Guidelines: Anaesthesia in the context of COVID-19 pandemic☆☆☆

Objectives The world is currently facing an unprecedented healthcare crisis caused by the COVID-19 pandemic. The objective of these guidelines is to produce a framework to facilitate the partial and gradual resumption of intervention activity in the context of the COVID-19 pandemic. Methods The group has endeavoured to produce a minimum number of recommendations to highlight the strengths to be retained in the 7 predefined areas: (1) protection of staff and patients; (2) benefit/risk and patient information; (3) preoperative assessment and decision on intervention; (4) modalities of the preanaesthesia consultation; (5) specificity of anaesthesia and analgesia; (6) dedicated circuits and (7) containment exit type of interventions. Results The SFAR Guideline panel provides 51 statements on anaesthesia management in the context of COVID-19 pandemic. After one round of discussion and various amendments, a strong agreement was reached for 100% of the recommendations and algorithms. Conclusion We present suggestions for how the risk of transmission by and to anaesthetists can be minimised and how personal protective equipment policies relate to COVID-19 pandemic context.


INTRODUCTION
The outbreak of COVID-19 (SARS-CoV-2) has been spreading globally outside the first Chinese outbreak since January 2020 and the World Health Organization (WHO) declared a pandemic situation on March 11, 2020. The epidemic situation has led to a drastic reduction in hospital activities. The evolution of the pandemic allows us to resume some of these activities. Beyond this resumption, the persistence of the virus defines a new situation that will have to be taken into account for the care of patients in the coming months.
The size and type of activities that will resume depend on many factors outside the organisation of care within our establishments. These factors include the availability of personal protective equipment, anaesthesia/critical care drugs, and critical care beds. Finally, it seems important to point out that the epidemic situation is fluctuating not only in time but also in space, so it will be necessary to modulate the recommendations according to the region of exercise and the incidence of COVID-19 cases.
We need to organise access to this care by meeting a dual imperative: 1) providing access to quality care for patients whose procedures cannot (or can no longer) be postponed, and 2) limiting the risk of contamination of these patients and healthcare professionals.
The choice of specific measures to be implemented for the management of a patient in this context will be guided by the risk associated with the patient and the risk associated with the procedure.
The persons at risk of serious forms of COVID-19 are:  people aged 70 years and over (although people aged 50 to 70 years should be monitored more closely);  people with a history of cardiovascular disease: complicated high blood pressure, history of stroke or coronary artery disease, heart surgery, NYHA stage III or IV heart failure;  insulin-dependent diabetics who are unbalanced or have secondary complications;  people with chronic respiratory disease that may decompensate for a viral infection;  people with morbid obesity (body mass index > 30 kg/m 2 ).
 Concerning the risk related to surgery, two situations have been identified:  surgery with a high risk of contamination of caregivers by aerosolisation of SAR-CoV-2 (intervention with opening or exposure of the airways: lung resection surgery, ENT surgery, neurosurgery of the base of the skull, rigid bronchoscopy);  major surgery, with a high risk of postoperative critical care stay, where the perioperative respiratory risk inherent to surgery and anaesthesia is likely to be increased by SAR-CoV-2 infection or even porting.

Purpose of the recommendations
The objective of these guidelines is to produce a framework to facilitate the partial and gradual resumption of intervention activity in the context of the COVID-19 pandemic. The group has endeavoured to produce a minimum number of recommendations to highlight the strengths to be retained in the 7 predefined areas. The basic rules of universal good medical practice in perioperative medicine were considered to be known and were therefore excluded from the recommendations.

