【Guidelines consensus】Anesthesia response strategies and procedures for emergency trauma surgery during the novel coronavirus epidemic

Huang Yuguang (co-author), Ma Hong (co-author), Cao Xuezhao (co-author), Gong Yahong (co-author), Liu Cunming, Wei Xinchuan, Gu Xiaoping, Xue Jixiu, Wang Jun, Wang Sheng, Lu Zhijie, Dai Ruping, Wang Yun, Yu Chunhua, Pei Lijian

Trauma is the third leading cause of death and disability in humans, with more than 5 million people dying from severe trauma each year and likely to exceed 8 million
by 2020.
With the international pandemic of COVID-19, most hospitals in severely affected countries are postponing elective surgeries in order to focus medical resources on treating COVID-19 patients and reducing nosocomial infections
.
However, emergency surgeries often cannot be postponed, and some surgeries are urgent, making screening for COVID-19 and infection prevention and control difficult
.
Although the domestic epidemic situation is improving, the epidemic is spreading globally, and imported cases are still increasing
.
With the gradual implementation of the resumption of work and production across the country, emergency surgery, especially trauma surgery, will increase
day by day.

During the pandemic, patients undergoing emergency trauma surgery included both patients with a complete COVID-19 diagnosis ruled out and patients in hospital
with confirmed and suspected COVID-19 。 However, as the epidemic progressed, the epidemiological history of COVID-19 showed that the role was significantly weakened; The incubation period of COVID-19 is extended, up to 24 days; Viral mutations, an increased proportion of asymptomatic infections, and short preparation time for preoperative evaluation in emergency trauma patients, often accompanied by elevated body temperature, increased breathing and heart rate in the early stages, make preoperative COVID-19 screening and diagnosis difficult
.
Therefore, avoiding cross-infection during emergency trauma surgery during the pandemic remains an important and arduous task [1].


With reference to the guidance of the National Health Commission's "Diagnosis and Treatment Plan for Novel Coronavirus Pneumonia (7th Edition)" and the "Recommendations on the Management and Prevention and Control Process of Routine Surgical Anesthesia during the COVID-19 Epidemic" of the Chinese Society of Anesthesiology, the Trauma and Emergency Anesthesiology Group of the Chinese Medical Association and the Youth Committee of the Chinese Society of Anesthesiology Branch have formulated the response strategies and procedures for anesthesia for emergency trauma surgery during the novel coronavirus epidemic.
Provide guidance
for timely and effective treatment of emergency trauma patients.

1.
Preoperative assessment and preparation for anesthesia for emergency trauma surgery patients during the epidemic

1.
Pre-anesthesia assessment of emergency trauma surgery patients

Trauma patients need to be quickly and effectively assessed, treated, and treated in the shortest possible time, so rapid COVID-19 screening and preoperative evaluation are critical
.
During the epidemic period, it is recommended to conduct preoperative evaluation through electronic medical records or online for ASA grade I-II patients, and for ASA grade III-IV patients, it is recommended to visit patients in person for preoperative evaluation of anesthesia
.
In areas with small-scale sporadic outbreaks, lung CT scan and viral nucleic acid testing are recommended for patients with suspected emergency trauma with epidemiological history or clinical symptoms; In areas where the epidemic has not been effectively controlled and confirmed cases continue to grow, lung CT scanning, routine blood testing and viral nucleic acid testing, as well as IgM antibody and IgG antibody testing are recommended for all emergency trauma patients ^[2], and those who cannot undergo lung CT scan due to critical condition should be treated as suspected patients until new coronavirus infection is excluded; In epidemic areas, it is recommended that all emergency patients should undergo comprehensive COVID-19 screening, and if possible, all emergency general anesthesia surgeries, medical staff should appropriately strengthen the level of protection to avoid infection of medical staff caused by asymptomatic infections
.
Due to the low sensitivity of SARS-CoV-2 nucleic acid detection in throat swab specimens, bronchoalveolar lavage specimens can be considered after intubation (positive rate 93%), and the results may better guide postoperative treatment
.
If the serological test of the suspected case is positive for coronavirus-specific IgM antibodies and IgG antibodies; Serum new coronavirus-specific IgG antibodies change from negative to positive, or the recovery period is more than 4 times higher than that of the acute stage, and new coronary pneumonia
can also be diagnosed.
Emergency trauma surgery
is performed in a negative pressure operating room with tertiary protection for suspected and confirmed COVID-19 positive patients.
Patients with negative preoperative COVID-19 screening but a history of epidemiology and suspicious symptoms should also have an increased level
of protection.
At the same time, with the development of the epidemic, some patients have mild onset symptoms, no fever (only 43.
8% of patients showed fever symptoms in the early stage), or the incubation period is prolonged (up to 24 days), so the clinical identification
of asymptomatic COVID-19 patients should be strengthened.
At the same time, attention should be paid to the differentiation of pulmonary contusion images from COVID-19 lung images in trauma patients, and vigilance should be paid to the combination
of both.
Special attention should be paid to emergency trauma care for patients with severe COVID-19, or patients with mild disease who develop severe disease after their condition worsens during emergency trauma treatment
.
Preoperative identification of high-risk groups for severe disease is beneficial to reduce the occurrence of poor prognosis ^[3].

