Anesthesia Implications of Post-COVID-19 and Long COVID-19 Syndrome

Educational Objectives

The goal of this program is to improve use of anesthesia in patients with postacute sequelae of COVID-19 virus infection. After hearing and assimilating this program, the clinician will be better able to:

1. Optimize use of anesthesia in patients with dysautonomia after COVID-19 virus infection.
2. Explain anesthetic considerations in patients with respiratory complications after COVID-19 virus infection.
3. Use systemic anticoagulation in patients with venous thromboembolism after COVID-19 virus infection.

Summary

Risk factors: risk factors for postacute sequelae of SARS-CoV-2 (PASC) coronavirus infection include female sex, increased age, pre-existing comorbidities, need for hospitalization, greater severity of acute disease, and increased hospital length of stay, according to Ceban et al (2021)

Fatigue: is the most commonly reported symptom following recovery from acute COVID-19 disease with 5-wk prevalence of 11.9%; a meta-analysis (Ceban et al [2022]) found approximately one-third of patients reported fatigue ≥12 wk after COVID-19 diagnosis; more common in women and in adults; no difference in risk between hospitalized and nonhospitalized patients or time frame of <6 or >6 mo

Cognitive dysfunction: also known as “brain fog”; involves problems with reasoning, spatial planning, and verbal fluency; Ceban et al (2022) revealed 1 in 5 people had cognitive impairment ≥12 wk after diagnosis; nonsignificant trend toward higher risk in women; no difference between hospitalized and nonhospitalized people

Postinfectious fatigue syndrome: includes fatigue and cognitive impairment; shares phenotypic similarities with myalgic encephalomyelitis and chronic fatigue syndrome; proposed mechanisms include direct viral encephalitis, neuroinflammation, hypoxia, cerebrovascular disease, neurodegeneration, cerebral microvascular injury, and metabolic aberrations in the brain

Post-COVID neurologic syndrome: refers to structural brain and spinal cord damage caused by ischemic or hemorrhagic stroke, anoxic brain injury, encephalopathy, seizures, and immune-mediated neurologic disorders that occurred in the initial SARS-CoV-2 infection

Preoperative evaluation: includes thorough neurologic examination; avoid succinylcholine in patients with cerebrovascular accident, patients with Guillain-Barre syndrome, or patients with prolonged immobility because of the risk for severe hyperkalemia and arrhythmia

Psychiatric sequelae: it is difficult to determine if COVID causes psychiatric symptoms or if comorbidities and environmental factors play a more significant role; according to a systematic review, posttraumatic stress disorder (PTSD) affects 6.5% to 42.8% of patients following infection with COVID; most studies show anxiety, depression, and PTSD improve after 6 mo

Effect on quality of life: at 12 wk after COVID diagnosis, 21% to 63% of individuals have functional impairment; 50% of critical survivors experienced new pain in first month after hospital discharge

Anesthetic implications: for patients with mood disorders, continue psychiatric medications preoperatively unless contraindicated; be aware of chronic pain medications; recognize opioid tolerance and dependence; nonopioid adjuncts may reduce opioid requirements

Post-COVID 19 tachycardia syndrome: in patients with cardiovascular system involvement, chest pain and palpitations are the most common subjective findings; patients may experience prolonged tachycardia for ≥12 wk after COVID-19 infection (ie, post-COVID 19 tachycardia syndrome); underlying mechanisms of tachycardia — presumed to be dysautonomia; several subsyndromes exist, including postural orthostatic tachycardia syndrome (POTS); acute COVID-19 causes long-term vascular, pericardial, and myocardial inflammation; COVID-19 recovered patients have 3 times the risk for heart failure, arrhythmias, and myocardial infarction as matched controls; 10% to 35% of patients develop pulmonary hypertension as a result of fibrotic lung damage, leading to right ventricular dysfunction; 32% to 55% of patients develop diastolic dysfunction ≤12 wk after COVID-19 infection

Anesthetic implications with tachycardia: evaluate patients with palpitations with electrocardiography (ECG); thyroid function studies should be performed to rule out hyperthyroidism; chest pain is atypical in nature; in the presence of low exercise tolerance, a history of ischemic cardiomyopathy, or multiple cardiac risk factors, stress testing and ECG are advised; patients with significant cardiac abnormalities require invasive monitoring and preparation of vasopressors, inotropes, and antiarrhythmic medications depending on underlying pathology; patients with dysautonomia (eg, POTS syndrome) may have labile hemodynamics intraoperatively because of overcorrections of blood pressure (BP) and heart rate in response to reductions in BP; careful intravenous fluid administration and titration of phenylephrine are therapies of choice for hypotension

