**5. Clinical scenarios in the era of COVID-19**

The COVID-19 health crisis has been changing the way we practice medicine. Fortunately, the WHO vaccination programs in agreement with the governments of almost the entire planet have reduced infections and positively modified morbidity and mortality figures. Some clinical scenarios can be considered in this era [7]: patients with active COVID-19, patients recovered from SARS-CoV-2, potential carriers, vaccinated and unvaccinated patients, and a majority group of patients without COVID-19. The pre-anesthetic evaluation and perioperative anesthesiological management are now based on these assumed groups, as well as on the type of urgent or scheduled surgery, on the available resources, and, of course, on the experience of each anesthesiologist.

#### **5.1 Patients with active COVID-19**

Despite the enormous number of clinical trials and vaccines available, unfortunately, we still lack an effective cure for COVID-19. Therefore, the anesthesiologic approach to these patients must be safe and effective for both the patient and the medical team. Transporting patients with active COVID-19 from their bed to the operating room and vice versa is a critical maneuver that requires both the patient and the HCWs to be properly protected and to do so through a pre-established route. An interesting experimental study showed that the surgical smoke generated by the electric scalpel and ultrasonic scalpel is not a risk factor; the coronavirus present in the smoke was unable to induce plaque formation in cultured cells. In addition, filtration of surgical smoke through a surgical mask effectively reduces the amount of viral RNA by at least 99.80% [53].

#### **5.2 COVID-19 survivors**

People who got COVID-19 and survived can be divided into two groups; recovery ad-integrum and those who develop the long-term disease. Those in the first group do not represent a special risk for anesthesiological management, but patients in the second group should be carefully evaluated for long-term cardiac, pulmonary, kidney, hematological, and neurological conditions.

#### *5.2.1 Long term COVID-19 patients*

Two years after the start of this pandemic, more than 287 million cases and 5.4 million deaths had been reported worldwide [6, 54]; approximately 253 million people around the world have recovered from Covid-19, of which 10 to 40% continued with symptoms of this disease for a few weeks to months. This is a new disease that has been called post-COVID-19, Prolonged COVID-19, or Post-acute COVID-19 syndrome [55–57].

COVID-19 long-term sequelae are yet unknown, but they can situate these patients at high risk when they undergo anesthesia and surgery [56]. The chronic post-COVID-19 lesions of greatest interest to the anesthesiologist are cardiovascular, pulmonary, kidney, hematological, and metabolic.

## *5.2.1.1 Cardiovascular*

Up to 20–30% of hospitalized patients with COVID-19 have evidence of myocardial involvement, including acute myocardial injury, arrhythmias, cardiogenic shock, and even sudden death. Acute coronary syndrome (ACS) can be one of the initial presentations of COVID-19 infection which may range from ST elevation and myocardial infarction to Takotsubo cardiomyopathy [57]. The incidence of myocardial injury as reported in China increases with the severity of illness, uprising to 22.2% of patients needing ICU care [58]. Additionally, drug interactions with COVID-19 therapies can put the patient at risk for arrhythmias, cardiomyopathy, and sudden death [22]. A comprehensive cardiovascular review has been recommended in patients who recovered from heart injury due to COVID-19 since they may have residual damage even in asymptomatic patients, especially in search of arrhythmias and myocarditis [59, 60].

#### *5.2.1.2 Lung*

Mild to severe dyspnea are frequent manifestations of the post-COVID-19 syndrome. The lungs are the most damaged organs in patients with moderate to severe COVID-19; an undetermined percentage of recovered persons will develop structural pulmonary abnormalities that usually last for several months. The prospective study of Sonnweber et al. [61] with 145 patients with COVID-19 showed that 41% had respiratory symptoms 100 days after the onset of the disease—dyspnea reduced diffusion capacity in 21% of the studied cohort. The CT scans with alterations in 63%, with bilateral ground-glass opacities and/or reticulation of lower lobes. Other studies have found residual ground-glass opacities, consolidations, reticular and linear opacities, residual crazy paving patterns, melted sugar signs, and parenchymal fibrotic bands [62, 63]. A decreased lung diffusing capacity for carbon monoxide possibly due to loss of alveolar units with alveolar membrane damage was reported recently [64].

Long-term hematologic damage is not accurately recognized. It is unknown whether pulmonary thromboembolism in COVID-19 resolves completely in survivors or presents with long-term sequelae of lung parenchymal or pulmonary vascular damage or pulmonary hypertension. It is prudent to determine if there is thrombocytopenia, D-dimer levels, prothrombin time (PT) prolongation, international normalized ratio (INR), thrombin time (TT), and activated partial thromboplastin time (aPTT) reduction.
