Asian Journal of Anesthesiology: 1-4, 2021

DOI:10.6859/aja.202107/PP.0001
Correspondence

All Is Not Well in COVID-19 Recovered Patients:

Anesthesiologist Viewpoint
Prakash K. Dubey1, Kunal Singh2
1
Department of Anesthesiology and Critical Care Medicine, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
2
Department of Anesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India

To the Editor, from COVID-19 will have clinical sequelae.3 Approx-

Coronavirus disease 2019 (COVID-19) which imately 20% of the hospitalized patients get admitted
originated in Wuhan city, China in December 2019 to the intensive care unit (ICU) for severe disease.
has spread to more than 190 countries affecting mil- These patients admitted to ICU may later develop
lions of people worldwide. COVID-19 is caused by physical and cognitive dysfunction known as post-in-
the novel severe acute respiratory syndrome coronavi- tensive care syndrome. There have also been instanc-
rus 2 (SARS-CoV-2) which belongs to CoV β-species es where patients developed reinfection or there was
possessing spike protein and positive-strand RNA. In reactivation due to possibly long-standing viral car-
the majority of patients, infection with SARS-CoV-2 riage.4 The patients who recovered from COVID-19
results in asymptomatic or mild disease. However, the who come for the surgery may have a lot of issues
disease may cause pneumonia, acute respiratory dis- which have to be evaluated carefully by anesthesiol-
tress syndrome (ARDS), and multiple complications ogists to prevent perioperative complications. Thus
in a significant number of patients. Also, the morbid- preoperative assessment by detailed medical history,
ity, due to the disease, may last for a few months in physical examination, and analysis of organ function
some patients. Those patients who recovered from and surgical conditions are necessary for identifica-
COVID-19 may return to hospitals for elective or tion of high-risk patients and optimization of patient’s
emergency surgeries unrelated to the disease. These condition before undergoing sedation and anesthesia.
patients are more susceptible to perioperative com- There is evidence that suggests survivors may
plications because of disabilities due to COVID-19, develop lung fibrosis and damage. Data regarding
pre-existing comorbidities, and risks associated with lung scar after SARS-CoV-2 infection is very limited,
surgery and anesthesia. By meticulous planning of but researchers are going on to find out the answer.
anesthetic management according to the patient’s According to some studies, a computed tomography
condition and proposed surgery, perioperative com- (CT) scan abnormality persisted 3 months after hos-
plications can be reduced. The aim is to address the pital discharge of COVID-19 patients.5,6 Other lung
anesthetic concerns in patients who recovered from function abnormalities like restrictive pattern, mus-
COVID-19. cle weakness, and reduced diffusion capacity were
As there is no definitive treatment of the observed at the time of discharge from hospitals. 7
COVID-19, management is mainly supportive de- Patients who recovered from COVID-19 ARDS are
pending on the severity of infection. Patients largely at much higher risk of developing lung function im-
return to their previous state of health in 14–21 days pairment. Pulmonary risk assessment is necessary by
but a small number of cases may remain unwell for inquiring about coughing patterns, worsening of dys-
several weeks.1,2 Some of the patients who recovered pnea, and recent infection. Any abnormal respiratory

Received: 13 November 2020; Accepted: 7 June 2021.

Corresponding Author: Kunal Singh, MD, Department of Anesthesiology, All India Institute of Medical Sciences, Aurangabad Rd., Phulwari
Sharif, Patna, Bihar 801507, India ([email protected]).

