References: Safety Considerations For Neuraxial Anaesthesia in Parturients With COVID-19

COVID-19 Correspondence - e313
and for vastly less oxygen to be used.10 Furthermore, it will References

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Declarations of interest coronavirus disease 2019. Crit Care Med 2020 April 17.
The authors declare that they have no conflicts of interest. https://doi.org/10.1097/CCM.0000000000004386
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Acknowledgements 1033e9
The authors are grateful to Ruth Benson for suitably resur-
recting the old photographs.
doi: 10.1016/j.bja.2020.05.035
Advance Access Publication Date: 1 June 2020
© 2020 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
Safety considerations for neuraxial anaesthesia in parturients with

COVID-19
Xingxing Sun, Yong Liu and Wei Mei*
Wuhan, China
*Corresponding author. E-mail: [email protected]
Keywords: ACE2; Caesarean section; COVID-19; dural puncture; neuraxial anaesthesia; neurological complications;
SARS-CoV-2; spinal anaesthesia
e314 - COVID-19 Correspondence
EditordNeurological symptoms have been reported in both might be an acceptable alternative. However, general anaes-
severe and non-severe patients with coronavirus disease 2019 thesia can impair the bloodebrain barrier,10 which might
(COVID-19; 36.4%).1 To decide the mode of anaesthesia for facilitate the invasion of SARS-CoV-2 into the CNS. Additional
parturients with COVID-19, one should evaluate neurological studies are necessary to determine the best anaesthetic
symptoms in addition to respiratory symptoms. In recent strategy for patients with COVID-19.
clinical practice in Wuhan, China, neuraxial anaesthesia is
the first and main choice in parturients with COVID-19
undergoing a Caesarean section.2e5 Other than the general
Declarations of interest
benefits offered by neuraxial anaesthesia over general
anaesthesia, an additional advantage of neuraxial The authors declare that they have no conflicts of interest.
anaesthesia for Caesarean delivery in parturients with
COVID-19 is avoidance of airway manipulation and patient
coughing during intubation and extubation, thus reducing
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Hospital, a university-affiliated general hospital in Wuhan Wuhan, China. JAMA Neurol 2020. https://doi.org/10.1001/
with COVID-19 confirmed in 11 parturients (31%). In total, 31 jamaneurol.2020.1127. Advance Access published on April 10
parturients (86%) received neuraxial anaesthesia and five 2. Chen R, Zhang Y, Huang L, Cheng BH, Xia ZY, Meng QT.
(14%) received general anaesthesia.6 Is neuraxial anaesthesia Safety and efficacy of different anesthetic regimens for
safe for COVID-19 patients? Should we reconsider neuraxial parturients with COVID-19 undergoing Cesarean delivery:
anaesthesia because of reported neurological symptoms in a case series of 17 patients. Can J Anaesth 2020; 67: 655e63
these patients? 3. Xia H, Zhao S, Wu Z, Luo H, Zhou C, Chen X. Emergency
Angiotensin-converting enzyme 2 (ACE2) is the functional Caesarean delivery in a patient with confirmed coronavi-
receptor for severe acute respiratory syndrome coronavirus 2 rus disease 2019 under spinal anaesthesia. Br J Anaesth
(SARS-CoV-2)7; it is expressed in the cell membrane of various 2020; 124: e216e8
tissues and organs including lung, small intestine, and brain.8 4. Zhong Q, Liu YY, Luo Q, et al. Spinal anaesthesia for pa-
ACE2 in the brain might provide a mechanism for SARS-CoV-2 tients with coronavirus disease 2019 and possible trans-
to cause neurological symptoms, but the possible invasion mission rates in anaesthetists: retrospective, single-
routes of SARS-CoV-2 remain unknown. Considering the inva- centre, observational cohort study. Br J Anaesth 2020;
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CNS through the olfactory bulb, bloodstream, or peripheral 5. Chen X, Liu Y, Gong Y, et al. Perioperative management of
nerve.9 patients infected with the novel coronavirus: recom-
The neurological symptoms of patients with COVID-19 can mendation from the joint task force of the Chinese society
be divided into two categories: 1) CNS symptoms such as of anesthesiology and the Chinese association of anes-
headache (13.1%), dizziness (16.8%), impaired consciousness thesiologists. Anesthesiology 2020; 132: 1307e16
(7.5%), ataxia (0.5%), acute cerebrovascular disease (2.8%), and 6. Zhou ZQ, Sun XX, Li SY, Wan L, Luo AL, Han DJ. [Anes-
epilepsy (0.5%)1; and 2) peripheral nervous system symptoms, thesia management of cesarean section during COVID-19
such as hyposmia (loss of smell) (5.1%), hypogeusia (loss of pandemic]. Chin J Anesthesiol 2020. https://doi.org/10.3760/
taste) (5.6%), hypopsia (visual deterioration) (1.4%), and neu- cma.j.issn.0254-1416.2020.0006
ralgia (2.3%).1 It is difficult to distinguish between post-dural 7. Zhou P, Yang XL, Wang XG, et al. A pneumonia outbreak
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mechanical injury during dural puncture and neuralgia caused 8. Hamming I, Timens W, Bulthuis ML, Lely AT, Navis G, van
by SARS-CoV-2. Spinal anaesthesia could carry the risk of Goor H. Tissue distribution of ACE2 protein, the functional
introducing virus from blood or tissues into the CSF, which receptor for SARS coronavirus. A first step in under-
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doi: 10.1016/j.bja.2020.05.005
Advance Access Publication Date: 14 May 2020
© 2020 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

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COVID-19 Correspondence - e313

and for vastly less oxygen to be used.10 Furthermore, it will References

Safety considerations for neuraxial anaesthesia in parturients with

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