The treatment of patients with severe trauma needs to be treated against the clock, and during the epidemic, the patient's condition and treatment
must not be delayed.
The anesthesia procedure for emergency trauma surgery is shown in Figure 1
.

Figure 1

Remark:

1.
If there are multiple suspected and confirmed cases at the same time, the relatively more critical patients will be given first, and the negative pressure operating room will be vacant and disinfected for 30min after the end of the operation, and then the next operation will be performed;

2.
If the medical institution does not have a negative pressure operating room, the operation of patients with suspected and confirmed COVID-19 trauma can be performed in the ordinary operating room, but the purification air conditioning system should be turned off;

2.
Staffing and protection of anesthesiologists

During the epidemic, the preoperative preparation of anesthesia for emergency trauma surgery should follow the "principle of safe rescue", and carry out emergency trauma surgery under the premise of ensuring the safety of medical staff, so as to achieve the purpose of treatment and avoid the infection of rescue personnel and the pollution
of hospital equipment and environment to the greatest extent.
Anesthesia is performed jointly by one senior attending physician or above and another junior anesthesiologist, and one anesthesiologist is arranged to assist
in the buffer zone (outside the operating room).
For patients with ASA class III-IV or expected difficult airways, it is recommended to have 3 anesthesiologists to administer anesthesia, including assistance in the preparation of difficult airway tools.

The protection of medical personnel is implemented
in accordance with the Technical Guidelines for the Protection of Medical Personnel during the COVID-19 Pandemic (Trial).
Because endotracheal intubation and monitoring and support throughout the procedure allow for prolonged close contact with the patient, anesthesiologists must administer anesthesia under tertiary protection ^[4].

Wearing protective equipment should be supervised and guided by a professional infection control doctor or nurse on site, and only after confirming that it is qualified can enter the operating room for anesthesia
.
For details of the prevention of different areas of anesthesiologists, please refer to the regional graded protection specifications during the new crown pneumonia epidemic in the operating room of the anesthesiology department of Peking Union Medical College Hospital (Figure 2).

It should be noted that tertiary protective equipment will reduce the visual, auditory and tactile functions of anesthesiologists, affect the accuracy and success rate of anesthesia operations, and even reduce the sensitivity of anesthesiologists to changes in patient vital signs monitoring
.

Fig.
2 Regional graded protection specifications during the new crown pneumonia epidemic in the operating room of the anesthesiology department of Peking Union Medical College Hospital

3.
Operating room and item preparation

Emergency trauma surgery
is performed using routine procedures for patients temporarily excluded from coronavirus infection.
For patients who cannot be excluded, appropriate personal protective equipment should be worn, surgery should be carried out in the negative pressure operating room (set up contaminated area, buffer zone, clean area), open the purification and negative pressure system 30min before surgery, and show a negative pressure value below -5Pa in the operating room before surgery ^[5].

A "new crown" warning sign
is hung outside the operating room.
During the procedure, the operating room door must be kept closed and the number of
people entering and exiting must be restricted.
Streamline people and goods
in the operating room.
Necessary equipment, such as computers, anesthesia machines, and telephones, should be covered with disposable plastic wrap
.
The patient's preoperative preparations are done
in the negative pressure operating room.
During the operation, the contents of the negative pressure operating room only enter and exit
.
Adequate medications and fluids should be prepared before surgery and placed away from the surgical area
.
For patients with COVID-19 who cannot be excluded, do not use a central suction system, and a conventional electric aspirator
is recommended.

