an outbreak of this century, and surely it will not be the last pandemic. The progressive appearance of variants, especially Delta and Omicron with a rapid transmission potential confirms that the pandemic is endless, with a greater negative impact which commits us to maintain prevention and management protocols in accordance with the recommendations dictated by experts. Perioperative SARS-CoV-2 infection increases postoperative mortality, which is why it has been determined that these patients should postpone elective surgery whenever possible. A prospective, multicenter, international study compared patients with and without COVID-19 undergoing urgent surgery, finding a 30-day adjusted primary mortality in patients without COVID-19 of 1.5% (95% CI: 1.4–1.5), while those affected by SARS-CoV-2 mortality was significantly increased in those who undertook surgery within 0–2 weeks, 3–4 weeks and 5–6 weeks of diagnosis (odds ratio (95% CI) 4.1 (3.3–4.8), 3.9 (2.6–5.1) and 3.6 (2.0–5.2), respectively). This study recommends that surgery should be postponed for at least 7 weeks after COVID-19 infection, and patients with ongoing symptoms ≥7 weeks from diagnosis may benefit from a longer delay [102]. Proper triage of urgent and non-urgent surgical patients is mandatory for the surgical team to minimize the exposure of HCWs and patients during this era. All patients with unknown COVID-19 status should be considered suspect and therefore essential precautions should be taken for their management.

#### *Regional Anesthesia in Times of COVID-19 DOI: http://dx.doi.org/10.5772/intechopen.104977*

Although a large number of patients affected by COVID-19 require urgent surgery under general anesthesia, an undetermined number of cases can be properly managed with regional anesthesia, especially those patients without severe respiratory failure, myocardial involvement, or coagulation disorders. Regarding the best anesthetic management of all types of patients in this era of COVID-19, we must identify all the available pieces and prudently put them together in a plan based on the evolutionary complexity of this pandemic puzzle, in such a way that patients, HCWs, and the use of supplies and medical equipment are optimized to the maximum. On the other hand, this goal should consider anesthetic management that reduces the possibility of perpetuating the global, regional and local spread of this virus. Regional anesthesia has come to reach a prominent place in the comprehensive management of these patients, and the various clinical environments must be considered, with obstetrics being a special group due to the particular physiological changes of pregnant women.

The coronavirus 2 pandemic will continue to change humanity and we as anesthesiologists will continue to run in this deadly marathon under new and changing health care modalities, whether in the perioperative areas, the emergency rooms, or the intensive care units. Undoubtedly, our professional practice will continue to be of very high risk, so the perioperative management of patients with COVID-19 and the various clinical scenarios that this health crisis has generated must keep us alert and in need of continuous updating.
