A 54-year-old man, 169 cm tall and weigh 56 kg, was diagnosed with gastric ulcer by gastroscopy at the Luoyang Hospital after presenting with epigastric pain in January 2020. Black stool and epigastric pain occurred on March 10, 2020. The patient, however, did not pay enough attention and did not receive any treatment. Hematemesis occurred at the Beijing railway station in the afternoon on March 13, 2020. The patient was transferred to our emergency room by ambulance as soon as possible. According to the epidemiologic investigation, there was one case of confirmed COVID-19 infection in the village where the patient lived. He had direct contact with that person. The patient did not cough and had no fever. Routine blood examination showed that white blood cell (WBC) count was 8.08 × 109, of which lymphocyte accounted for 0.72 × 109. Chest CT showed that the two lungs had diffuse ground glass opacity with exudative lesions. A COVID-19 nucleic acid test on a throat sample was negative. The COVID-19 expert group concluded that the patient could not be completely ruled out of COVID-19 infection. In the emergency room, the patient spat out a large volume of blood, and his blood pressure dropped. After surgical consultation, it was assumed that the patient had active gastric bleeding and needed an emergency operation. After reporting to the Beijing Center for Disease Control and Prevention (CDC), we prepared for surgery, treating the patient as a suspected case.
We prepared an operating room for infected patients. Such an operating room should have a negative pressure airflow. The Anesthetists and other medical staff wore protective gear before contacting the patient. This included wearing washed clothes inside, N95 mask, disposable surgical cap, goggles or protective screen, C-class protective clothing outside, double latex gloves, and shoe covers. The patient was covered with a single operation sheet before being transported to the operating theater. The patient wore a medical protective mask without a breathing valve throughout the process.
The anesthesia process
On entering the operating room, the heart rate of the patient was 98 beats per minute (bpm), invasive arterial blood pressure was 88/54 mmHg, and peripheral oxygen saturation (SpO2) was 96%. Radial artery blood-gas analysis showed: pH 7.32, hemoglobin (Hb) 78 g/L, and partial oxygen pressure (PaO2) 76 mmHg. We removed the patient’s N95 mask for oxygen inhalation before anesthesia induction, and connected an artificial nose to a anesthesia respiratory pathway in advance. The drugs of anesthesia induction were midazolam 2 mg, sufentanil 20 µg, etomidate 0.2 mg/kg, and rocuronium 1.2 mg/kg. When the patient lost consciousness, he was intubated with a visual laryngoscope. There was no noticeable coughing during intubation. The intubation equipment was immediately placed inside a double-layer sealed bag to be sterilized or discarded after the operation. Then the right internal jugular vein was punctured and catheterized for blood and fluid transfusion. Continuous mechanical ventilation was initiated with a tidal volume of 8 mL/kg after general anesthesia was achieved. Target controlled infusion (TCI) of propofol and remifentanil was given for anesthesia maintenance and adjusted according to the Bispectral Index (BIS). Muscle relaxants were added according to the Train of Four (TOF), and the Stroke Volume Variation (SVV) was used to guide fluid therapy. During the operation, we transfused 800 mL of red blood cells and 400 mL of plasma. After the operation, the patient was transferred to the intensive care unit (ICU) of the isolation ward with the endotracheal tube in place.
The patient was extubated two hours after entering the ICU. Before extubation, two pieces of gauze were placed over his mouth to reduce the spatter caused by coughing. After extubation, the vital signs of the patient were stable, and he was transferred to the general surgical isolation ward 24 hours later. All doctors and nurses involved in the operation were placed under medical observation for two weeks, with their temperatures and other symptoms recorded by a person dedicated for the task. A second COVID-19 nucleic acid test of the patient was performed the next day, and fortunately, it turned out to be negative as well. The COVID-19-specific IgM and IgG antibody test seven days later was also negative. The COVID-19 expert group ruled out infection of COVID-19 on March 20, 2020, and all doctors and nurses involved in the case were relieved from medical observation.