中英双语：麻醉和“新冠后综合征”:既往感染SARS-CoV-2患者的围手术期注意事项

本文由“麻醉新超人"授权转载

翻译：高   寒 徐医2020级麻醉学研究生

审校：赵林林 徐医附院麻醉科

Anesthesia and the “post-COVID syndrome”: Perioperative considerations for patients with prior SARS-CoV-2 infection

麻醉和“新冠后综合征”:既往感染SARS-CoV-2患者的围手术期注意事项

The COVID-19 pandemic continues to present a major global health threat. Although most patients infected with SARS-CoV-2 do not develop fatal or critical illness, even mild cases may have long-term health consequences. A recent study in The Lancet by Huang et al found that, among 1733 previously-hospitalized COVID-19 patients, 76% experienced at least one residual symptom 6 months after diagnosis [1]. Symptoms ranging from chest tightness and dyspnea to anosomia and headaches have been described as part of a chronic “post-COVID syndrome.” [1,2] [Table 1].

This “post-COVID syndrome” may have significant implications for anesthetic and perioperative care, and is likely to affect a large number of patients worldwide. Very little is known about perioperative management, morbidity and mortality in patients who have recovered from COVID-19. In this paper, we summarize what is known regarding the chronic effects of SARS-CoV-2 infection, and raise key considerations for the perioperative evaluation and anesthetic management of previously- infected patients [Table 2].

新冠大流行继续对全球卫生构成重大威胁。尽管大多数感染SARS-CoV-2的患者不会发展成致命或危重疾病，但即使是轻症病例也可能产生长期的健康后果。Huang等人最近在《柳叶刀》上发表的一项研究发现，在1733名此前住院的COVID-19患者中，76%的人在确诊6个月后至少出现一种残留症状[1]。从胸闷、呼吸困难到失聪和头痛，这些症状都被描述为慢性“新冠后综合征”的一部分[1,2][表1]。

这种“新冠后综合征”可能对麻醉和围手术期照护产生重大影响，并可能影响全球大量患者。对于COVID-19康复患者的围手术期管理、发病率和死亡率，我们知之甚少。在本文中，我们总结了关于SARS-CoV-2感染慢性影响的已知情况，并提出了对既往感染患者围手术期评估和麻醉管理的关键考虑因素[表2]。

1. Neurologic considerations

Neurologic manifestations of COVID-19 range from dizziness and headache to encephalitis, seizures and stroke and demyelinating polyneuropathy [3]. SARS-CoV-2 is also known to cause loss of smell and taste, which may reflect direct injury to olfactory neurons. Neurologic sequelae may persist beyond acute illness. In the recent Lancet article, Huang et al found that 11–13% of previously-hospitalized COVID pa-tients experienced ongoing loss of smell after 6 months, while 7–9% reported loss of taste. In addition, 5–8% experienced dizziness, and 2–3% complained of persistent headaches [1].

Data are limited regarding optimal anesthetic management of this population. If a patient presents with evidence of peripheral neuropathy, it may be prudent to apply management strategies used in patients with other neuromuscular disorders. These include the judicious use of opiates and neuromuscular blockers (NMBs), and quantitative monitoring of NMB reversal. Avoidance of regional anesthesia may also be advisable. In some cases, patients might also be encouraged to consult a Neurologist postoperatively.

1.神经系统方面的考虑

COVID-19的神经学表现包括头晕和头痛、脑炎、癫痫和中风以及脱髓鞘多发性神经病[3]。SARS-CoV-2还会导致嗅觉和味觉丧失，这可能反映了嗅觉神经元的直接损伤。神经系统后遗症可在急性疾病后持续存在。在最近发表在《柳叶刀》上的文章中，Huang等人发现，11-13%的既往住院新冠患者在6个月后持续失去嗅觉，而7-9%的患者报告失去味觉。此外，5-8%的人感到头晕，2-3%的人抱怨持续头痛。

关于这一人群的最佳麻醉管理的数据有限。如果患者出现周围神经病变的证据，谨慎的做法可能是应用其他神经肌肉疾病患者的管理策略。这些措施包括明智地使用阿片类药物和肌松药(NMBs)，以及NMB逆转的定量监测。避免使用区域麻醉也是可取的。在某些情况下，也可以鼓励患者术后咨询神经科医生。

2. Cardiovascular considerations

SARS-CoV-2 infection is associated with significant adverse cardiovascular effects. 20–30% of hospitalized COVID patients show evidence of acute myocardial injury, potentially leading to dysrhythmias and ischemic or non-ischemic cardiomyopathy [4]. Acute cardiac involvement is associated with worse clinical outcomes in COVID-19 patients, but chronic cardiovascular effects of COVID may also be significant [4]. Huang et al found that 4–10% of patients reported chest pain and 9–11% experienced palpitations after 6 months [1]. These effects may reflect myocardial fibrosis or inflammation [4]. In another study of 26 patients who complained of new cardiac symptoms following COVID-19 infection, 58% demonstrated evidence of myocardial edema and/or

decreased perfusion on cardiac MRI, at a median of 47 days after symptom-onset [5].