2.
Anesthesia management of emergency trauma surgery patients during the epidemic

1.
Anesthesia-induced intubation for emergency trauma patients

During the pandemic, all emergency patients wore masks without exhalation valves at all times, except
during intubation.
In patients with emergency trauma, cervical spine and airway injuries and difficult airways
should be evaluated prior to anesthesia-induced intubation.
Patients with suspected or confirmed COVID-19 may have co-respiratory distress and/or hypoxaemia (respiratory rate> 30 breaths/minute, oxygenation index <150 mmHg), and the time tolerated by hypoxia at anesthesia induction is significantly shortened<b12>.
Therefore, it is recommended that experienced anesthesiologists perform rapid induction intubation under visual laryngoscopy to shorten the intubation time and increase the success rate
of one intubation.

The specific process of airway management for patients under general anesthesia can refer to the "Expert Recommendations for the Safe Implementation of Tracheal Intubation in Critically Ill Patients with COVID-19"
written by the Airway Management Group of the Anesthesia Branch of the Chinese Medical Association.
The vast majority of emergency patients, especially trauma patients, who have insufficient time for fasting water, recommend rapid sequential induction intubation, use ring cartilage compressions at the time of induction and ensure adequate muscle relaxation conditions to avoid coughing during intubation ^[6].

Compression of the annular cartilage should be done with caution in patients with suspected or confirmed COVID-19 as it may cause pharyngeal reflexes, and its role in preventing aspiration remains controversial
.
Inducing drugs can choose propofol (1-2.
5 mg/kg) combined with rocuronium bromide (3-4 times ED95), such as choosing etomidate and opioids (fentanyl and sufentanil) for anesthesia induction, choosing the principle of muscle relaxant preinjection, and giving small doses of muscle relaxants first to avoid patients holding their breath or choking
.
Etonomidate can be used in patients with hemorrhagic shock, but it has immunosuppressive effects and should be used
with caution in patients with COVID-19.
Positive pressure-assisted ventilation should be avoided as much as possible after induction, and if assisted ventilation is required, small tidal volume assisted ventilation
is recommended.
In patients who cannot exclude COVID-19 and cannot be auscultated, the location of
endotracheal intubation should be determined by observing chest undulations and end-expiratory carbon dioxide waveforms.
In difficult airways, guidelines for difficult airway management should be
followed.
For anticipated difficult airways, clear bronchoscopic intubation is recommended; If the patient is at risk of an urgent airway, cricothyrotomy is performed directly or tracheostomy by an otolaryngologist
.
For patients with preoperative traumatic shock, appropriate vasoactive agents should be prepared prior to anesthesia induction to correct hemodynamic fluctuations
during induction.

2.
Anesthesia method selection

For patients with suspected or confirmed COVID-19, it is recommended to choose the most familiar and time-saving anesthesia according to the patient's condition, trauma extent, and surgical modality: regional block anesthesia is preferred for patients with limb injury, and general anesthesia
for endotracheal intubation is recommended for patients with other trunk trauma, combined shock or multiple injuries, acute abdomen, who have used high-flow oxygen, mechanical ventilation, or have other indications for endotracheal intubation due to COVID-19.
Patients with COVID-19 can cause acute liver and kidney injury due to viral infection, hypoxia, and shock, so the dose
of anesthetic drugs should be adjusted appropriately.
For patients with severe trauma, the anesthesia to the start of surgery is shortened as much as possible, saving time
.
Patients with regional block anesthesia can be given nasal cannula oxygen + surgical mask coverage
.
It should be noted that it has recently been discovered that the new coronavirus may also infect the central nervous system, and the new coronavirus nucleic acid has been detected in the cerebrospinal fluid of patients, and the new coronavirus has also been found in the brain tissue of autopsies ^[7-8].

It has also been clinically found that some new coronavirus patients have symptoms similar to intracranial infection such as headache, epilepsy, and impaired consciousness ^[6].

