Thoracic Anesthesia during the COVID-19 Pandemic: 2021 Updated Recommendations by the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) Thoracic Subspecialty Committee

      The novel coronavirus pandemic has radically changed the landscape of normal surgical practice. Lifesaving cancer surgery, however, remains a clinical priority, and there is an increasing need to fully define the optimal oncologic management of patients with varying stages of lung cancer, allowing prioritization of which thoracic procedures should be performed in the current era. Healthcare providers and managers should not ignore the risk of a bimodal peak of mortality in patients with lung cancer; an imminent spike due to mortality from acute coronavirus disease 2019 (COVID-19) infection, and a secondary peak reflecting an excess of cancer-related mortality among patients whose treatments were deemed less urgent, delayed, or cancelled.
      The European Association of Cardiothoracic Anaesthesiology and Intensive Care Thoracic Anesthesia Subspecialty group has considered these challenges and developed an updated set of expert recommendations concerning the infectious period, timing of surgery, vaccination, preoperative screening and evaluation, airway management, and ventilation of thoracic surgical patients during the COVID-19 pandemic.

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        • Senturk M
        • El Tahan MR
        • Szegedi LL
        • et al.
        Thoracic anesthesia of patients with suspected or confirmed 2019 novel coronavirus infection: Preliminary recommendations for airway management by the European Association of Cardiothoracic Anaesthesiology Thoracic Subspecialty Committee.
        J Cardiothorac Vasc Anesth. 2020; 34: 2315-2327
        • Cacciapaglia G
        • Cot C
        • Sannino F.
        Multiwave pandemic dynamics explained: How to tame the next wave of infectious diseases.
        Sci Rep. 2021; 11: 6638
      1. World Health Organization. Coronavirus disease 2019 (COVID-19) Situation Report –70. Available at: Accessed June 18, 2021

        • World Health Organization
        World Health Organization.
        2021 (Available at) (Accessed June 18)
        • Fiorelli S
        • Menna C
        • Piccioni F
        • et al.
        The cutting edge of thoracic anesthesia during the coronavirus disease 2019 (COVID-19) outbreak.
        J Cardiothorac Vasc Anesth. 2020; 34: 3203-3210
        • Piccioni F
        • Droghetti A
        • Bertani A
        • et al.
        Recommendations from the Italian intersociety consensus on Perioperative Anesthesia Care in Thoracic surgery (PACTS) part 1: Preadmission and preoperative care.
        Perioper Med (Lond). 2020; 9: 37
        • Piccioni F
        • Droghetti A
        • Bertani A
        • et al.
        Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: Intraoperative and postoperative care.
        Perioper Med (Lond). 2020; 9: 31
        • Reebye R
        • Finlayson H
        • May C
        • et al.
        Practical guidance for outpatient spasticity management during the coronavirus (COVID-19) pandemic: Canadian Spasticity COVID-19 Task Force.
        Can J Neurol Sci. 2020; 47: 589-593
        • Thornton M
        • Reid D
        • Shelley B
        • et al.
        Management of the airway and lungisolation for thoracic surgery during the COVID-19 pandemic: Recommendations for clinical practice endorsed by the Association for Cardiothoracic Anaesthesia and Critical Care and the Society for Cardiothoracic Surgery in Great Britain and Ireland.
        Anaesthesia. 2020; 75: 1509-1516
        • Coccolini F
        • Perrone G
        • Chiarugi M
        • et al.
        Surgery in COVID-19 patients: Operational directives.
        World J Emerg Surg. 2020; 15: 25
        • El-Boghdadly K
        • Cook TM
        • Goodacre T
        • et al.
        SARS-CoV-2 infection, COVID-19 and timing of elective surgery: A multidisciplinary consensus statement on behalf of the Association of Anaesthetists, the Centre for Peri-operative Care, the Federation of Surgical Specialty Associations, the Royal College of Anaesthetists and the Royal College of Surgeons of England.
        Anaesthesia. 2021; 76: 940-946
        • Ren R
        • Zhang Y
        • Li Q
        • et al.
        Asymptomatic SARS-CoV-2 infections among persons entering China From April 16 to October 12, 2020.
        JAMA. 2021; 325: 489-492
        • Bi Q
        • Wu Y
        • Mei S
        • et al.
        Epidemiology and transmission of COVID-19 in 391 cases and 1286 of their close contacts in Shenzhen, China: A retrospective cohort study.
        Lancet Infect Dis. 2020; 20: 911-919
        • Huang C
        • Huang L
        • Wang Y
        • et al.
        6-month consequences of COVID-19 in patients discharged from hospital: A cohort study.
        Lancet. 2021; 397: 220-232
        • The American Society of Anesthesiology (ASA) and Anesthesia Patient Safety Foundation (APSF) joint consensus
        ASA and APSF Joint Statement on Elective Surgery and Anesthesia for Patients after COVID-19 Infection.