Fields of the recommendations
The recommendations made concern 7 fields: to the drafting of the recommendations to adopt a format of expert opinion. The recommendations were then drafted using the terminology "experts suggest doing" or "experts suggest not doing". Proposed recommendations were presented and discussed one by one. The aim was not to necessarily arrive at a single, convergent expert opinion on all the proposals, but to identify points of agreement and points of divergence or indecision. Each recommendation was then evaluated by each of the experts and subjected to an individual rating using a scale ranging from 1 (complete disagreement) to 9 (complete agreement). The collective rating was based on a GRADE grid methodology. In order to validate a recommendation, at least 70 per cent of the experts had to express a favourable opinion, while less than 20 per cent expressed an unfavourable opinion. In the absence of validation of one or more recommendations, the recommendation(s) was/were reformulated and submitted again for scoring with the aim of reaching consensus. The experts' synthesis work resulted in 51 recommendations. After one round of scoring, a strong agreement was reached for 100% of the recommendations and algorithms. In order to protect them during this pandemic, strict safety measures should be implemented. These measures should be carried out all throughout the patient's healthcare pathway: preanaesthetic assessment, operating theatres, recovery rooms, intermediate care units and critical care units.
These safety measures will be implemented directly by providing healthcare professionals with adequate PPE, but also indirectly by supplying patients with the right equipment.
Administrative measures (patient information, preoperative laboratory testing, check-up modalities, anaesthesia modalities, dedicated healthcare pathways, patient and surgery selection), which also help protecting staff members, will be detailed in the following/other chapters.
Staff members should apply strict social and physical distancing measures when not caring for patients (team rounds, discussions about patients, hand-offs, breaks, meals...): they must keep at least 1 to 2 meters apart from one another, especially during times when wearing a mask is not possible.

R1.2.1 -Experts suggest that all patients coming in for a preanaesthetic assessment perform hand disinfection
using alcohol-based hand sanitiser and put on a surgical mask type II/IIR when entering a hospital. This also applies to kids for whom fitted masks should be provided.

R1.2.2 -During preanaesthetic assessment, experts suggest performing hand hygiene using
Page 11 of 57 J o u r n a l P r e -p r o o f 11 alcohol-based hand sanitiser before and after every contact with the patient or his surroundings, in addition to wearing a surgical mask type II or IIR and eye protection (goggles) during any clinical examination which requires the patient to take off his mask.  Setting up a safety distance in addition to specific physical distancing devices (like temporary plexiglass barriers, interphones…) for those whose work position requires them to be in physical proximity to other people. These devices should be cleaned frequently, following the same cleaning procedures that are used on other surfaces;  Removing magazines, documents and other commonly used objects from waiting rooms and common areas, including children's toys;

Rationale
During this COVID-19 pandemic, every patient could potentially be contaminated and should therefore protect other patients and hospital staff by applying alcohol-based hand gel and wearing a surgical mask type II or IIR. [1][2][3] By blocking large droplets, surgical masks protect staff members from droplet and contact transmission. 4 Surgical masks can provide protection for healthcare professionals against droplet transmission within a one-meter radius of the patient. Four RCTs compared the efficiency of N95 or FFP2 masks and surgical masks in healthcare workers performing non aerosol-generating procedures. 5-8 A meta-analysis including these studies reported no significant difference in the occurrence of viral respiratory infections (RC 1,06; 95% IC 0, 25) between the 2 types of mask. 9 Only one study specifically evaluated coronaviruses and reported no significant difference between the 2 types of masks in non-aerosol generating procedures. 6 1.3. Operating theatre 12 R1.3.1 -Experts suggest that healthcare professionals involved in airway management (intubation, extubation, supraglottic airway insertion and/or removal…), or those who could be brought to do so in some given situations, wear a fit tested respirator mask (Respirator N95 or FFP2 standard, or equivalent) in addition to a disposable face shield or at least, in the absence of the latter, safety goggles, regardless of the patient's COVID-19 status (Table 1)