Clinically, coagulopathy occurs in nearly 20 percent of patients with COVID-19, and almost all severe and critical patients have coagulopathy ^[9], so neuraxial anesthesia should be selected as contraindications
.

Drugs widely used to target COVID-19 can interact
with narcotic drugs.
Some animal studies suggest that chloroquine increases the severity of neuronal apoptosis and memory impairment induced by sevoflurane anesthesia ^[10].

There is also evidence that taking lopinavir-ritonavir significantly increases placental metastasis of the bupivacaine isomer during caesarean section epidural ^[11].

Therefore, it is recommended to have a detailed preoperative medication history and pay particular attention to the side effects of COVID-19 treatment and possible interactions
with anesthetics.
In addition, there is speculation that ACE inhibitors and NSAIDs may worsen infection
.
However, these drugs
cannot be strictly avoided clinically.

3.
Anesthesia monitoring

Patients with mild emergency trauma are monitored with basic noninvasiveness, including ECG, blood pressure, central temperature, pulse oximetry, and exhaled CO2 monitoring, and urine output
.
Exhaled CO2 monitoring can assist in determining catheter location
during an outbreak.
Invasive surveillance, including direct arterial pressure, central venous pressure, and pulmonary artery wedge pressure, should be used for patients with severe trauma and/or severe
COVID-19.
COVID-19 is characterized by severe impairment of lung function, and intraoperative monitoring of lung compliance, airway pressure, oxygenation index, and arterial blood gas analysis should be strengthened to guide the implementation
of intraoperative lung protection strategies.
If patients with new coronavirus pneumonia have coexisting acute myocardial damage, renal injury and inflammatory response, it is recommended to perform myocardial troponin, echocardiogram, renal function analysis, C-reactive protein and other tests to optimize myocardial oxygen supply and demand balance, renal function management and anti-inflammatory management in time ^[12].

4.
Management during anesthesia

Emergency trauma patients require prompt and prompt treatment to avoid the triad of hypothermia, acidosis, and coagulopathy
.
Patients are treated with surgical hemostasis, volume resuscitation, coagulation monitoring and management, temperature monitoring and protection, and thromboprophylaxis
.

(1) Injury control surgery

The new coronavirus infection causes immune dysfunction, which is mainly manifested as a comprehensive decrease in immune function and impaired
function of multiple organs.
Immune dysfunction also occurs in the body after trauma
.
If infection occurs, it may lead to complications such as sepsis and multiple organ dysfunction syndrome, so emergency surgical anesthesia should follow the principle of
injury control.
During the pandemic, emergency surgery for trauma patients should be limited to injury control procedures of a resuscitation nature, including: (1) a prehospital score (PHI≥) of 4 for blunt injury patients; (2) unstable vital signs of thoracic and abdominal penetrating injuries; (3) External bleeding
that is difficult to control.
Specifically, there are abdominal organ injury, tension or open pneumothorax, cardiac tamponade, massive hemothorax, severe craniocerebral injury, cerebral herniation, and other serious injuries [^3].

(4) Severe surgical emergencies that occur during hospital treatment of suspected or confirmed COVID-19 patients, such as perforation of internal organs, obstruction, etc
.
The concept of injury control surgery should be strictly followed, the surgical operation should be streamlined, and the operation time
should be shortened as much as possible.

(2) Hemodynamics and volume management

Perioperative systolic blood pressure (SBP) in emergency trauma patients should be controlled at 80-90mmHg or mean arterial pressure (MAP) should be controlled at 50~60 mmHg; In the presence of head injury, SBP is controlled at approximately 100 to 110 mmHg at resuscitation ^[13].

Goal-oriented fluid therapy recommends avoiding hypovolemia or hypervolemia
.
Uncontrolled bleeding is the leading controllable cause
of death in trauma patients.
Rapid bleeding control in patients with active bleeding is the primary prerequisite for
circulatory stability.
In patients with incomplete bleeding control, injury control resuscitation strategies should be followed to maintain target blood pressure
with fluid therapy and vasoactive agents, in addition to ensuring smooth breathing and adequate oxygenation.
When giving blood transfusions to patients undergoing emergency trauma, volume, oxygen, and hemostatic function
should be considered.
Allogeneic transfusion may cause circulatory overload and lung injury, and caution should be
exercised during transfusion.
Red blood cell infusions are based on
maintaining an adequate oxygen supply, lactate levels, and mixed venous oxygen saturation.
Blood products
should be transfused based on coagulation test results.
During the epidemic, patients suspected of COVID-19 can collect blood samples in the emergency department, fill in the "blood application form" and prominently mark "new crown suspected", etc.
, and inform the staff on duty of the blood transfusion department by phone to initially estimate the blood components and blood consumption
required.
During the epidemic, blood sources are in short supply in various places, and various blood protection measures should be taken during surgery to reduce the need
for allogeneic blood transfusion.

