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COVID-19: How regional anaesthesia can avoid aerosol generation  

Nathan Nagel

By Nathan Nagel

Nathan is the CEO of the Middle East Medical Portal

The COVID-19 pandemic has created unique challenges for anaesthesia care. Dr Stewart Southey, a UK-based NHS Anaesthetic Consultant, discusses the need for increased attention on patient safety in the tentative world of COVID-19 – and how regional anaesthesia can help minimise infection risks.

More than 35 million cases have been registered in over 200 countries since the coronavirus pandemic began.

For now, many of us remain the inhabitants of a precarious ‘new normal’, and as we enter the sixth month since the outbreak was declared a pandemic, it remains unclear how long this will persist.

What we do know is that the disease has challenged the very nature of how many critical health services are delivered – and is likely to continue doing so for the foreseeable future. Across the world researchers and scientists are hard at work to develop a vaccine and therapeutic drugs for COVID-19.

Until then infection control and measures such as social distancing remain our best hope to prevent the spread of SARS-CoV-2, helping to avoid unnecessary harm and suffering, including in hospital settings.

Aerosol Generating Procedures (AGPs)

In the world of anaesthesia, evolving understanding of the risk of infection transmission has been critical, strengthening the need for increased attention on patient safety during COVID-19.

This has been propelled by the mounting body of evidence pertaining to the risks of aerosol generating procedures such as tracheal intubation, which studies have shown increase the odds of transmission of acute respiratory infection 6.6 times[1].

These procedures place clinicians in close proximity to patients – including those with suspected or confirmed cases of COVID-19 – putting them at greater risk.

The American Society of Regional Anesthesia and Pain Medicine (ASRA) and European Society of Regional Anaesthesia and Pain Therapy (ESRA)  have released a joint recommendation stating that, “Regional anesthesia should be preferred for providing anaesthesia care wherever possible[2].”

This is due to the nature of Regional Anaesthesia (RA) procedures, which deliver a local anaesthetic to a specific region of the body and are therefore not considered aerosol-generating.

In is worth nothing, however – as the Royal College of Anaesthetists conclude – that at present we are reliant on syntheses of limited evidence pertaining to the risks of AGPs[3]. More definitive research is desperately needed.

The IntubateCOVID study, for instance, reported that approximately 10% of those involved with the intubation of COVID-19 patients subsequently developed symptoms consistent with infection or a positive antigen test, despite the vast majority of staff wearing airborne protection PPE. However, the links between performing these procedures and subsequent infection remains uncertain.

Benefits of RA

Independent of the COVID-19 pandemic, studies have shown that there are wider patient benefits to regional anaesthesia in standard anaesthetic practice.

A 2018 article in BJA Education4 provides a broad and balanced overview of the available evidence for a variety of outcomes relevant to the patient, the surgeon, and the institution.

Though not all studies examined in that paper conclusively favoured one technique over the other, there appears to be some clear advantages for RA: in respect to improved postoperative pain management, reduced opioid use and lower post-operative nausea and vomiting. Patient satisfaction scores are higher too, while early mobilisation and reduced length of stay bring institutional benefits as well as clinical ones.

More recently5, one of the authors revitalised the discussion, concluding that in the context of SARS CoV-2, “the scales that balance risk and benefit in the perennial regional vs general anaesthesia debate have tipped slightly more towards regional anaesthesia”.

Meanwhile, another significant impact of COVID-19 has been the unprecedented demand for supplies in hospitals, in particular anaesthetic drugs because of high levels of ventilation. In the midst of a second wave, the advantages of RA further include the opportunity to preserve these vital drugs. For patients and clinicians both, the advantages are stark.

Making RA safer

In the face of inconclusive studies, it appears sensible that anaesthetists should still consider RA where possible. It also remains prudent to limit the period of close proximity between patient and healthcare workers during regional anaesthesia, place a surgical mask (rather than nasal prongs) on the patient and minimise manipulation of oxygen therapy devices. The flow of supplemental oxygen should be kept to the minimum (preferably < 5 l.min−1) needed to maintain arterial oxygen saturation to reduce the risk of aerosolization[4].

It is likewise necessary to have only essential staff present during procedures and to maintain a safe distance of 2m from the patient where possible5.

A device recently launched by a UK-based company, Medovate (SAFIRA®: SAFer Injection for Regional Anesthesia) may be an interesting safety addition given that it transforms RA into a one-person procedure, with the assistant able to maintain a safe distance.

Developed in collaboration with UK National Health Service (NHS) clinicians, the pioneering device makes use of a foot operator which controls a syringe driver to either aspirate or inject the local anaesthetic drug. Dr Emad Fawzy, a Consultant Anaesthetist with a special interest in regional anaesthesia, and co-inventor of SAFIRA®, currently working at SKMC Hospital in Abu Dhabi, presented and demonstrated the device at the Arab Health 2020 exhibition.

Dr Fawzy adds: “SAFIRA® is a revolution in regional anaesthesia. It is the first device which makes the procedure single-operator, it makes it safer, and it gives the anaesthetist total control over the procedure.

 “For hospitals it also has real additional benefits, with the potential to deliver economic value and drive down the cost of regional anaesthesia.

 “SAFIRA® is the first device that would give the anaesthetist objective evidence that he has done a safe block. It is proven to bring significant benefits to both patients and clinicians.”

An attractive feature of SAFIRA® is that the technology improves patient safety by helping to reduce the risk of nerve damage as anaesthetic is prevented from being injected at high pressures. Furthermore, economic modelling has shown SAFIRA® to have the potential to help deliver significant time and cost savings, which is particularly poignant at a time when the best healthcare systems across the world are operating under great strains, which is likely to worsen during winter.

In a study by Health Enterprise East for Medovate, 23 out of the 30 Anaesthetists interviewed commented that they were confident the SAFIRA® device would allow them to save five or more minutes per procedure. The company claims that health economic modelling shows that SAFIRA® also saves time and reduces costs by up to £40 per patient[5].

The SAFIRA® device has recently obtained European CE Mark approval alongside FDA clearance. It has been launched in the US with other markets to follow before the end of 2020. There are ongoing discussions with potential partners to support  the launch of SAFIRA® in the Middle East.

 With cases of COVID-19 infections continuing to mount worldwide, and with the second wave now in full flow, we remain obliged to provide the best care to as many patients as possible. While it is recognised that minimising AGPs is desirable, Regional Anaesthesia can facilitate that goal with perceived advantages, helping to avoid unnecessary suffering in both clinicians and patients.

[1] https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0035797

[3] https://icmanaesthesiacovid-19.org/airway-gudiance-endemic

[4] Cook TM, El‐Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID‐ 19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia 2020; 75:785‐99

[5] SAFIRA® Budget Impact Analysis for UK, France, Germany, Italy & Spain by Health Enterprise East (Sept 2020)