Rationale
There is a great risk of becoming infected during airway management. Therefore, strict safety measures should be applied during aerosol-generating procedures such as bag mask ventilation, endotracheal intubation, open/endotracheal suctioning and extubation. The use of a respirator FFP (filtering face piece mask) type 2 is recommended by the French Society of Hospital Hygiene (SF2H) and the French-Speaking Society of Infectious Disease for all healthcare professionals manipulating the airway. 10 Respirators are tight fitting masks, designed to create a facial seal that protect the person wearing them from droplets and airborne particles inhalation.
However, wearing this type of mask can bring more discomfort than wearing a surgical mask (overheating, Page 13 of 57 J o u r n a l P r e -p r o o f 13 respiratory resistance...). They have the advantage of blocking at least 94% of aerosol particles (total inward leaking < 8%) and are more effective than surgical masks type II/IIR in blocking < 5 µm particles. 11 Nonetheless, a poorly fitted N95 or FFP2 respirator does not protect more than a surgical mask. A leak test must be performed systematically. Furthermore, a beard (even a stubble one) reduces the mask's adherence to the face and thus decreases its global efficiency.
In case of N95 or FFP2 respirators shortage, some experts suggested using N99 or FFP3 respirators which block at least 99% of aerosol particles (total inward leaking < 2%). However, the problem with these respirators in that the air is most often exhaled through an expiratory valve without being filtered. They do not filter the wearer's exhalation, only the inhale. This one-way protection puts others around the wearer at risk, in a situation like COVID-19.
COVID-19 can also be transmitted by aerosol contact with conjunctiva 12 and lead to a respiratory infection. 13 The fact that unprotected eyes increase the risk of transmission has been demonstrated with coronaviruses. 14 Face shields provide a barrier against high velocity aerosol particles and are commonly used as alternatives to safety goggles as they provide greater face protection. 15 Using a droplets simulator loaded with influenza viruses (mean droplet diameter: 3.4 µm) and a breathing simulator, it was demonstrated/shown that the use of a face shield reduces the risk of aerosol inhalation by 70%. 16 When spraying fluorescent dye (particle diameter = 5 µm) from a distance of 50 cm towards a mannequin head equipped with an N95 respirator and a face shield, no contamination was noted in either nostrils nor eyes nor mouth folds. The same researchers found that using safety goggles in combination with an N95 respirator did not prevent some eye contamination. 17 Face shields also contribute to sparing N95 or FFP2 respirators by limiting their contamination with aerosol projections. N95 or FFP2 respirators can be used for up to 8 hours.

R1.4.4 -Experts suggest maintaining a minimal one-meter distance between each patient in recovery rooms
during the pandemic period, and a minimal distance of 7-8 meters if an extubation is performed in the recovery room.

Rationale
Whenever possible, in order to spare N95 or FFP2 respirators and to protect staff members and other patients, extubation should be performed in the operating theatre by the person who performed the intubation. If this is not possible, the same precautions should be taken in the recovery room for staff protection. In the latest World Health Organization (WHO) recommendations for COVID-19, health care personnel and other staff are advised to maintain a one-meter distance away from a person showing symptoms of disease. 19 The Centre for Disease Control and Prevention recommends a two-meters separation. 20 However, these distances are based on estimates of range that have not considered the possible presence of a high-momentum cloud carrying the droplets long distances Recent work has shown that exhalations, sneezes and coughs emit turbulent multiphase flows that can contain pathogen-bearing droplets of mucosalivary fluid. 21 When sneezing or coughing, these droplets/gas clouds can travel in the air for up to 7 to 8 meters. 22 This new understanding of respiratory emissions dynamics has implications on social distancing strategies during the COVID-19 pandemic. Similarly, swabs taken from air exhaust outlets in COVID+ patients' rooms were found to contain RNA fragments, suggesting that small virus-laden droplets may be displaced by airflows. 23 However, in this study, no viral culture was done to demonstrate virus viability. For these reasons, extubation should remain exceptional in the recovery room, and giving out surgical masks type II/IIR to patients after their extubation is essential.  Administration of nebulised treatment by a device other than vibrating membrane nebulisers. R1.5.3 -When the patient's COVID-19 status is unknown, experts suggest using a closed suction system for tracheal suctioning. If this system is unavailable, it is necessary to interrupt the patient's ventilation during suctioning, ideally with the help of a second operator.

Rationale
Respiratory droplets are the main source of contamination in healthcare professionals. 2 During aerosol-generating procedures, there is a consensus on the efficiency of N95 or FFP2 respirators (see questions 1.3) and the wear of protective gear such as a fluid resistant long-sleeved gown or a combination of a conventional gown and a plastic apron. 10, 24 The number of asymptomatic patients carrying the virus is high 25 , which is why caregivers should systematically use protection during high-risk procedures. 10,24,25 1.6. Paediatric particularities R1.6.1 -Experts suggest allowing only one parent to be present during kids' preanaesthetic assessment.