The timing of fluid therapy for emergency trauma patients is divided into two stages
: early and late, based on whether active bleeding is controlled or not.
In the early stage, restrictive fluid resuscitation was the mainstay, and if necessary, vasoactive drugs were combined to maintain perfusion of heart, brain and other organs; In the later stage, based on the principle of goal-oriented circulation management, the crystalloid solution, colloidal solution and blood components (concentrated red blood cells, fresh frozen plasma, platelets or fibrinogen, etc.
) were reasonably matched ^[13].

The pros and cons
of delayed resuscitation should be balanced clinically.
If bleeding cannot be identified in time and stopped in time, timely resuscitation is required to ensure adequate tissue perfusion
.

In the process of fluid resuscitation, if MAP persists below 50 mmHg, or MAP persists in patients with emergency trauma with severe head injury is less than 80 mmHg, vasoactive drugs can be used under fluid resuscitation and continuous blood pressure monitoring to raise blood pressure to meet the blood flow perfusion of important organs such as the heart and brain [13], and norepinephrine is recommended, and the usual dose is 0.
01 to 1.
0 μg/(kg·min).

。 In the early stages of hemorrhagic shock, cardiac function assessment or cardiac output monitoring is usually not available, and if the patient is not responsive to fluid resuscitation or vasopressor therapy, cardiac insufficiency
should be considered.
If available, rapid cardiopulmonary ultrasound screening is recommended, and once cardiac insufficiency is diagnosed, inotropes such as epinephrine, dobutamine
are required.

The new coronavirus binds to ACE2 receptors ^[14], and some patients with hypertension and COVID-19 may have abnormally elevated blood pressure, increasing the risk of
cerebral hemorrhage 。 Angiotensin-converting enzyme inhibitors (ACEs) and angiotensin II receptor blockers (ARB) antihypertensive drugs may increase ACE2 receptor expression, and although evidence-based evidence is lacking, we recommend stopping ACE inhibitors and ARB antihypertensive drugs preoperatively to avoid affecting blood pressure control in patients with COVID-19 and hypertension, and calcium channel blockers to control blood pressure
perioperatively.
Some COVID-19 patients have inflammatory reactions or even acute myocardial damage, and perioperative hemodynamic monitoring should be strengthened to avoid volume overload and increase cardiopulmonary burden
.

(3) Respiratory management

Since the main organ affected by the new coronavirus is the lung, the lung manifests as varying degrees of consolidation, and mucus plugs are formed in the bronchi in the lungs, so patients diagnosed with COVID-19 have hypoxemia
.
Coexisting pulmonary contusions are also common in patients with emergency trauma, so perioperative strategies for lung-protective ventilation are recommended to reduce the risk of
mechanical ventilation-related lung injury.
Intraoperative monitoring of lung compliance, airway pressure, oxygenation index, and arterial CO2 partial pressure should be strengthened to guide the implementation of
intraoperative lung protection strategies.
The Diagnosis and Treatment Protocol for Pneumonia Infected with Novel Coronavirus (7th Edition) recommends the use of lung-protective ventilation strategies, i.
e.
, small tidal volume (6-8 ml/kg ideal weight) and low airway platform pressure (≤ 30 cmH_2O) for mechanical ventilation to reduce ventilator-related lung injury ^[4]; Permissible hypercapnia; When ensuring that the airway platform pressure ≤ 35cmH₂O, high PEEP can be appropriately used to maintain airway warmth and humidification; According to the airway secretion, choose closed suction; Ventilatory manoeuvres with renewed lung radiance 3-5 times per hour; Avoid prolonged anesthesia, wake up the patient early and perform pulmonary rehabilitation
.
To reduce virus contamination of anesthesia machines and to retain heat and moisture in the breathing circuit, high-efficiency particulate air filters
should be installed between the mask and the breathing circuit and at the expiratory end of the breathing circuit.
Fulminant inflammation of the lungs caused by the novel coronavirus can cause severe interstitial edema, so controlling inflammation and stress response and limiting fluid management can also help protect
lung function.

