Regional Anesthesia in Times of COVID-19

*Víctor M. Whizar-Lugo, Karen L. Iñiguez-López and Guillermo Castorena-Arellano*

#### **Abstract**

The globalized coronavirus pandemic 2019 has kept us on our toes. Although confusion is widespread and there is a trend toward normalization of almost all human activities, outbreaks remain frequent. The majority of patients with COVID-19 have a trivial to moderate clinical course; a small group develops severe pneumonia and other life-threatening complications. Vaccination against this virus has contributed to better control of the pandemic, but there are no antiviral drugs that have demonstrated efficacy; therefore, the management of surgical patients confirmed or suspected of this disease is a challenge for health care workers, including the anesthesiologists, as well as the non-COVID-19 patients who at a given moment could become carriers or sick. General anesthesia produces aerosols and risks medical and technical personnel being infected, especially those who manage the airway. On the other hand, regional anesthesia has advantages over general anesthesia because the airway is not handled; however, its limited duration is the most important concern. It is reasonable that regional anesthesia occupies a preponderant place in the safe management of all patients, as long as the type of surgery allows it, the anesthesiologist has sufficient skills and patients accept the proposed technique. At this time of globalized crisis due to COVID-19, the intrapandemic anesthetic management of patients undergoing surgery continues to be a changing task, a challenge that has been solved as new data based on solid scientific evidence arise, besides the development of drugs, safer vaccines, equipment, and health prophylactic methods. There is a clear tendency to use regional anesthesia whenever this is possible.

**Keywords:** COVID-19, regional anesthesia, safety

#### **1. Introduction**

In early December 2019, the first cases of coronavirus disease 2019 (COVID-19) were reported in Wuhan, a city located in the Chinese province of Hubei. Most of these patients stated exposure to the Huanan seafood wholesale market selling several alive animals. On the eve of 2020, the WHO office in China was informed of cases of atypical pneumonia with mysterious etiology. Three days later, the first 44 patients with this new pathology were notified and a new member of enveloped RNA coronavirus was identified in bronchoalveolar lavage fluid from a patient in Wuhan and subsequently confirmed as the cause of this infection by the Chinese Center for Disease Control and Prevention. On January 7, 2020, the WHO named

this virus a 2019 novel coronavirus (2019-nCoV). On February 11, 2020, the WHO named the illness associated with 2019-nCoV the 2019 novel coronavirus disease (COVID-19). On January 23, 2020, the central government of China imposed a lockdown in Wuhan and other cities in Hubei in an effort to quarantine the center of an outbreak of COVID-19; this action is commonly referred to as the Wuhan lockdown. The Huanan seafood market became recognized worldwide as the "Ground Zero" site of COVID-19. Since then, the disease has spread rapidly to all countries and territories of the planet—with the exception of Turkmenistan, North Korea, Tuvalu, and Nauru, which have reported no cases—becoming a pandemic that has devastated the world in all its activities and collapsing all health systems [1–5].

Although the available global statistics are approximations, as December 31, 2021; 287,574,670 cases had been recorded, with 5,449,965 deaths and 253,516,625 people recovered [6]. These data are changing every moment in relation to the virulence of the new strains, the worldwide resources for the comprehensive care of the population, and the attitude of the people. As COVID-19 spreads across the planet, perioperative medical and surgical personnel must prepare for the challenges associated with the best care for the pandemic. Rapid suspicion, diagnosis and isolation, proper clinical management, and prevention of disease transmission are vital not only for COVID-19 patients but also for other patients and healthcare workers (HCWs) who are at risk of transmission.

Professionals in perioperative areas, such as other specialties, have been developing timely guidelines based on experiences acquired since the beginning of this pandemic in such a way that peri anesthetic care is the safest and most effective for patients and health personnel. Care policies must be endorsed by hospital administrators, medical societies involved, governments, and the third-party payer, to establish an adequate consensus that can adapt to the frequent changes that are necessary for such a way that the infrastructure and available supplies are optimized.

At this time of the COVID-19 pandemic, we must consider five large groups of patients [7]—people with active COVID-19, patients with a history of remission of SARS-CoV-2, potential carriers, vaccinated and unvaccinated patients, and patients without COVID-19. The pre-anesthetic evaluation and perioperative anesthesiological management are based on these groups according to the type of urgent or scheduled surgery, the available resources, and, of course, the experience of each anesthesiologist.

This chapter reviews the actual role of regional anesthesia in the era of COVID-19, considering the different clinical scenarios that this pandemic has generated. Nowadays, there is no information on how regional anesthesia could affect patients with active COVID-19, those with the post-COVID-19 syndrome, carriers, or recently vaccinated people. Practical recommendations that guarantee both the safety of each patient and also of HCWs are addressed, as well as the protection of the equipment. More research is needed to justify the design of management guidelines in regional anesthesia based solidly on global scientific evidence.

### **2. SARS-CoV-2 virus**

COVID-19 or coronavirus disease is caused by the SARS-CoV-2 virus that belongs to the betacoronavirus genus and shares high homology to the severe acute respiratory syndrome coronavirus (SARS-CoV) that occurred in 2003. This virus is closely related to SARS-CoV-1 and possibly originated either from bats or pangolins. Pneumonia and acute respiratory distress syndrome are the primary complications, although there are other disorders such as cardiovascular, hematological with lethal thrombotic complications, renal, gastrointestinal, hepatic, endocrine,

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

and central nervous system diseases, just to mention a few. This sequence of events is due to the activation of immune responses that trigger uncontrolled massive inflammatory responses mediated by elevated serum levels of pro-inflammatory cytokines that can cause localized and systemic tissue damage. Eosinopenia and lymphopenia with reduction of CD4 + and CD8 + T cells, B cells, and natural killer (NK) cells have been identified in severe cases, severe disease suggests a reduction in NK cell number and function, resulting in decreased clearance of infected and activated cells. A higher ratio of neutrophils to lymphocytes has also been reported, being an indicator of inflammation and infection. COVID-19 patients display high levels of inflammatory cytokines and chemokines (IL-1, IP-10, MCP-1), with severe cases showing elevation in TNF alfa, IL-1, IL-6, IL-8, IL-10, MCP-1, and MIP-1A, leading to severe pulmonary damage and IL-1 has also been linked to the expression of thromboxane-A2 resulting in increased platelet activation and aggregation [8–11].