Anesthesiologists must be vigilant of possible cardiac dysfunction in patients with prior SARS-CoV-2 infection. Surveillance EKG and TTE have been recommended for COVID-19 patients 2–6 months after acute infection [2]. A low threshold for pre-operative transthoracic echocardiography (TTE) or further evaluation may be appropriate.

2.心血管方面的考虑

SARS-CoV-2感染与严重的心血管不良反应相关。20-30%的COVID住院患者有出急性心肌损伤的证据，可能导致心律失常和缺血性或非缺血性心肌病[4]。COVID-19患者的急性心脏受累与较差的临床预后相关，但COVID的慢性心血管影响也可能很严重。Huang等发现，4-10%的患者报告胸痛，9-11%的患者在6个月后出现心悸[1]。这些可能反映心肌纤维化或炎症[4]。在另一项对26名患者的研究中，他们在COVID-19感染后抱怨出现新的心脏症状，58%的患者在症状出现后的中位时间47天内，在心脏MRI上表现出心肌水肿和/或灌注减少的迹象[5]。

麻醉医师必须警惕既往感染过SARS-CoV-2的患者可能出现的心功能障碍。COVID-19急性感染后2 -6个月建议监测心电图和TTE[2]。术前经胸超声心动图(TTE)阈值较低或进一步评估可能是合适的。

3. Pulmonary considerations

COVID-19 may cause long-lasting pulmonary injury in patients who initially develop mild respiratory symptoms. Among patients who did not require supplemental oxygen when hospitalized for COVID-19, 22% demonstrated diffusion impairment on pulmonary function testing (PFTs) 6 months after acute infection, and 22–29% of patients performed below normal on a 6-min walk test [1]. Small-airway dysfunction and new-onset restrictive lung disease have also been described in recovered COVID-19 patients, independent of acute pneumonia severity. [6]

Anesthesiologists must remain vigilant regarding possibly compromised pulmonary function in patients with prior COVID-19. Depending on history and symptom severity, surveillance PFTs and lung imaging may be indicated [7]. If general anesthesia is planned, it may be prudent to emphasize the possibility of postoperative mechanical ventilation.

3.呼吸系统方面的考虑

对于最初出现轻微呼吸道症状的患者，COVID-19可能导致持久的肺损伤。在因COVID-19住院时不需要补充氧气的患者中，22%在急性感染后6个月的肺功能测试(PFTs)中表现出弥散功能障碍，22-29%的患者在6分钟行走测试中低于正常水平[1]。在康复的COVID-19患者中也描述了小气道功能障碍和新发限制性肺部疾病，与急性肺炎严重程度无关。

麻醉医师必须对既往感染COVID-19患者可能出现的肺功能损伤保持警惕。根据病史和症状严重程度，可能需要监测PFTs和肺影像学[7]。如果计划全身麻醉，谨慎的做法是强调术后机械通气的可能性。

4. Renal considerations

Moderate or severe SARS-CoV-2 infection is frequently associated with acute kidney injury (AKI). Mechanisms of kidney damage include the pre-renal impact of systemic inflammation, as well as direct viral injury to the kidney via the angiotensin converting enzyme 2 (ACE2) receptor [1]. Renal injury may persist beyond the acute phases of COVID-19. Huang et al found that 35% of patients demonstrated decreased glomerular filtration rate at follow up, as did 10% of patients with no evidence of AKI in the acute illness setting [1].

Further research is needed to determine the duration of COVID- induced kidney injury, and it has been recommended that patients who develop AKI in the setting of SARS-CoV-2 infection receive medical follow-up for at least 2–3 months to monitor renal function [8].Although COVID-induced renal injury is unlikely to be diagnosed in the perioperative setting, Anesthesiologists should continue to pay careful attention to clinical and biologic markers of renal function when evaluating patients perioperatively. Avoidance of known nephrotoxic agents may be warranted.

4.肾脏方面的考虑

中重度SARS-CoV-2感染常伴有急性肾损伤(AKI)。肾损害的机制包括系统性炎症的肾前影响，以及通过血管紧张素转换酶2 (ACE2)受体对肾脏的直接病毒损伤[1]。肾损伤可能会持续到COVID-19急性期之后。Huang等人发现，随访时35%的患者表现出肾小球滤过率下降，在急性疾病时，无AKI证据的患者中有10%表现出肾小球滤过率下降[1]。

需要进一步的研究来确定COVID引起的肾脏损伤的持续时间，有人建议在SARS-CoV-2感染的情况下发生AKI的患者至少接受2-3个月的医疗随访以监测肾功能[8]。尽管COVID引起的肾脏损伤不太可能在围手术期环境下被诊断出来。麻醉医生在围手术期评估患者时应继续密切关注肾功能的临床和生物学标志物。可能需要避免使用已知的肾毒性药物。

5. Hematologic considerations

Critically ill COVID-19 patients are at particular risk of thromboses affecting all major organs, but patients with mild illness may also be affected. Large vessel ischemic strokes and acute embolic limb ischemia have been reported in young and otherwise healthy patients, at a median 78 days following initial COVID diagnosis [9].