(4) Coagulation management

About one-third of trauma patients arrive at the emergency department with coagulopathy
.
Anesthesiologists should monitor and maintain normal
coagulation as soon as possible in patients with severe trauma, especially those with suspected or confirmed COVID-19 trauma.
Prevention and timely detection of acute traumatic coagulopathy
.
Volume resuscitation and anti-shock therapy are themselves part of the prevention and treatment of
acute traumatic coagulopathy.
The real benefit of transfusion may be to gain time for stopping bleeding and not blindly pursuing hemoglobin levels
.
Routine coagulation monitoring includes prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen, and platelet count, and should guide the management
of coagulation based on composite measurements.

Improvement of coagulation
as soon as possible in trauma patients.
For patients with major bleeding or at risk of major bleeding, tranexamic acid (1 g intravenously within 10 minutes) should be used as soon as possible within 3 hours of injury, and repeated within 8 hours
.
During massive transfusions, calcium concentrations should be monitored and maintained within the normal range
.
For trauma patients, attention should be paid not only to the number of platelets, but also to platelet function
.
Fibrinogen concentrate or cryoprecipitate
is recommended if bleeding is evident and thromboelastography is manifested as functional fibrinogen deficiency or plasma fibrinogen levels below 1.
5 to 2.
0 g/L.
The decision to continue the infusion
is based on thromboelastogram results and fibrinogen levels.

(5) Body temperature management

During the epidemic, it is necessary to strengthen the monitoring and management
of patients' body temperature.
Concern should be given to both elevated temperature in patients with suspected or confirmed COVID-19 and perioperative temperature drop
in patients with emergency trauma.
Hypothermia may cause acidosis, coagulopathy, and microcirculation disorders
.
In patients with head injury, mild hypothermia may reduce mortality and improve neurological recovery remains controversial
.
Therefore, body temperature monitoring should be strengthened and appropriate insulation measures
should be given.

(6) Tracheal extubation

Extubation
in the operating room was requested during the pandemic.
During extubation, the number of
healthcare workers should be limited.
For extubation of new coronary pneumonia patients, medical staff should take level 3 protection, and for non-new crown pneumonia patients, take level 1 or 2 protection
.
Try to avoid choking
during extubation.
Prophylactic intravenous lidocaine, dexmedetomidine, or refentanil can be given to reduce coughing during extubation
.
Before extubation, the patient's respiratory secretions should be cleaned in advance under deep anesthesia to avoid agitation and choking
caused by immediate cleaning of the airway before extubation.
If the patient is at risk associated with difficult extubation, the laryngeal mask can be used or taken directly back to the intensive isolation unit
.
For patients with severe new coronary pneumonia, it is recommended to return to the ICU isolation ward with a tracheal tube to continue treatment
.

(7) Thrombosis prevention

The incidence of thrombosis in patients with multiple trauma is as high as 50%, and pulmonary embolism is the leading cause
of death in patients who survive more than 3 days.
The acute inflammatory response caused by the COVID-19 virus can affect coagulation and fibrinolytic function through a variety of pathways, including decreased levels of circulating protein C and antithrombin-III.
, upregulation of plasminogen activator inhibitor-1 levels, and other factors, ultimately leading to the activation of the coagulation cascade and the inhibition of the fibrinolytic process
, thereby further promoting thrombosis.
Therefore, perioperative thromboprophylaxis is an important measure
to optimize the treatment of emergency trauma patients, especially COVID-19 trauma patients.
Intermittent pneumatic compression devices (IPCs) and/or antithrombotic stockings may be used to prevent thrombosis in trauma patients
.
Low molecular weight heparin also has a significant effect
on preventing blood clots.
For the prevention of proximal deep vein thrombosis or pulmonary embolism, low molecular weight heparin is more effective than the antithrombotic effect
of intermittent pneumatic compression devices.
However, it should be noted that low molecular weight heparin is mainly excreted through the kidneys, so it may accumulate in patients with renal insufficiency
.