Respiratory sequelae: common symptoms are shortness of breath and coughing; prevalence is lower in patients with mild initial disease; patients may have abnormal findings on chest X-rays or computed tomography (CT) at 3- to 6-mo follow-up; ground-glass opacity and architectural distortion are most common abnormalities; 21% to 50% have reduced carbon monoxide diffusion capacity on pulmonary function tests; restrictive flow patterns and impaired alveolar volume may be observed; underlying interstitial lung disease causes respiratory muscle weakness, ongoing oxygen requirements, and, in rare cases, tracheostomy dependency and need for lung transplantation; patients with pulmonary sequelae have reduced functional capacity and are at risk for postoperative respiratory failure; this risk significantly decreases ≥7 wk after recovery

Anesthetic considerations in respiratory issues: if the patient has not recovered baseline pulmonary function, pulmonary imaging, spirometry, and transthoracic echocardiography (TTE) may be performed; continue home respiratory medications; patients who have been tracheostomized or previously intubated for long periods of time may have vocal cord injuries, subglottic stenosis, or tracheomalacia, making airway manipulation difficult; ensure backup airway equipment is available; if the patient is oxygen or ventilator dependent, the anesthesiologist must assess baseline oxygen requirements and/or ventilator settings to assist with intraoperative ventilator management and extubation planning; patients should be ventilated using lung protective strategies with tidal volumes of 4 to 8 mL/kg ideal body weight and driving pressures <15 cm of water; in patients with residual lung damage, carefully titrate fluids to avoid pulmonary edema

Hematologic issues: prevalence of deep venous thrombosis (DVT) and pulmonary embolism (PE) are 15% and 8%, respectively; the incidence of hematologic complications decreases with time after recovery from the initial infection; microthrombi are common in the pulmonary vasculature, which increases pulmonary vascular resistance and can lead to right ventricular dysfunction

Anesthetic implications of hematologic issues: if DVT or PE is suspected preoperatively, assessment of D-dimer levels or duplex ultrasonography of the extremities is advised; CT angiography of the chest for patient suspected of PE based on Wells criteria (to be avoided in patients with acute renal dysfunction); TTE is performed to guide intraoperative inotropic invasive pressor support in patients with significant pulmonary clot burden and right ventricular dysfunction; patients diagnosed with venous thromboembolism (VTE) require systemic anticoagulation for a duration of ≥3 mo; assess the need to discontinue preoperative anticoagulation; resume anticoagulation when the risk for bleeding is low

Renal manifestations: ≈28% of hospitalized patients develop acute kidney injury (AKI) and 9% receive renal replacement therapy; subclinical renal inflammation and injury persists, leading to progressive decline in kidney function and chronic kidney disease (CKD); patients who have a high burden of frailty, chronic diseases, disability, and immunosenescence are more likely to develop kidney disease and progress to kidney failure

Anesthetic implications of renal issues: obtain preoperative potassium levels and basic metabolic panel; assess volume status using current weight vs dry weight, timing of last dialysis session, and amount of fluid removed; intravenous fluids should be titrated carefully in patients with oliguric renal disease to avoid volume overload; dialysis lines and arteriovenous fistulas should be used for access only as a last resort; check for compression and adequate padding to prevent thrombosis of arteriovenous fistulas intraoperatively

Gastrointestinal (GI) manifestations: 5% to 10% of patients develop diarrhea; patients remain malnourished; dysphagia can occur with stroke or prolonged intubation; patients may be dependent on gastric or postpyloric tube feeds; electrolyte and volume status can guide resuscitation if diarrhea is frequent or large in volume; hospitalized patients are at increased risk for developing Clostridium difficile infection if their intestinal flora has been altered by broad spectrum antibiotics

Anesthetic implications of GI issues: identify and treat reversible causes of diarrhea; perioperative nutrition screen is used to identify patients at risk for malnutrition and to allow for preoperative nutritional optimization

Diabetes mellitus (DM): rate of new onset DM is ≈3% at average follow-up of 140 days; DM contributes to the severity of acute COVID-19 via compromised innate immunity, an exaggerated proinflammatory cytokine response, and decreased angiotensin-converting enzyme (ACE)-2 expression; use of ACE inhibitors or angiotensin II receptor blockers in patients with DM may contribute to disease severity; COVID-19 worsens glucose control in diabetic patients through direct virus-mediated ß-cell damage, augmentation of insulin resistance via cytokines, fetuin-A, and hypokalemia

Thyroid function: in most patients with abnormal thyroid function during acute hospitalization, normalization occurs at follow up; 3% to 5% develop antithyroid peroxidase antibodies; <2% develop subclinical thyrotoxicosis and hypothyroidism

Adrenal insufficiency: patients treated with steroids for acute conditions are at risk

