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  In this article
Genetic Genesis
Mode of Transmission
Risk Stratification
COVID-19 –...
Approach to the ...
Preoperative Con...
History Taking
Intraoperative I...
Intraoperative C...
Risk Out of Bene...
Airway Considera...
Fluid Choice
Extubation Strat...
Critical Ill Pat...
Poor Prognosis
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  Table of Contents 
Year : 2021  |  Volume : 22  |  Issue : 1  |  Page : 3-10

Novel SARS-COV-2 virus (COVID-19): Essential insights for perioperative management of suspected or confirmed pediatric cases

1 Department of Anesthesiology, Superspeciality Pediatric Hospital and Post Graduate Teaching Institute, Noida, Uttar Pradesh, India
2 Department of Anesthesiology, ESI, Faridabad, Haryana, India
3 Department of Onco-Anesthesiology and Palliative Medicine, DRBRAIRCH, AIIMS, New Delhi, India
4 Department of Anaesthesiology, Pain Medicine and Critical Care, AIIMS, New Delhi, India

Date of Submission15-Jul-2020
Date of Acceptance16-Aug-2020
Date of Web Publication22-Feb-2021

Correspondence Address:
Dr. Anju Gupta
Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Room No. 6, 4th Floor, Porta Cabin, Teaching Block, Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/TheIAForum.TheIAForum_109_20

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The COVID-19 is an ongoing global crisis. To deal with it efficiently, health-care system has to gear up to the increasing burden by judicious use of workforce and resources. In the perioperative setting, adequate preventive measures are of prime importance to prevent infection spread among health-care workers. The knowledge regarding the disease is still evolving. In this article, we have outlined the basic epidemiology, pathology, presentation, and diagnosis of COVID-19 along with the considerations for operating room preparedness, personal protective equipment required, airway management, anesthesia conduct, and perioperative concerns when managing positive or suspected COVID-19 pediatric patients and have suggested ways to overcome potential hindrances based on available literature. We have also deliberated upon the specific considerations for a COVID child undergoing regional anesthesia and critically ill COVID-19 pediatric patients. Careful adaptation of working principles based on local needs can help in the prevention of disease spread when optimizing care to the patients.

Keywords: Child, perioperative care, SARS-COV-2

How to cite this article:
Sharma R, Choudhary R, Gupta N, Gupta A. Novel SARS-COV-2 virus (COVID-19): Essential insights for perioperative management of suspected or confirmed pediatric cases. Indian Anaesth Forum 2021;22:3-10

How to cite this URL:
Sharma R, Choudhary R, Gupta N, Gupta A. Novel SARS-COV-2 virus (COVID-19): Essential insights for perioperative management of suspected or confirmed pediatric cases. Indian Anaesth Forum [serial online] 2021 [cited 2021 May 9];22:3-10. Available from: http://www.theiaforum.org/text.asp?2021/22/1/3/309741

  Introduction Top

The severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic 2020 has challenged the health-care providers worldwide. In 2019, December, an outbreak of “novel coronavirus ” disease (COVID-19), engendered by the SARS coronavirus 2 (SARS-CoV-2), occurred in Wuhan, China, and in no time, it has rapidly spread and clutched to other areas worldwide.[1],[2] The World Health Organization (WHO), on January 30, 2020, proclaimed COVID-19 as a Public Health Emergency of International Concern and thus a pandemic. Although similar corona viruses have caused epidemics in the past also, like SARS and MERS and projected mortality from COVID-19 (2%) is lower than SARS and MERS (10% and 35%, respectively), the infectivity of SARS-CoV-2 is much more and the fast spread and much higher number of patients has potentially overwhelmed all healthcare systems across the globe over a very short span.[3]

Anesthesiologists have multifold roles to play in the management of COVID patients and therefore stand a much higher risk to its infection. Hence, a sound knowledge of the infectious characteristics, personal protective measures, and working principles is of enormous importance for the anesthesiologists. The disease affects adult and pediatric populations differently.[4] Pediatric anesthesiologists can encounter suspected or confirmed COVID-positive patients for emergency surgical intervention, in emergency room or in intensive therapy unit and hence may face unique unaccustomed challenges for the anesthetists. The present review aims to increase the insight of anesthesiologists dealing with pediatric patients toward managing them amid this pandemic. The authors conducted a literature search using Ovid Medline, PubMed, and Google Scholar using the search terms “COVID-19,” “Coronavirus disease 2019,” “SARS CoV-2,” “pandemic,” “Acute respiratory distress syndrome,” “perioperative,” AND “children,” OR “pediatrics” to identify publications relevant to perioperative management of pediatric COVID-19 patients.