R1.6.2 -Experts suggest that all clinical anaesthesia personnel wear a surgical mask type II or IIR, safety goggles
and gloves, when performing any procedure with a high transmission risk, particularly when examining the oral cavity. R1.6.3 -Experts suggest wearing an N95 or FFP2 respirators, a head cap, a gown with an apron, gloves and a face shield or, failing that, protective goggles, when performing airway procedure in children who are awake in the recovery room, regardless of their COVID status.

Rationale
During this COVID-19 pandemic, applying enhanced safety measures for the paediatric population is justified due to the existence of a significant proportion of possibly asymptomatic COVID+ children (up to 16% depending on the series) and the likely difficulty in complying with social distancing and safety measures (difficulty of continuous wearing of the surgical mask) by children. [26][27][28] These findings imply that anaesthesia staff should wear a surgical mask type II/IIR, protective goggles (or a face shield) and gloves when performing any procedure with a high risk of transmission, and particularly when examining the oral cavity during anaesthesia consultation.

BENEFIT AND RISK OF OPERATING, AND PATIENT INFORMATION
R2.1 -In asymptomatic patients, during a COVID-19 pandemic, experts suggest evaluating the benefit/risk ratio of the intervention according to criteria related to the patient, the pathology and the procedure ( Table 2).

Rationale
The circulation of SARS-CoV-2 in the population and the existence of asymptomatic carriers affect the risk-benefit ratio of performing a planned surgical procedure during the COVID-19 pandemic and require rigorous evaluation.
This consideration must integrate three types of criteria related to the patient, the pathology and the procedure.
The data in the literature, although heterogeneous and with a low level of evidence, identify several patientrelated risk factors for serious forms of COVID-19 potentially associated with an increase in postoperative complications: ASA class, obesity, age (> 65 years, < 1 year), underlying respiratory (asthma, COPD, cystic fibrosis) or cardiovascular (hypertension, coronary artery disease and chronic heart failure) pathology, obstructive sleep apnoea syndrome, diabetes, and immunosuppression. 29,30 This increase in perioperative risk is, however, offset by the potential deleterious effect of cancelling or postponing the procedure on the patient. 31 The loss of chance in the absence of intervention must be estimated and the effectiveness and availability of therapeutic alternatives (curative or waiting) explored. Finally, two types of factors related to the surgical procedure must be considered: resource utilisation and the risk of transmission of CoV-2-SARS to the healthcare team. Surgical time and expected length of stay provide an indication of the staff and hospital resources required. For each intervention, the foreseeable use of postoperative management in a critical care area must be anticipated in order to adapt surgical activity to the supply available at the time. Transfusion needs must also be assessed due to the difficulties of public access to blood donation collection points. The number of personnel required must be taken into account as it increases the risk of contamination of the health care team due to the impossibility of complying with the recommendations for intraoperative distancing. Finally, the risk related to the type of anaesthesia and the type of surgery must be evaluated. Upper airway management has been identified as a high-risk event for potential transmission of the aerosolised airway secretion virus that persists several minutes after the procedure. 32,33 The same risk is observed for upper aerodigestive tract and thoracic procedures. Finally, the risk related to the surgical site must take into account the probability of postoperative mechanical ventilation, the consequences of which could be aggravated in the context of an infection, or even portage, with SARS-CoV-2.

Rationale
During the preanaesthetic consultation, detailed information must be provided to the patient and/or his/her legal representative about the perioperative strategy decided regarding his specific situation in the context of COVID-19 pandemic. The message must be clear, objective and based on the currently available data, while trying to be reassuring for the patient and/or his legal representative. This message must be given orally during the consultation but also disseminated through a document (established and validated by each structure), which can be given to the patient and/or his legal representative during the preoperative consultation (surgical or preanaesthetic). This information must appear in the medical record. In the appendix, based on current data, we propose examples of model documents (Appendix 1, 2 and 3). In the event of cancellation or postponement of the intervention, it is essential to keep in touch with the patient, mostly through the surgical teams, and to reassess the possible alternatives and the feasibility of the procedure according to the evolution of the circumstances. If the decision of postponement or cancellation of the surgery is taken by the patient, it must be recorded in the medical record.