Anesthetic implications of adrenal insufficiency: for patients with DM, preoperative glucose and HbA1c levels must be obtained together with intraoperative glucose monitoring; patients with hypothyroidism may have low cardiac output, impaired baroreceptor reflexes, and hypovolemia; temperature monitoring is critical; laboratory studies are obtained for patients who may be anemic, coagulopathic, hypoglycemic, and have electrolyte abnormalities; intravenous thyroid replacement therapy is initiated if cardiovascular instability is severe and risk for myxedema coma is high; elective surgery is postponed in symptomatic patients until thyroid-stimulating hormone values normalize; avoid the onset of a thyroid storm in patients with hyperthyroidism; in patients with mild or subclinical disease, preoperative ß-blockade is sufficient; monitor hemodynamic status in patients with overt hyperthyroidism undergoing emergency surgery and administer ß-blockade and propylthiouracil; difficult airway precautions should be taken in patients with goiter; if refractory hypotension occurs, consider stress dose steroids for adrenal insufficiency

Timing of surgery: patients recovering from COVID-19 undergoing elective or emergent surgery have increased risk for 30-day adjusted mortality, which returns to baseline at ≥7 wk after initial infection; patients with persisting symptoms continue to have increased risk even after 7 wk; patients undergoing emergency surgery, surgery at <6 wk, or with American Society of Anesthesiologists (ASA) classification III or IV have the highest risk for mortality; ASA and the Anesthesia Patient Safety Foundation recommend deferring elective surgery for 12 wk if the patient was critically ill during the acute illness, 10 wk if the patient was hospitalized or has DM or is immunocompromised, 6 wk if the patient was symptomatic during the initial illness but was not hospitalized, and 4 wk if the patient was asymptomatic or just had mild nonrespiratory symptoms

Readings

Borel M, Xie L, Kapera O, et al. Long-term physical, mental and social health effects of COVID-19 in the pediatric population: a scoping review. World J Pediatr. 2022;18(3):149-159. doi:10.1007/s12519-022-00515-7; Ceban F, Ling S, Lui LMW, et al. Fatigue and cognitive impairment in post-COVID-19 syndrome: A systematic review and meta-analysis. Brain Behav Immun. 2022 Mar;101:93-135. doi: 10.1016/j.bbi.2021.12.020. Epub 2021 Dec 29. PMID: 34973396; PMCID: PMC8715665; Ceban F, Nogo D, Carvalho IP, et al. Association between mood disorders and risk of COVID-19 infection, hospitalization, and death: a systematic review and meta-analysis. JAMA Psychiatry. 2021;78(10):1079-1091. doi:10.1001/jamapsychiatry.2021.1818; Huang C, Huang L, Wang Y, et al. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet. 2021 Jan 16;397(10270):220-232. doi: 10.1016/S0140-6736(20)32656-8. Epub 2021 Jan 8. PMID: 33428867; PMCID: PMC7833295; Khetpal V, Berkowitz J, Vijayakumar S, et al. Long-term cardiovascular manifestations and complications of COVID-19: spectrum and approach to diagnosis and management. R I Med J (2013). 2022;105(7):16-22. Published 2022 Sep 1; López-Sampalo A, Bernal-López MR, Gómez-Huelgas R. Persistent COVID-19 syndrome. A narrative review. Rev Clin Esp (Barc). 2022;222(4):241-250. doi:10.1016/j.rceng.2021.10.001; Poudel AN, Zhu S, Cooper N, et al. Impact of Covid-19 on health-related quality of life of patients: A structured review. PLoS One. 2021;16(10):e0259164. Published 2021 Oct 28. doi:10.1371/journal.pone.0259164; Salari N, Hosseinian-Far A, Jalali R, et al. Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: a systematic review and meta-analysis. Global Health. 2020;16(1):57. Published 2020 Jul 6. doi:10.1186/s12992-020-00589-w; Silva Andrade B, Siqueira S, de Assis Soares WR, et al. Long-COVID and post-COVID health complications: an up-to-date review on clinical conditions and their possible molecular mechanisms. Viruses. 2021;13(4):700. Published 2021 Apr 18. doi:10.3390/v13040700; Stafie CS, Solomon SM, Sufaru IG, et al. Pathogenic connections in post-COVID conditions: what do we know in the large unknown? a narrative review. Viruses. 2022;14(8):1686. Published 2022 Jul 30. doi:10.3390/v14081686; Stefanou MI, Palaiodimou L, Bakola E, et al. Neurological manifestations of long-COVID syndrome: a narrative review. Ther Adv Chronic Dis. 2022;13:20406223221076890. Published 2022 Feb 17. doi:10.1177/20406223221076890.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Chen was recorded at the Texas Society of Anesthesiologists 2022 Annual Meeting, held September 8-11, 2022, in Round Rock, TX, and presented by the Texas Society of Anesthesiologists. For information about upcoming CME activities from the Texas Society of Anesthesiologists, please visit tsa.org. Audio Digest thanks the speakers and the Texas Society of Anesthesiologists for their cooperation in the production of this program.

CME/CE INFO

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The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Lecture ID:

AN644701

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.