        2021 (Available at) (Accessed June 18)
        • Kaufman HW
        • Chen Z
        • Niles J
        • et al.
        Changes in the number of US patients with newly identified cancer before and during the coronavirus disease 2019 (COVID-19) pandemic.
        JAMA Netw Open. 2020; 3e2017267
        • Eskander A
        • Li Q
        • Hallet J
        • et al.
        Access to cancer surgery in a universal health care system during the COVID-19 pandemic.
        JAMA Netw Open. 2021; 4e211104
        • Passaro A
        • Addeo A
        • Von Garnier C
        • et al.
        ESMO management and treatment adapted recommendations in the COVID-19 era: Lung cancer.
        ESMO Open. 2020; 5
        • Shipe ME HD
        • Deppen SA
        • Kozower BD
        • et al.
        Modeling the impact of delaying the diagnosis of non-small cell lung cancer during COVID-19.
        Ann Thorac Surg. 2021; 112: 248-254
        • Korompoki E
        • Gavriatopoulou M
        • Kontoyiannis DP.
        COVID-19 vaccines in patients with cancer—A welcome addition, but there is need for optimization [e-pub ahead of print].
        JAMA Oncol. 2021 May 13;
        • Donatelli F
        • Miceli A
        • Glauber M
        • et al.
        Adult cardiovascular surgery and the coronavirus disease 2019 (COVID-19) pandemic: The Italian experience.
        Interact Cardiovasc Thorac Surg. 2020; 31: 755-762
        • Patel V
        • Jimenez E
        • Cornwell L
        • et al.
        Cardiac surgery during the coronavirus disease 2019 pandemic: Perioperative considerations and triage recommendations.
        J Am Heart Assoc. 2020; 9e017042
        • Guarracino F
        • Shernan SK
        • Tahan ME
        • et al.
        EACTA/SCA Recommendations for the Cardiac Anesthesia Management of Patients With Suspected or Confirmed COVID-19 Infection: An Expert Consensus from the European Association of Cardiothoracic Anesthesiology and Society of Cardiovascular Anesthesiologists with Endorsement from the Chinese Society of Cardiothoracic and Vascular Anesthesiology.
        J Cardiothorac Vasc Anesth. 2021; 35: 1953-1963
        • Engelman DT
        • Lother S
        • George I
        • et al.
        Adult cardiac surgery and the COVID-19 pandemic: Aggressive infection mitigation strategies are necessary in the operating room and surgical recovery.
        J Thorac Cardiovasc Surg. 2020; 160: 447-451
        • Shao JM
        • Ayuso SA
        • Deerenberg EB
        • et al.
        A systematic review of CT chest in COVID-19 diagnosis and its potential application in a surgical setting.
        Colorectal Dis. 2020; 22: 993-1001
        • Mullen-Fortino M
        • Rising KL
        • Duckworth J
        • et al.
        Presurgical assessment using telemedicine technology: Impact on efficiency, effectiveness, and patient experience of care.
        Telemed J E Health. 2019; 25: 137-142
        • Chao GF
        • Li KY
        • Zhu Z
        • et al.
        Use of telehealth by surgical specialties during the COVID-19 pandemic [e-pub ahead of print].
        JAMA Surg. 2021; (2021 Mar 26Accessed June 18)
        • Mihalj M
        • Carrel T
        • Gregoric ID
        • et al.
        Telemedicine for preoperative assessment during a COVID-19 pandemic: Recommendations for clinical care.
        Best Pract Res Clin Anaesthesiol. 2020; 34: 345-351
        • He H
        • Zhao S
        • Han L
        • et al.
        Anesthetic management of patients undergoing aortic dissection repair with suspected severe acute respiratory syndrome COVID-19 infection.
        J Cardiothorac Vasc Anesth. 2020; 34: 1402-1405
        • Quraishi SA
        • Berra L
        • Nozari A.
        Indoor temperature and relative humidity in hospitals: Workplace considerations during the novel coronavirus pandemic.
        Occup Environ Med. 2020; 77: 508
        • Cassorla L.
        Decontamination and reuse of N95 filtering facepiece respirators: Where do we stand?.
        Anesth Analg. 2021; 132: 2-14
        • Sickbert-Bennett EE
        • Samet JM
        • Clapp PW
        • et al.
        Filtration efficiency of hospital face mask alternatives available for use during the COVID-19 pandemic.
        JAMA Intern Med. 2020; 180: 1607-1612
        • Matsuo T
        • Kobayashi D
        • Taki F
        • et al.
        Prevalence of health care worker burnout during the coronavirus disease 2019 (COVID-19) pandemic in Japan.
        JAMA Netw Open. 2020; 3e2017271
        • Delaney RK
        • Locke A
        • Pershing ML
        • et al.