  Genetic Genesis Top

The animal reservoir of the virus has not yet been identified, but it has been postulated to originated from bat coronavirus since the genome of COVID-19 has striking resemblance to bat coronavirus (98%).[5],[6]

COVID-19 pathogen is classified as a member of the beta-coronavirus genus and has high binding affinity to the angiotensin-converting enzyme 2 receptor in humans.[5],[6] It is a single, positive-stranded RNA virus enveloped in a lipid bilayer.[7],[8] The lipid bilayer fuses with the host cell membrane, releasing RNA into the cytoplasm and causing translation of various viral proteins. The replicated RNA genome and synthesized viral proteins reassemble into new viruses, which burst out of the cell.[9],[10]

The viral spike protein (S-protein) consists of two subunits. S1 subunit targets receptors on host cells, and S2 regulates the membrane fusion. S-protein binds with the human protein receptor ACE2 and allows introduction of COVID-19 RNA into the cell.[5],[6],[11]

  Mode of Transmission Top

In accordance with the WHO report, 2019-CoV spreads via oral and nasal droplets; also, the virus of COVID-19 can hover in the air as aerosols and can lead to infection in other healthy persons.[12] There exists little evidence on the oral–fecal transmission. However, the coronavirus viral load was found to appear in the feces of 54% of the COVID positive patients.[13],[14]

Incubation period (the time from infection to the onset of symptoms) for the new pathogen varies from 2 to 14 days in human-to-human transmission.[15] The mean incubation period is about 3–9 days, with a range between 0 and 24 days.[16],[17],[18],[19] This virus is highly contagious, and transmission can take place before the symptoms arise.

  Risk Stratification Top

The main impediment in managing pediatric subset is the significant convergence of signs and symptoms between common pediatric respiratory illnesses and COVID-19. Moreover, there is an additional risk of the parents or caretakers accompanying these children to be already infected with the virus and thereby posing risk to other patients and health-care workers.

The pediatric population has been found to be less susceptible to the disease, with the majority of children having milder symptoms and only rare pediatric death has being reported globally so far.[20],[21],[22] Despite this, strategies need to be put in place to prevent further spread of the virus.

It is of utmost importance to recognize clinical symptoms and signs [Table 1] for immediate optimization and current management. Mild illness may not require hospitalization; on the contrary, deterioration of symptoms requires prompt recognition, treatment, and admission to intensive care unit [Table 1].
Table 1: Clinical features

Click here to view

  COVID-19 – “Pediatric Shielding Guidance” Top

In this current pandemic, various national and international data have revealed that there exist a small fraction of children requiring hospitalization and out of those needing PICU (pediatric intensive care unit) admission are still less. However, a group of children stand at the risk of COVID-19 virus infection due to existing underlying pathology or any immunocompromised status and these children should be protected as far as possible from infection by “shielding”.

This guidance is recommended by most of the pediatric associations and include the following patients:[23]

  • Children with recent transplant
  • Immunocompromised patients
  • Pediatric inflammatory bowel disease
  • Children on steroid (>20 mg prednisolone or >0.5 mg/kg)
  • Required parental or any other nutritional support
  • On regular blood transfusion with coagulopathy from iron overload
  • Splenectomy
  • Sickle cell disease, leukemia, lymphoma on chemotherapy, or any other malignancy
  • Cystic fibrosis, asthma, obliterative bronchiolitis, interstitial lung disease, or any other lung disease related to underlying systemic disease.

  Approach to the Diagnosis Top

  • Laboratory diagnostic tests
  • Image diagnostic test.