The duration of the COVID-induced pro-thrombotic state is unknown. However, perioperative inflammation and immobility are independent risk factors for venous thromboembolism. Anesthesia providers should be aware of the elevated and possibly compounded risk of thrombosis in surgical patients recovering from COVID-19, and should follow best-practice guidelines regarding thromboprophylaxis in the peri-operative period. “Enhanced Recovery After Surgery” (ERAS) protocols, to facilitate early ambulation and reduce venous thromboembolism risk, may be particularly important.

5.血液系统方面的考虑

COVID-19危重患者的所有主要器官都有血栓形成的风险，但轻症患者也可能受到影响。大血管缺血性中风和急性栓塞肢体缺血在年轻和其他健康患者中都有报道，在最初的COVID诊断后平均78天[9]。

COVID诱导的促血栓状态的持续时间尚不清楚。然而，围手术期炎症和制动是静脉血栓栓塞的独立危险因素。麻醉医师应意识到COVID-19恢复期手术患者血栓形成的风险升高，并应遵循关于围手术期血栓预防的最佳实践指南。启动“术后快速康复”(ERAS)方案，以促进早期下床活动和降低静脉血栓栓塞风险，可能是特别重要的。

6. Frailty and decreased functional status

Frail patients have decreased physiologic reserve and significantly increased risk of postoperative complications [10]. Huang et al reported that 59–81% of previously-hospitalized COVID patients experienced fatigue and muscle weakness 6 months after diagnosis; between 6 and 14% of patients reported decreased mobility [1].

Anesthesiologists should carefully assess each patient’s functional status. If a patient remains de-conditioned following COVID illness, it may be prudent to defer non-urgent procedures. Pre-operative exercise programs, shown to reduce complications in frail patients [10], should be considered.

6.虚弱和功能状态下降

体弱患者生理储备下降，术后并发症风险显著增加[10]。Huang等人报告说，59-81%的既往住院的COVID患者在诊断后6个月出现疲劳和肌肉无力；6-14%的患者报告活动能力下降[1]。

麻醉医师应仔细评估每个病人的功能状态。如果患者在COVID疾病后仍然处于不适状态，推迟非紧急手术可能是谨慎的做法。应该考虑术前锻炼计划，该计划被证明可以减少体弱病人的并发症[10]。

7. Conclusion

Even beyond the acute crises of the COVID-19 pandemic, millions of people worldwide remain at risk for long-term sequelae of SARS-CoV-2 infection. Anesthesiologists must be prepared to recognize and safely manage these residual effects of COVID-19 infection.

7.总结

即使在COVID-19大流行的严重危机之外，全球仍有数百万人面临SARS-CoV-2感染的长期后遗症的风险。麻醉医师必须做好识别和安全管理COVID-19感染后遗症的准备。

Disclosure

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors report not proprietary or commercial interest in any product mentioned or concept discussed in this article.

信息披露

这项研究没有从公共、商业或非营利部门的资助机构获得任何特定的资助。作者报告在本文中提到的任何产品或讨论的概念中没有专有或商业利益。

参考文献

[1] Huang C, Huang L, Wang Y, et al. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. The Lancet.

[2] Davido B, Seang S, Tubiana R, de Truchis P. Post-COVID-19 chronic symptoms: a postinfectious entity? Clin Microbiol Infect 2020;26(11):1448–9.

[3] Aghagoli G, Gallo Marin B, Katchur NJ, Chaves-Sell F, Asaad WF, Murphy SA. Neurological involvement in COVID-19 and potential mechanisms: a review. Neurocrit Care 2020:1–10. https://doi.org/10.1007/s12028-020-01049-4.

[4] Mitrani RD, Dabas N, Goldberger JJ. COVID-19 cardiac injury: implications for long-term surveillance and outcomes in survivors. Heart Rhythm 2020;17(11): 1984–90.

[5] Huang L, Zhao P, Tang D, et al. Cardiac involvement in patients recovered from COVID-2019 identified using magnetic resonance imaging. JACC Cardiovasc Imaging 2020;13(11):2330–9.

[6] Torres-Castro R, Vasconcello-Castillo L, Alsina-Restoy X, et al. Respiratory function in patients post-infection by COVID-19: a systematic review and meta-analysis. Pulmonology. 2020. https://doi.org/10.1016/j.pulmoe.2020.10.013. S2531-0437 (20)30245-2.

[7] Hull JH, Lloyd JK, Cooper BG. Lung function testing in the COVID-19 endemic. Lancet Respir Med 2020;8(7):666–7.

[8] Nadim MK, Forni LG, Mehta RL, et al. COVID-19-associated acute kidney injury: consensus report of the 25th acute disease quality initiative (ADQI) workgroup. Nat Rev Nephrol 2020;16(12):747–64.

[9] Fan BE, Umapathi T, Chua K, et al. Delayed catastrophic thrombotic events in young and asymptomatic post COVID-19 patients. J Thromb Thrombolysis 2020: 1–7.

[10] Howard R, Yin YS, McCandless L, Wang S, Englesbe M, Machado-Aranda D. Taking control of your surgery: impact of a Prehabilitation program on major abdominal surgery. J Am Coll Surg 2019;228(1):72–80.

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