        Experiences of a health system's faculty, staff, and trainees’ career development, work culture, and childcare needs during the COVID-19 pandemic.
        JAMA Netw Open. 2021; 4e213997
        • Muller AE
        • Hafstad EV
        • Himmels JPW
        • et al.
        The mental health impact of the covid-19 pandemic on healthcare workers, and interventions to help them: A rapid systematic review.
        Psychiatry Res. 2020; 293113441
        • Shapiro J
        • McDonald TB.
        Supporting clinicians during Covid-19 and beyond – Learning from past failures and envisioning new strategies.
        N Engl J Med. 2020; 383: e142
        • Spence NZ
        • Lu ME
        • Larson AR
        • Ortega R.
        COVID-19 and occupational skin hazards for anaesthetists.
        Br J Anaesth. 2020; 125: e476-e478
        • Guy Jr, GP
        • Massetti GM
        • Sauber-Schatz E.
        Mask mandates, on-premises dining, and COVID-19.
        JAMA. 2021; 325: 2199-2200
      2. COVIDSurg Collaborative GC. SARS-CoV-2 vaccination modelling for safe surgery to save lives: Data from an international prospective cohort study [e-pub ahead of print]. Br J Surg 2021 Mar 24. doi: 10.1093/bjs/znab101.40

        • Greinacher A
        • Thiele T
        • Warkentin TE
        • et al.
        Thrombotic thrombocytopenia after ChAdOx1 nCov-19 vaccination.
        N Engl J Med. 2021; 384: 2092-2101
        • Schultz NH
        • Sorvoll IH
        • Michelsen AE
        • et al.
        Thrombosis and thrombocytopenia after ChAdOx1 nCoV-19 vaccination.
        N Engl J Med. 2021; 384: 2124-2130
        • Carvalho T
        • Krammer F
        • Iwasaki A.
        The first 12 months of COVID-19: A timeline of immunological insights.
        Nat Rev Immunol. 2021; 21: 245-256
        • Klok FA
        • Kruip M
        • van der Meer NJM
        • et al.
        Incidence of thrombotic complications in critically ill ICU patients with COVID-19.
        Thromb Res. 2020; 191: 145-147
        • Moores LK
        • Tritschler T
        • Brosnahan S
        • et al.
        Prevention, diagnosis, and treatment of VTE in patients with coronavirus disease 2019: CHEST Guideline and Expert Panel Report.
        Chest. 2020; 158: 1143-1163
        • Sadeghipour P
        • Talasaz AH
        • Rashidi F
        • et al.
        Effect of intermediate-dose vs standard-dose prophylactic anticoagulation on thrombotic events, extracorporeal membrane oxygenation treatment, or mortality among patients with COVID-19 admitted to the intensive care unit: The INSPIRATION randomized clinical trial.
        JAMA. 2021; 325: 1620-1630
        • Jackson T
        • Deibert D
        • Wyatt G
        • et al.
        Classification of aerosol-generating procedures: A rapid systematic review.
        BMJ Open Respir Res. 2020; 7e000730
        • El-Boghdadly K
        • Wong DJN
        • Owen R
        • et al.
        Risks to healthcare workers following tracheal intubation of patients with COVID-19: A prospective international multicentre cohort study.
        Anaesthesia. 2020; 75: 1437-1447
        • Lamb CR
        • Desai NR
        • Angel L
        • et al.
        Use of tracheostomy during the COVID-19 pandemic: American College of Chest Physicians/American Association for Bronchology and Interventional Pulmonology/Association of Interventional Pulmonology Program Directors Expert Panel Report.
        Chest. 2020; 158: 1499-1514
        • Nasa P
        • Azoulay E
        • Khanna AK
        • et al.
        Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method.
        Crit Care. 2021; 25: 106
        • Chiesa-Estomba CM
        • Lechien JR
        • Calvo-Henríquez C
        • et al.
        Systematic review of international guidelines for tracheostomy in COVID-19 patients.
        Oral Oncol. 2020; 108104844
        • Sorbello M
        • Rosenblatt W
        • Hofmeyr R
        • et al.
        Aerosol boxes and barrier enclosures for airway management in COVID-19 patients: A scoping review and narrative synthesis.
        Br J Anaesth. 2020; 125: 880-894
        • Wong DJN
        • El-Boghdadly K
        • Owen R
        • et al.
        Emergency airway management in patients with COVID-19: A prospective international multicenter cohort study [e-pub ahead of print].
        Anesthesiology. 2021; (2021 Apr 13Accessed June 18)
        • Foley LJ
        • Urdaneta F
        • Berkow L
        • et al.
        Difficult airway management in adult COVID-19 patients: Statement by the Society of Airway Management [e-pub ahead of print].
        Anesth Analg. 2021; (2021 Mar 12Accessed June 18)
        • Binks AC
        • Parkinson SM
        • Sabbouh V.