Laboratory diagnostic tests

The following laboratory findings can be helpful in approaching the diagnosis [Table 2].[4],[24] Hence, the detection of SARS-CoV-2 nucleic acid using real-time reverse transcriptase polymerase chain reaction (RT-PCR) is considered credential for COVID-19 diagnosis.[25],[26] The virus can be detected in upper and lower airway secretions (nasopharynx swab or tracheal secretions (when intubated), sputum, and bronchoalveolar lavage), blood, urine, and stool.[27],[28],[29]
Table 2: Laboratory diagnosis

Click here to view

Imaging diagnostic tests

Imaging modalities are also invaluable in diagnosing COVID-19 [Table 3].[24],[30]
Table 3: Imaging modalities

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  Preoperative Consideration Top

Apart from the standard preanesthetic evaluation, four main principals should be followed in case of suspected COVID-19 child, i.e., early identification, isolation, diagnosis, and early possible treatment.

In case if COVID-19 tests positive or detailed history is found to be positive of the following points, the child should be categorized in a high-risk group:

  • Positive history of fever, sore throat, dry cough, runny nose, and diarrhea
  • Suspicious or positive signs on chest imaging
  • History of close contact with confirmed case
  • History of travel/residence from a COVID-19 containment zone area.
  • Presence of risk factors for a poor COVID-19 outcome.

  History Taking Top

Detailed history including sore throat, fever, runny nose, diarrhea, and dry cough should be the part of initial assessment. In the current pandemic, history of recent travel by the child and family members plays an important role.

Any history of positive test of COVID-19 in the family member or any symptoms in the family members or caregivers should be positively extracted in the history taking and presence of any risk factors for a poor outcome should be ruled out. The number of caregivers per child should be restricted to minimum, possibly one.

  Intraoperative Indications for Personal Protective Equipment Top

It is of paramount importance, to provide perioperative care to suspected or known COVID-19 patients and to minimize the risk of viral transmission to health-care workers and other non-COVID-19 patients.[31] Hence, appropriate use of personal protective equipment (PPE) and adequate infection control measures have shown reduced risk of transmission of COVID-19.[32]

Operation theater: Recommendation

Complete PPE should include:

  • N95 mask or Powered air-purifying respirator
  • Double gloves, shoe cover, head to toe cover all
  • Eye protection goggle with or without a face shield.

The most crucial step in preventing transmission is correct donning and doffing of PPE following the guidelines. It has been seen that in the vast majority of such cases of healthcare worker's self-contamination, the fallacy occurs during doffing.[33] The common technique “mask on first” and “mask off last” should be followed along with other guidelines.

  Intraoperative Consideration Top

The operating area workflow is like an adult patient, for confirmed or suspected COVID-19 pediatric patients.[33] Designated negative-pressure operating room with a separate designated access route from non-COVID-19 patients should be there. Anaesthesia room logistics recommended for such cases are mentioned in [Table 4].[15],[34],[35],[36],[37]
Table 4: Recommended logistics for anesthesia in a COVID-19 Pediatric patient

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  Premedication Top

The role of premedication is highly crucial, in order to prevent crying, coughing, and anxious child, as this will decrease the chance of droplet and aerosol contamination. Sedation can be done using fentanyl (1–2 μ/kg), ketamine (1–2 mg/kg), or any other agents. Oral premedication is recommended over nasal administration due to the potential risk of high viral load causing contamination via sneezing and coughing. Ensure adequate effect of premedication, before separating the child from the parent to facilitate smooth separation.

  Risk Out of Benefit in Intravenous or Inhalational Induction Top

Intravenous (IV) induction is considered better, if already secured in the ward, otherwise give optimal premedication, and give optimum time between premedication and subsequent IV cannula placement.

Inhalational induction requires high fresh gas flows and increases the chance of droplets and infection with the virus. In case, then also, inhalation induction is required, then tight facemask seal should be maintained with minimum possible fresh gas flow.