Rationale
The use of a standardised questionnaire increases the completeness of the symptom collection and the reproducibility of the medical examination. It is an appropriate tool for collecting accurate information from a large number of subjects. The data collected are easily quantifiable and traceable. The essential qualities of such a questionnaire are acceptability, reliability and validity. The questions must be formulated to be understood by the largest number of patients, without ambiguity, and be based on validated items. Because of the wide variety of symptoms attributable to the SARS-CoV-2, the questionnaire should be designed to look for the most frequent symptoms (fever, dry cough, etc.) and/or the most evocative ones (anosmia, ageusia, etc.), without however declining all the unusual symptoms that have been reported in the literature. An example of a standardised questionnaire distinguishing between major and minor symptoms is proposed for adults in the Appendix #4 and for children in the Appendix #5.

R3.1.2 -In adults and children, the experts suggest searching systematically symptoms compatible with a SARS-
CoV-2 infection at the minimum during the preanaesthetic consultation/teleconsultation and during the preanaesthetic visit. Whenever possible, searching symptoms during a phone call with the patient or his legal representative 48-72 hours before the intervention is also recommended to avoid a last-minute postponement of surgery.

Rationale
Assessment of specific perioperative risk during the COVID-19 pandemic requires, as in the usual situation, the joint consideration of the surgical, patient and anaesthetic risks. In addition, searching usual and/or evocative symptoms of SARS-CoV-2 infection is an important time of the preanaesthetic consultation in the current pandemic context and during the first months following the easing of the lockdown. The presence of major (i.e., very frequent or relatively characteristic) and/or minor (i.e. more inconsistent and/or less specific) symptoms allows to orient the preoperative COVID-19 status assessment, and then to estimate the benefit/risk balance of maintaining or postponing the surgery, taking into account the risk of contamination of health personnel and others patients within the care structure. 34 The integration of these different risks must be collectively weighed against the potential consequences of postponing or cancelling a scheduled intervention. 31 This search for symptoms compatible with a SARS-CoV-2 infection must take place at the time of the preanaesthetic consultation in order to discuss the postponement of the intervention, if possible, and to anticipate the protective measures that should be applied for the health personnel, and the care circuit that should be used. The questionnaire can be completed by the patient himself, by a nurse just before the consultation or by the anaesthesiologist during the consultation. Then, it must be explained that the patient must immediately contact the anaesthesia team, without waiting for admission to the hospital, in case one or more symptoms compatible with a SARS-CoV-2 infection appear between the preanaesthetic consultation and the day of the intervention. It will also be necessary to explain the importance of the strictest compliance with protective measures, particularly hand-washing and wearing systematically a face mask outside home, between the preanaesthetic consultation and the day of the intervention. If the local organisation allows it, a contact with the patient 48 to 72 hours prior to its admission to the hospital, to ensure that no symptoms have appeared, can also be planned. This timeframe can be adapted locally, the objective of this contact being to have a PCR performed and its results available before coming to the hospital for surgery if the patient has become symptomatic since the preanaesthetic consultation. However, taking into account that the delay between the preanaesthetic consultation and the intervention may correspond to the incubation period of the disease, and that spontaneous reporting by the patient of the onset of symptoms since the consultation will not be systematic nor exhaustive, the search for these same symptoms must be systematically renewed during the "physical" preanaesthetic visit the day before or on the day of surgery.

Rationale
Fever, although non-specific, is a very common symptom of symptomatic SARS-CoV-2 infections, present in 75% to 95% of cases. [35][36][37][38] The presence of fever is a major symptom and an important warning sign that should raise the suspicion of a possible SARS-CoV-2 infection during the current pandemic.
However, since the sensation of fever is highly imperfectly correlated with the temperature objectively measured, 39 it is suggested that patient's temperature should be measured during the preanaesthetic consultation. In addition, antipyretic drug intake should also be systematically collected at the same time as the temperature measurement because acetaminophen (or even NSAIDs when taken as self-medication by the patient) can normalise the patient's temperature. As the delay between the pre-anaesthetic consultation and the intervention may correspond to the incubation period of the disease, an objective measurement of the patient's temperature must be renewed during the preanaesthetic visit the day before or on the day of the intervention. (Figures 1 and 2) for the preoperative COVID-19 status assessment and perioperative strategy before scheduled or emergency surgery.

