**2.2 Clinical manifestations**

COVID-19 is an infectious disease primarily of the respiratory system that is transmitted from animal to human and from human to human through air droplets, aerosols, and contaminated fomites. The most characterized symptoms are fever, cough, fatigue, dyspnea, sore throat, headache, myalgias, and arthralgias. Mild respiratory symptoms are the most frequent clinical manifestation; however, a broad plethora of signs and symptoms have been described, from asymptomatic patients to severe pneumonia, acute respiratory distress syndrome, respiratory failure, sepsis, and multi-organ failure. Even though the respiratory system is the most prominent target of SARS-CoV-2, the extrapulmonary damage is very extensive and devastating, contributing to its morbidity and lethality. Non-pulmonary manifestations are abundant and can affect systems, such as cardiovascular, central and peripheral nervous, hematological, digestive, hepatobiliary, renal, endocrine, olfactory, and taste disturbances, as well as skin signs [19–25]. **Table 2** lists the most frequent clinical manifestations of greatest clinical interest. The clinical picture varies according to its evolution, especially in seriously ill patients. These manifestations are usually modified with the various vaccination schemes.

#### *2.2.1 Post-COVID-19 syndrome*

The chronic post-COVID-19 syndrome is another aspect that is slightly known, as well as the psychological alterations secondary to the disease and the confinement that this pandemic has produced. SARS-CoV-2 fatality rates have been estimated between 1 and 7% [26], so there will be a large population recovered from COVID-19; patients who can acquire a multitude of long-term systemic disorders that are of paramount importance, especially when this group of patients undergoes


#### **Table 2.**

*Common disorders in patients with acute COVID-19.*

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


#### **Table 3.**

*Frequent clinical manifestations/lesions of the chronic post-COVID-19 syndrome.*

surgical interventions. Post-COVID-19 chronic damage, to the cardiopulmonary, hematologic, renal, and neurological systems [26–30], is of special interest to the anesthesiologist. Of equal interest are the possible pharmacological interactions between the drugs that these patients have been taking during the acute and chronic phases and the drugs used in anesthesia. **Table 3** lists the most relevant alterations that should be detected in the pre-anesthetic evaluation. Laboratory tests that may persist altered in this syndrome and must be meticulously evaluated include hemoglobin level, erythrocyte sedimentation rate, white blood cell count, lymphocyte count, C-reactive protein, serum glutamic pyruvic transaminase, serum ferritin, prothrombin time, D-dimer, serum creatinine, as well as chest X-ray, CT or NMR.

#### **2.3 Diagnosis**

Clinical suspicion of infection with COVID-19 is the first step toward the diagnosis of this disease. However, the initial clinical picture can easily be mistaken with other viral diseases of the respiratory tract, and sometimes it can be totally asymptomatic. On the other hand, the available vaccines have modified the clinical manifestations. This makes it necessary to start a diagnostic approach with laboratory tests and thorax imaging (X-ray, CT, and NMR) at the slightest suspicion of COVID-19.

Although the gold standard test in the diagnosis of COVID-19 is PCR (polymerase chain reaction), it is also necessary to establish other techniques with high sensitivity and specificity that can be used on a large scale. Currently, there are three diagnostic tests used—nucleic acid detection tests (PCR), antigen detection tests (Ag), and antibody detection tests (Ab): IgM/A and IgG [31–33].

#### **3. Risk of infection and death for the health personnel**

Health personnel who work on the front lines caring for patients with COVID-19 have a high risk of contagion and death compared to those who work in non-COVID-19 areas, although physicians from all specialties may die from COVID-19. Lack of

personal protective equipment was cited as a common cause of death. Although there are no reliable statistics, the published data mention figures of contagion and death not previously seen among HCWs, being emergency physicians, internal medicine, anesthesiologists, intensivists, pulmonologists, infectious disease specialists, primary care physicians, and nurses being the most affected [34–36]. The study of Ing and coworkers [37] reported 278 physicians who died from COVID-19 infection—the average age of 63.7 years, 90% male (235/261). General practitioners and emergency room doctors (108/254), respirologists (5/254), internal medicine specialists (13/254), and anesthesiologists (6/254) comprised 52% of those dying. Two percent of the deceased were epidemiologists (5/254), 2% were infectious disease specialists (4/254), 6% were dentists (16/254), 4% were ENT (9/254), and 3% were ophthalmologists (8/254). The countries with the most reported physician deaths were Italy (121/278; 44%), Iran (43/278; 15%), Philippines (21/278; 8%), Indonesia (17/278; 6%), China (16/278; 6%), Spain (12/278; 4%), USA (12/278; 4%) and UK (11/278,4%). In Mexico, the Mexican Federation of Anesthesiology AC has registered 62 anesthesiologists who died from COVID-19 since the beginning of the pandemic (Hernandez CE. Personal communication), although this figure could be higher since this association has only 5100 members and there are around 15,000 anesthesiologists in this country.