  Airway Considerations Top

  • Preoxygenation using a flexible nasal cannula with minimum possible flow (4 L/min flow) or a reservoir mask to maintain saturation of 93% can be done
  • Avoid positive-pressure ventilation with bag-valve mask, to prevent aerosols generation
  • Early tracheal intubation-rapid sequence intubation (preferably) or modified rapid sequence intubation is considered ideal
  • Avoid non-invasive ventilation in order to avoid aerosol dispersion and likelihood of HCW infection
  • Intubation in COVID-19 patients is considered a high-risk procedure, due to the risk of exposure to airway secretions, that can carry a high viral load.[38],[39] It mandates the use of proper PPE and follow-up of guidelines
  • Most experienced anesthesiologists should do airway management using a disposable pediatric version of videolaryngoscope[37]
  • Communication in full PPE can be problematic, hence comprehensive teamwork including assigning roles and making the airway plan before donning result in better safety and team effectiveness
  • Use of cell phones, pagers, or taking keys, papers, and bags inside the OR should be prohibited. Emergency phones kept in a sealed transparent envelope can be used in case of urgent communications.

In a simulation study, three-layered transparent plastic technique was used and a simulated cough spread particles of same size as the COVID virus. The study concluded that this barrier can trap the virus, creating a hot zone around the patient under the plastic sheet and hence, ultimately may reduce the risk of contamination of the health care personnel.[40]

Pediatric Difficult Intubation Collaborative (PeDI-C) from society of pediatric anaesthesia has recently come up with Consensus Guidelines for Airway Management in Pediatric Coronavirus Disease patients in association with the Canadian Pediatric Anesthesia Society. They recommended administering anxiolytic medications, intravenous anesthetic inductions, tracheal intubation in negative-pressure rooms using videolaryngoscopes, and use of in-line suction catheters. Importantly, PeDI-C strongly recommends the use of appropriate PPE when performing AGMPs even in asymptomatic children, in addition to suspected or known positive COVID-19 children. They have also recommended cuffed tracheal tube to secure the airway in children with COVID-19. Microcuffed tube is preferred under the age of 6 years. They mentioned that a supraglottic airway device was acceptable if a good seal was ensured. Regarding use of barrier enclosures, they recommended the use of clear plastic sheet. There was no recommendation for or against use of intubation box.

Rationale of using supraglottic devices

Supraglottic airway devices with a good seal are considered admissible in few of the cases. Second-generation supraglottic airway devices are considered better than first generation due to high leak pressure.[41]

Anticipated or unanticipated difficult airway

  • The strategy of utilization of videolaryngoscopy should be considered as the primary technique to limit aerosolization followed by fiberoptic intubation
  • Fiberoptic intubation through a supraglottic airway device in situ can be used as an alternative technique
  • Other method is to use combined videolaryngoscopy and fiberoptic technique in combination and finally free fiberoptic
  • Oral fiberoptic intubation is preferred over nasal fiberoptic intubation
  • Intermittent two-hand mask ventilation, maintaining good seal with low tidal volume, can be used in case of hypoxia
  • Neuromuscular blocking agent can be given after I. V induction, if considered safe
  • Endoscopy mask with diaphragm provides better seal around the fiberoptic scope and also allowing tracheal intubation
  • The Association of Paediatric Anaesthetists and the Difficult Airway Society have an algorithm for the cannot intubate and cannot oxygenate situation and should be followed in this scenario.[42]

Ventilatory strategies

The tracheal tube should be placed at adequate age-appropriate length, and then its cuff should be inflated to 20 cmH2O, before connecting to the ventilator. In case of excessive leak, the cuff volume can be increased judiciously when avoiding excessive cuff pressure and the need of tube exchange. A heat and moisture exchange filter (HMEF) should be placed between the patient's airway and the breathing circuit and another at the expiratory limb end at the connection to the anesthesia workstation machine. Lung protective mechanical ventilation strategies are recommended consisting of using lower tidal volumes of 5-6ml/kg, a higher respiratory rate to maintain adequate minute ventilation and maintaining the plateau airway pressures below 30 mmHg.