        Oxygen: Under or over a surgical facemask for COVID-19 patients?.
        Anaesthesia. 2020; 75: 1691-1692
        • Szegedi LL
        • Bardoczky GI
        • Engelman EE
        • et al.
        Airway pressure changes during one-lung ventilation.
        Anesth Analg. 1997; 84: 1034-1037
        • Mourisse J
        • Liesveld J
        • Verhagen A
        • et al.
        Efficiency, efficacy, and safety of EZ-blocker compared with left-sided double-lumen tube for one-lung ventilation.
        Anesthesiology. 2013; 118: 550-561
        • Cook TM
        • El-Boghdadly K
        • McGuire B
        • et al.
        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: 785-799
        • Sorbello M
        • El-Boghdadly K
        • Di Giacinto I
        • et al.
        The Italian coronavirus disease 2019 outbreak: Recommendations from clinical practice.
        Anaesthesia. 2020; 75: 724-732
        • Jerath A
        • Ferguson ND
        • Cuthbertson B.
        Inhalational volatile-based sedation for COVID-19 pneumonia and ARDS.
        Intensive Care Med. 2020; 46: 1563-1566
        • Nieuwenhuijs-Moeke GJ
        • Jainandunsing JS
        • Struys M.
        Sevoflurane, a sigh of relief in COVID-19?.
        Br J Anaesth. 2020; 125: 118-121
        • Piccioni F
        • Di Gregorio G
        • Rosboch GL
        • et al.
        Sometimes less is worse: A recommendation against nonintubated video-assisted thoracoscopy during the COVID-19 pandemic.
        J Cardiothorac Vasc Anesth. 2020; 34: 2859-2861
        • Wei H
        • Jiang B
        • Behringer EC
        • et al.
        Controversies in airway management of COVID-19 patients: Updated information and international expert consensus recommendations.
        Br J Anaesth. 2021; 126: 361-366
        • Gattinoni L
        • Chiumello D
        • Caironi P
        • et al.
        COVID-19 pneumonia: Different respiratory treatments for different phenotypes?.
        Intensive Care Med. 2020; 46: 1099-1102
        • Botta M
        • Tsonas AM
        • Pillay J
        • et al.
        Ventilation management and clinical outcomes in invasively ventilated patients with COVID-19 (PRoVENT-COVID): A national, multicentre, observational cohort study.
        Lancet Respir Med. 2021; 9: 139-148
        • Conway H
        • Lau G
        • Zochios V.
        Personalizing invasive mechanical ventilation strategies in coronavirus disease 2019 (COVID-19)-associated lung injury: The utility of lung ultrasound.
        J Cardiothorac Vasc Anesth. 2020; 34: 2571-2574
        • Alhazzani W
        • Evans L
        • Alshamsi F
        • et al.
        Surviving Sepsis Campaign Guidelines on the Management of Adults With Coronavirus Disease 2019 (COVID-19) in the ICU: First update.
        Crit Care Med. 2021; 49: e219-e234
        • Suwanwongse K
        • Shabarek N.
        Pneumomediastinum in mechanically ventilated coronavirus disease 2019 patients.
        J Cardiothorac Vasc Anesth. 2021; 35: 686-688
        • Blanc T
        • Pinar U
        • Anract J
        • et al.
        Impact of the COVID-19 pandemic on oncological and functional robotic-assisted surgical procedures.
        J Robot Surg. 2021; 28: 1-8
        • Vigneswaran Y
        • Prachand VN
        • Posner MC
        • et al.
        What is the appropriate use of laparoscopy over open procedures in the current COVID-19 climate?.
        J Gastrointest Surg. 2020; 24: 1686-1691
        • Leow L
        • Ramanathan K
        • Kofidis T
        • et al.
        Organization of thoracic surgical services during the COVID pandemic.
        Surgeon. 2021; 19: e1-e8
        • Patterson TJ
        • Currie PJ
        • Beck J
        • et al.
        A systematic review of viral transmission risk to healthcare staff comparing laparoscopic and open surgery.
        Surgeon. 2020; 18: e72-e77
        • D'Silva DF
        • McCulloch TJ
        • Lim JS
        • et al.
        Extubation of patients with COVID-19.
        Br J Anaesth. 2020; 125: e192-e195
        • Duffy C
        • Kidd A
        • Francis S
        • et al.
        Chest drain aerosol generation in COVID-19 and emission reduction using a simple anti-viral filter.
        BMJ Open Respir Res. 2020; 7e000710
        • Uppal V
        • Sondekoppam RV
        • Landau R
        • et al.
        Neuraxial anaesthesia and peripheral nerve blocks during the COVID-19 pandemic: A literature review and practice recommendations.
        Anaesthesia. 2020; 75: 1350-1363