(8) Improve postoperative analgesia

During the pandemic, ultrasound-guided nerve blocks, local incision infiltrates, and non-opioid and technology-based multimodal analgesia
such as NSAIDs are recommended.
Appropriate doses of kappa receptor agonists may also be selected for postoperative visceral pain
.
When using NSAIDs for analgesia, it should be noted that patients with severe or critical COVID-19 may have coexisting liver and kidney damage and coagulation dysfunction, and the indications and contraindications
of NSAIDs should be strictly mastered.
When using opioid analgesia, attention should be paid to adjusting the dose to prevent respiratory suppression from aggravating the already impaired lung function of COVID-19 patients, and to avoid hypoxia and_CO2 accumulation
.

(9) Prevention and treatment of postoperative nausea and vomiting (PONV).

In order to avoid the risk of exposure and infection between healthcare workers and patients due to PONV in patients with COVID-19, more attention should be paid to the prevention and treatment
of patient PONV.
We suggest a multimodal prevention strategy based on patient risk factors (female sex, nonsmokers, history of motion sickness, and postoperative opioid use) ^[15].

With 1 risk factor, anti-nausea and vomiting drugs
can be used without prophylactics.
In patients with two or more risk factors, a combination of dexamethasone and 5-HT3 blockers is recommended for intravenous anesthesia and multimodal postoperative analgesia
with non-opioid and technology.

3.
Special treatment after surgery

Terminal disinfection must be carried out after all suspected patients in the operating room or after the same-day operation, including the table and buttons of the anesthesia machine; The external breathing circuit of the anesthesia machine and the disposable laryngeal lenses, tracheal tubes, suction tubes, threaded tubes, masks, balloons and filters involved in them should be disposed of in medical garbage bags after use; It is recommended that the breathing circuit in the anesthesia machine be docked and disinfected (the disinfection method refers to the disinfection instructions of each anesthesia machine).

The disinfection situation is inspected and recorded by the infection control team for retrospectiveness
.
Medical staff take off protective equipment in strict accordance with the requirements of procedures, and be supervised and guided by professional infection control physicians or nurses on site, and protective clothing should be discarded in place or double-layered yellow garbage bags, wrapped and placed in designated areas
.

4.
Anesthesia and nursing staff carry out follow-up and management
after surgical anesthesia for patients with suspected/confirmed emergency trauma.

After contacting patients suspected / confirmed surgery for new coronavirus infection, if symptoms such as fever or cough and fatigue appear, please check blood routine and lung imaging in time; At the same time, report to the department and isolate at home or
medically.
A special person in the department is responsible for registering the observation cases of medical staff, tracking and observation every day, and reporting to the medical department of the hospital for further diagnosis and treatment ^[16].

Available data indicate that 17 to 30 percent of infected people are asymptomatic, so all health workers should practice social distancing in restaurants, rest areas, and offices ^[17,18].

In summary, the "safe rescue principle" should be followed when administering anesthesia for emergency trauma surgery during the COVID-19 pandemic, in which screening to rule out COVID-19 is central
.
Emergency screening
is performed by moving the emergency gate forward.
To exclude patients with COVID-19, emergency trauma surgery is performed as usual; For patients whose COVID-19 cannot be excluded, tertiary protection is used for emergency trauma surgical anesthesia
.
After surgery, closely monitor the patient's body temperature, blood routine and other laboratory tests, and review lung CT and throat swab nucleic acid and serum IgG/IgM if
necessary.
Trauma patients need prompt and timely treatment, and through comprehensive strategies such as timely surgical hemostasis, volume resuscitation, coagulation monitoring and management, temperature monitoring and management, and thromboprophylaxis, trauma patients should avoid the triad of hypothermia, acidosis, and coagulopathy
.
Only by strengthening the protection of medical staff and patients, and improving all aspects of preoperative assessment, intraoperative and postoperative management, can we ensure the safety of anesthesia for emergency trauma surgery patients during the epidemic and accelerate their recovery
.

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Estimating the asymptomatic proportion of coronavirus disease 2019 (COVID-19) cases on board the Diamond Princess cruise ship, Yokohama, Japan, 2020.
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2020; 25:2000180.