  Fluid Choice Top

Isotonic crystalloids including Ringer's lactate and normal saline are generally preferred as fluids intraoperatively. Need for additional fluid boluses can also be determined, based on clinical responsiveness and improvement of perfusion targets, i.e., age appropriate in children (10–20 ml/kg). Adequate urine output should be maintained (1 ml/kg/h). Hypoglycemia is particularly concerning in the preterm and sick infants. Therefore, it is important to consider intraoperative glucose administration in these infants. Hourly maintenance fluids should provide glucose infused at the rate of 4–8 mg/kg/min. Ten percent dextrose is used as the primary maintenance fluid in the first 24–48 h of life. Neonates and infants who present for surgery on dextrose containing maintenance fluids should have their dextrose containing maintenance fluids continued during the case.

In septic shock in children, 20 ml/kg as a rapid bolus and up to 40–60 ml/kg in the first hour can be given. Hypotonic crystalloids, gelatin, or starches should not be used for resuscitation.

Role of regional anesthesia in COVID-19 children

COVID-19 is reported with mild symptoms in children as compared to adult patients.[20]

Patients with better oxygenation status should be considered for regional anesthesia when surgery can be done solely under RA.[43] Although peripheral nerve blocks and neuraxial anaesthesia are not considered aerosol-generating procedures, contact and droplet precautions necessitate the use of PPE.[44] The donning should be done before entering the operating room.

There exist limiting data in pediatric literature regarding the indication or contraindication spinal anesthesia in COVID-19-positive children and hence routine indications and contraindications should be applied before the procedure.[45] Caution should be exercised to decrease the duration of spinal anesthesia and also it is of utmost importance that the child is well cooperative and calm. Thrombocytopenia should be ruled out, as this finding is common in some COVID-19 patients.[46] The procedure should be done in all aseptic precautions. Sterile paper drapes can be used instead of plastic due to longer viability of virus on it.[47]

COVID-19 virus has been isolated from cerebrospinal fluid (CSF); therefore, there should be an attempt to reduce contamination by not allowing the CSF to leak freely after lumbar puncture.[48] Currently, there is no supporting literature advocating any dose adjustment in spinal anesthesia. The blocks should be performed with the ultrasound guidance and safe dose of local anesthetic (LA) should be used after calculation to prevent local anesthetic systemic toxicity (LAST).[49] It is recommended to disinfect all the reusable equipment as per the guidelines.

Spinal anesthesia with one touch technique could be considered.[50] Furthermore, all these procedures should be performed in a negative-pressure operation theater with more than 12–15 air cycles per hour.[51]

  Extubation Strategies Top

  • Extubation should be smooth without coughing or bucking. All precautions to be taken to prevent laryngospasm or vomiting
  • Closed in-line suction to be done in deep plane to minimize laryngospasm or coughing
  • Deep extubation can be planned after balanced against adverse impact on the respiratory drive and other factors[52]
  • In case of supplementary oxygen, use simple facemask with low oxygen flow
  • Recommendation is to observe the child in the operative room and bypass the PACU, i.e., direct transfer to the inpatient ward
  • The WHO recommended the use of protective barriers in all the phases of case to reduce viral contamination.[53]

  Critical Ill Patients Top

Protective lung strategies using a pressure-controlled or volume-cycled (pressure-controlled ventilation is preferred in synchronized intermittent mandatory ventilation with support pressure) are shown in [Table 5].[22],[24],[29],[39],[54]
Table 5: Ventilatory strategy in COVID-19 pediatric patients

Click here to view

  Poor Prognosis Top

Presence of organ dysfunction and requirement of renal replacement therapy in patients with renal dysfunction are indicators of poor prognosis in COVID-19 patients. Microthrombosis (ischemic events) are also common in adolescents and thereby D-dimer level should be monitored frequently.[24],[54]

  Conclusion Top

The COVID-19 has taken global health-care system by a storm. Pediatric patients are different in many aspects of disease pathogenesis, epidemiology, systemic and psychological impacts, and outcomes. In this article, we have outlined perioperative concerns specific to pediatric patients and have suggested methods to overcome potential complexities based on available literature. In the perioperative setting, adequate preventive measures are of prime importance to prevent infection spread among health-care workers.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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