Anesth Pain Med.  2020 Oct;15(4):498-504. 10.17085/apm.20041.

Emergency exploratory laparotomy in a COVID-19 patient - A case report -

• Lee SS
• Park JH
• Kim GH
• Kwon MY
• Kim HY
• Moon YJ
• Kim SJ
• Yun MJ

• KMID: 2508414
• DOI: http://doi.org/10.17085/apm.20041

Abstract

Background
Surgeries in patients with coronavirus disease 2019 (COVID-19) put medical staff at a high risk of infection. We report the anesthetic management and infection control of a mechanically ventilated COVID-19 patient who underwent exploratory laparotomy for suspected duodenal ulcer perforation. Case: A 73-year-old man, mechanically ventilated for confirmed COVID-19, showed clinical and radiographic signs of a perforated duodenal ulcer, and he was transferred under sedation and intubation to a negative-pressure operating room. The operating and assistant staff wore personal protective equipment. High-efficiency particulate absorbing (HEPA) filters were inserted into the expiratory circuits of the anesthesia machine and portable ventilator. No participating staff contracted COVID-19, although the patient later died due to pneumonia.
Conclusions
This report can contribute to establishing clinical guidelines for the surgical management and operation room setting of COVID-19 patients.

Keyword

Anesthetics; COVID-19; Infection control; Medical staff; Personal protective equipment; SARS-CoV-2; Surgery

Figure

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  Fig. 1. Chest radiograph of the patient. (A) Chest radiograph of the patient showing ill-defined, hazy, and streaky density in both the lungs. (B) Chest radiograph showing subphrenic free air on both sides, homogenous increased density in the right costophrenic angle, and aggravated bilateral peripheral lung consolidation. (C) Chest radiograph showing increased pneumonic consolidation in both lung fields, especially that of the right lower lobe and pleural effusion right.

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  Fig. 2. Medical staff in preparation for surgery. The medical staff who were going to be inside the operating room each wore a fluid-resistant gown, PAPR, gloves, boots, and an apron. Staff wore double layers of gloves and boots. The surgeon and scrub nurse wore sterile gowns and surgical gloves on top of the PPE. The surgeons in the picture wore N95 masks inside the PAPR hoods. There is no strong evidence for the added protective effects of the concurrent use of N95 masks with PAPR [4]. Laminar flows from the ceiling toward the operating field (dotted arrow). A: anesthesiologist, S: surgeon, SN: scrub nurse, CN: circulating nurse, PAPR: powered air-purifying respirator, PPE: personal protective equipment.

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  Fig. 3. Overall design of the negative-pressure operating room. Negative pressure is maintained only in (1) and (2), and when the doors of these rooms are opened, the negative pressure is temporarily lost. Square dotted arrow: pathway for entry of medical staff and patients; round dotted arrow: pathway for the patient’s exit, solid arrow: pathway for the exit of medical staff who do not participate in the patient transfer, overlaid arrow: pathway for medical staff who participate in the patient transfer after changing PPE that was worn during surgery. (1) main operating room, (2) anteroom, (3) waiting room, (4) doffing area, (5) buffer area. PPE: personal protective equipment.

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