Rationale
These 2 algorithms are the result of a work that tried to take into account a maximum number of clinical situations in a maximum number of structures, while trying to keep it simple. If local provisions, linked to access to diagnostic tests, to the typology of patients, to the prevalence of the virus in the geographical area concerned, or to an agreement between the different specialties at the local level, have led to propose a local algorithm different from those proposed, we suggest that the local algorithm may take precedence over those proposed here.  If the patient presents with signs compatible with a SARS-CoV-2 infection but that the PCR is negative, the evocative paraclinical signs are absent, the CT-scan shows no signs of SARS-CoV-2 viral pneumonia, and the serology performed after at least 7-10 days of symptoms is negative, a differential diagnosis is then the most likely, and the intervention will be postponed until this other pathology has recovered. In a completely asymptomatic patient, a distinction should be made between: 1) surgeries with opening or exposure of the airways (ENT surgery, thoracic surgery, oral surgery, surgery of the base of the skull, rigid bronchoscopy, etc.) for which there is a significant risk of aerosolisation for the operating theatre staff, motivating the realisation of a PCR even in an asymptomatic patient as long as the virus is circulating in the population; and 2) surgeries for which a SARS-CoV-2 infection could have serious postoperative consequences, thus motivating PCR testing. These surgeries can probably be summed up as "major" surgeries (open-heart surgery, major abdominal or pelvic surgery, organ transplantation, etc.), particularly due to their frequent respiratory impact, since the risk of synergy between SARS-CoV-2 and perioperative lung injury is not known. To date, this preoperative screening for COVID-19 indicated by the type of surgery is based on PCR and there is no indication to perform a thoracic CT scan in this context.
In these two situations, the PCR will ideally be performed in the 24 hours preceding the intervention, at most 48 hours, in order to have an idea of the viral carriage as close as possible to the high-risk procedure while taking into account the time required to obtain the results in each structure in order to have them available before the intervention.
Finally, non-major surgeries in an asymptomatic patient can be performed in a conventional non-COVID-19 circuit. 46 If possible, it is suggested that the close contacts of these patients (such as the immediate neighbours in the postoperative recovery room) should be traced to facilitate contact tracing if the patient develops symptoms consistent with SARS-CoV-2 infection in the days following surgery.
It should be noted that if the presence of antibodies in the plasma of a convalescent patient 7 to 10 days after the onset of symptoms has been reported, the positivity of the serology is sometimes later (up to several weeks).
In addition, the antibody titre and their neutralising character against SARS-CoV-2 may vary depending on the patient. [47][48][49][50][51][52] Furthermore, diagnostic performances vary greatly depending on the type of kit used in the laboratory. Finally, the neutralising character of the detected antibodies depends on the viral antigens against which the detected antibodies are directed. [47][48][49][50][51][52] Consequently, the only place of serology in the diagnostic strategy to date is in addition to a chest CT-scan and a new PCR sample if the first PCR in a symptomatic patient is negative and the symptoms have been evolving for at least 7 to 10 days. New data may change its place in the diagnostic algorithm in the future, especially if it allows the formal detection of patients who are genuinely cured and protected against re-infection, so that surgery can be performed without risk for the patient and staff.

FOR EMERGENCY SURGERY (Figures 2):
By definition non-deferrable, the surgery has to take place. However, PCR sampling should be performed in symptomatic or mildly symptomatic patients who have had close contact with a COVID-19 patient within the last 15 days, or who themselves have risk factors for severe forms of COVID-19 or are operated from surgery with postoperative respiratory risk. Surgery is performed without waiting for the results. In the case of major surgery, a postoperative surveillance in the intensive care unit (potentially already justified by the complexity of the surgery and/or the patient's comorbidities) may be considered, especially in a symptomatic patient, as a risk of synergy between perioperative lung injury and infection/carry of SARS-CoV-2 cannot be excluded at this time.