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 Dubey and Singh

rate, breath sounds, oxygen saturation (SpO2), and affected during SARS-CoV-2 infection. Acute kidney
peak expiratory flow rate need further investigation injury (AKI) has been observed in 37% of hospital-
for underlying lung pathology. Routine imaging with ized COVID-19 patients and incidence could be as
X-ray and CT scan may not be required in all patients, high as 70% in critically ill patients.12,13 The potential
but it needs to be considered in patients with positive causes of AKI can be due to viral entry to renal cells,
clinical findings. Lung ultrasound can be a useful tool microvascular dysfunction, or damage due to hyper-
for screening high-risk patients and patients posted immune responses.14-16 In around 50% of patients with
major surgery. In severe COVID-19 survivors, pulmo- renal injury, the prognosis is good, and remission
nary function tests may provide useful information. occurs in 3 weeks.17 However, it is still not clear in
These investigations can help in defining the post- how many patients the renal dysfunction will persist
COVID-19 lung injury and assist in altering anesthe- even after recovery. Therefore, it becomes imperative
sia plans. Patients may need specific therapy for the to check for renal function in patients who have a
optimization of the condition. Patients with persistent history of AKI and hemodialysis during COVID-19
bronchospasm should receive bronchodilator at a treatment.
fixed schedule and those having evidence of bacterial Venous thromboembolism has also been seen
infection require treatment with antibiotics. Incentive commonly in COVID-19 patients which would be
spirometry and deep breathing exercise if started be- the result of viral-mediated effects or inflammato-
fore surgery may help in reducing the postoperative ry responses. Studies from China have shown that
complication. thrombotic complications can be seen in up to 30%
A significant number of COVID-19 patients also of cases.18 How long the hypercoagulable state lasts
have an impact on their cardiovascular systems.8 The is still a mystery, so appropriate precaution to prevent
mechanism for cardiac involvement can be multifac- deep vein thrombosis should be taken in patients un-
torial resulting from viral myocardial injury, hypoxia, dergoing major surgeries. As neurologic, endocrine,
hypotension, and acute systemic inflammatory re- and gastrointestinal systems can also be affected due
sponse.9 Both young healthy patients and those with to COVID-19, and the recovery time is unknown,
pre-existing cardiovascular diseases may have various careful evaluation of these organ systems is also nec-
cardiac manifestations such as myocardial ischemia, essary to rule out any abnormality.19,20
myocarditis, arrhythmias, and cardiomyopathy.10,11 Anesthetic methods and agents should be wisely
For patients who recovered from severe COVID-19, chosen in COVID-19 recovered patients as some of
cardiac dysfunction can be present for several weeks. the patients may have been lasting morbidity. The
It is logical to evaluate the cardiac function before type of anesthesia will also depend upon the site,
surgery to identify the cardiac abnormality. Also, the type, and urgency of surgery. In addition to standard
severity of cardiovascular dysfunction is directly re- monitoring like pulse oximetry, capnography, blood
lated to the risk of anesthesia. Preoperative screening pressure monitoring, electrocardiogram, and tempera-
to detect any cardiac issues must be done by careful ture, advanced monitoring may be required depending
history as some survivors may have complaints of on the planned procedure and patient’s condition.
chest pain, dyspnea, and palpitations after COVID-19. Whenever feasible regional or neuraxial anesthesia
Also, clinical signs like peripheral edema, heart mur- should be used to reduce chances of pulmonary com-
mur, and basal crackles are sometimes present. Based plications with general anesthesia. Two big advantag-
on signs and symptoms, further investigations such es of regional and neuraxial anesthesia are that they
as blood tests, an electrocardiogram, and an echocar- avoid airway handling and mechanical ventilation.
diogram should be ordered. Cardiology consultation Neuraxial anesthesia also has the benefit of avoiding
and opinion may be required in cases where there is a airway, pulmonary, and hemodynamic complications
diagnostic dilemma. For patients who are on β-blocker related to intubation. Regional anesthesia is safe, but
or antiarrhythmic, it is prudent to continue their med- for patients having pulmonary impairment second-
ication during the perioperative period. For patients ary to COVID-19, ultrasound guidance helps limit
who are on anticoagulation or antiplatelet agents, dose the total dose of local anesthetics in brachial plexus
adjustment before surgery can be considered. blocks. General anesthesia may still be needed in
Studies suggest that the human kidney is also many patients due to the site of surgery. It alters the

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 Post-COVID-19 Anesthetic Issues

pulmonary function by impacting the gaseous ex- doi:10.1183/13993003.01217-2020

change and respiratory mechanics.21 Anesthetic drugs 8. Shi S, Qin M, Shen B, et al. Association of cardiac injury
reduce the ventilatory response of patients to carbon with mortality in hospitalized patients with COVID-19
dioxide which makes them prone to hypoxia in the in Wuhan, China. JAMA Cardiol. 2020;5(7):802-810.
postoperative period. For patients with residual car- doi:10.1001/jamacardio.2020.0950
diac dysfunction, anesthetic drugs should be selected 9. Tavazzi G, Pellegrini C, Maurelli M, et al. Myocardial
localization of coronavirus in COVID-19 cardiogenic
carefully to maintain in order to avoid any hemody-
shock. Eur J Heart Fail. 2020;22(5):911-915. doi:10.1002/
namic instability. Patients having multiple problems
ejhf.1828
after recovery from COVID-19, or those who are
10. Driggin E, Madhavan MV, Bikdeli B, et al. Cardiovas-
undergoing major surgery need to be monitored in a
cular considerations for patients, health care workers,
high dependency unit after surgery.
and health systems during the COVID-19 pandemic. J
More research and detailed analysis will be also
Am Coll Cardiol. 2020;75(18):2352-2371. doi:10.1016/
required to decide the timing of elective surgery for j.jacc.2020.03.031
patients recovered from COVID-19. Many times these 11. Madjid M, Safavi-Naeini P, Solomon SD, Vardeny O.
patients present with post-COVID-19 sequelae which Potential effects of coronaviruses on the cardiovascular
should be assessed for pulmonary, cardiovascular, and system: a review. JAMA Cardiol. 2020;5(7):831-840.
renal and venous thromboembolism risks involved in doi:10.1001/jamacardio.2020.1286
the procedure to be performed under anesthesia. It is 12. Hirsch JS, Ng JH, Ross DW, et al; on behalf of the
crucial to optimize patients before surgery to reduce Northwell COVID-19 Research Consortium and the
the risk and closely monitor postoperatively. Northwell Nephrology COVID-19 Research Consor-
tium. Acute kidney injury in patients hospitalized with

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