After the first outbreak in China, anesthesiologists in that country were the first to establish safety measures and online education for optimal perioperative management of patients with COVID-19: airway management, oxygen therapy, ventilatory and hemodynamic support, sedation, and analgesia, as well as attention to mental health aspects for workers in surgical areas and intensive care units [38]. After this publication, multiple recommendations appeared with two main goals: the safe management of COVID-19 and non-COVID-19 patients and the protection of all HCWs.

As these management guidelines were developed, the hospitals were reconfigured to increase their capacity to care for COVID-19 patients. "Not necessary" surgeries were postponed, supplies and personal protective equipment were provided to the staff, drugs were investigated for the disease and/or its complications, and preoperative tests were made mandatory for COVID-19, a practice which has generated much controversy, especially in countries with limited resources [31, 39]. On the other hand, asymptomatic carriers among the health personnel have been considered a risk of transmission of COVID-19, especially personnel working in emergency departments. An Egyptian study [40] revealed the prevalence of COVID-19 in asymptomatic HCWs in the emergency department of a tertiary care facility is 14.3% by RT-PCR. The study of Mostafa et al. [41] also done in Egypt included 4040 HCWs from 12 hospitals; 170 (4.2%) were positive for (RT-PCR) and rapid serological tests for IgM and IgG. Most of the infected HCWs were asymptomatic (116/170, 68.2%). The proportion of infection among the asymptomatic (n = 116/3424) was 3.4% (95% CI: 2.8–4.0). These researchers recommended to extend universal testing to all HCWs as infections among them may reflect community rather than nosocomial transmission. In a similar way to emergency physicians, anesthesiologists run a high risk of contagion since they are the providers of care both in the ICU and the perioperative areas and are exposed to the virus every day.

#### **4. Returning to quasi-normal activities after shutdown**


• The resumption of elective surgery during the various outbreaks and remissions of the pandemic has required adjustments to pre-pandemic routines.

All health systems on the planet have collapsed since the beginning of this pandemic; the rapid increase in critically ill patients exceeded the capacity of the emergency and intensive care services, which is why hospitals were transformed into COVID-19 care centers, new non-hospital areas were created or adapted to take care for these patients, and drastic preventive measures such as the social distancing policies, mandatory lockdowns, large isolation periods, confinement at home, home office work, mandatory face masks, frequent hand washing, and sanitation measures. Elective surgeries and many urgent procedures, as well as non-surgical medical hospitalizations, outpatient and home consultation, and the training of students, residents, and new specialists, underwent substantial changes which resulted in a serious increase in non-COVID-19 patient's morbidity and mortality. A systematic review of patients with an acute abdomen during the initial phase of the pandemic proposed that every effort be made to assess the feasibility of postponing surgery until the patient is no longer considered potentially infectious or at risk of perioperative complications. When surgery is necessary, the anesthesiologist and the surgeon must minimize the risk of exposure to the virus by involving the minimum number of personnel and reducing the time in the operating room. When there are no safety measures that allow safe laparoscopy, open surgery should be considered to decrease aerosols [42].

During the different stages of the pandemic, government hospitals and private health care institutions have been designing health care programs for COVID-19 and non-COVID patients in such a way as to return to normal pre-pandemic health care, or what we now know as the new health care routines. The surgeries of all specialties that had been suspended have been resuming a course quite different from the previously established sequences. New care guidelines have been oriented based on the experiences acquired since the beginning of this global health crisis, with the primary goal being to avoid contagion from other patients and health personnel without deterioration of the quality of care [43–45]. As soon as it was possible to adopt new safety measures for non-COVID patients and medical personnel, postponed surgeries that had endangered the lives of thousands of patients with cancers, cardiovascular disease, or organ transplant patients were restarted. Gradually, other types of surgeries were performed until hospital centers and outpatient and short-stay surgery units returned to the new normality. Management guidelines have also been issued to resume surgery in various specialties, with special care in pediatric and obstetric anesthesia [46].

The psychological disorders that the HCWs have undergone [47–49] are also of paramount importance for a reliable return to professional activities in anesthesia. Although for many physicians, returning to their pre-pandemic professional practice has been relatively quick and easy, for anesthesiologists who have been on the front line of this health crisis, returning to the anesthetic consultation, operating rooms, recovery areas or the ICU conveys still a high risk. Not only is it necessary to adopt the new guidelines, but it is prudent to prevent, diagnose and treat these psychological pathologies such as exhaustion, fear, anger, anguish, and uncertainty that are factors that could interfere with our professional performance. This almost "*two-year race is now a marathon that passes between nuclear reactors, next to war zones, of many unusual dangers*" where medical errors can flourish at any moment. As anesthesiologists, we must have the courage, resilience, determination, and conviction to continue with this new goal of providing safe anesthesia to each one of our patients in this era of COVID-19 [50, 51].

With the measures and precautions properly implemented it is now feasible and extremely safe without increased risk for patients to resume all surgical activities.

The health personnel of the surgical and recovery areas has been adapting to the new care guidelines that still have unresolved controversies [52]. Unfortunately, outbreaks with the new variants, including the new strain Omicron [19], continue to perpetuate the risks of contagion for HCWs, especially for professionals who manipulate the airway, which favors the use of regional anesthesia.