R3.1.5 -Paediatric Specificity: In children scheduled for a surgical procedure in a conventional hospital setting, given the large number of asymptomatic forms of CoV-2-SARS infection, experts suggest that a PCR screening test be routinely performed in the hours prior to the procedure (Appendix 6). When the child is scheduled for
an outpatient procedure, the experts suggest that the COVID-19 status should be sought, at a minimum by using the standardised questionnaire (paediatric version, Appendix 5) at the call on D-1. If the interview proves positive, the procedure is rescheduled at least 15 days later. If the questioning does not appear to be interpretable, the child will, depending on the degree of urgency of the procedure, either be rescheduled or hospitalised with a PCR screening test.

Rationale
Severe forms of COVID-19 are uncommon in children compared to adults, with an estimated incidence of resuscitation of 0.6% of symptomatic forms. 53 Clinical manifestations are generally limited to a mild form with fever, myalgia, dry (or productive) cough, runny nose and digestive disorders (nausea, vomiting, diarrhoea, abdominal pain) in 54% of cases. [53][54][55] Finally, more specific to COVID-19 is the presence of anosmia and/or ageusia without nasal obstruction, which are strongly suggestive of this pathology. 1,2 The presence of skin signs such as pseudo frostbite or urticarial elements are also signs suggestive of COVID-19 in children and adolescents. In all cases, the majority of reported paediatric cases are familial in origin and a history of COVID-19 in the family environment should be considered a risk factor for this disease in children, even if the child is asymptomatic. 56,57 Radiological signs are identical to those in adults but are inconsistently found (43% of cases on average) and therefore do not contribute much to the diagnosis in this population. 56,57 The same limitation applies to pulmonary ultrasonography given the lack of studies in the paediatric population. 58 Biologically, the published series show lymphopenia or hyperlymphocytosis associated with increased CRP. 56 It is important to note that recent studies conducted on cohorts of individuals on an epidemiological basis tend to show that for one person expressing the disease, 7 people are asymptomatic, which reflects the limitations of the clinic to screen all potentially contaminating patients (prepublication study 1) [9-10].
Taking into account these elements and the asymptomatic or paucisymptomatic nature of the disease, the problem of the preoperative assessment in paediatrics is above all that of diagnosing this pathology in children, given the risks incurred by caregivers (representing between 3 and 15% of COVID-19 infections) [6], but also that of nosocomial contamination of other patients given the particularly high number of reproductions of this condition (between 2 and 3.5). 56,57 In the same vein, ambulatory surgery should in theory be favoured in order to avoid cases of nosocomial contamination.
It is therefore proposed to perform a PCR test for the virus for each paediatric patient before surgery.

J o u r n a l P r e -p r o o f 23
In the context of the emergency department, PCR is carried out on admission of the child, but surgery can be performed before the results are obtained.

PREANAESTHETIC PATIENT ASSESSMENT
R4.1.1 -During COVID-19 crisis, the experts suggest that telemedicine is an alternative to face-to-face consultation and must be used to reduce patient in-visit.

Rationale
The current outbreak of COVID-19 has placed a heavy burden on global medical systems, particularly with regard to the preoperative assessment of patients for surgery. For all elective surgeries in France and in many countries for major surgery, preoperative physical assessment by physicians had become a standard of care. The current crisis has reduced this possibility because patients should not be exposed to potentially contagious structures. In For patients, prior agreement to carry out a telemedicine evaluation is a mandatory step. It is advisable to send beforehand a guide to prepare the teleconsultation (including: connection modalities, health questionnaire on current treatments, information documents...) to facilitate the smooth running of the consultation. If necessary, a person close to the patient or an interpreter may, if present during the TLC, assist the doctor in carrying data of the clinical examination within the limits of his or her competence. Not all patients desire remote evaluation, and the exact reasons for this have not been elucidated. Patient selection is an important step for virtual preoperative evaluation. For example, patients in whom arranging travel is complicated underwent successful telemedicine preoperative evaluation before oral and maxillofacial surgery with no complications, highlighting this patient population as one in whom remote evaluation may be beneficial. The use of telemedicine preoperative evaluation has been studied in a variety of patient populations. All types of surgery can be performed with telemedicine evaluation but major surgery (cardiac, vascular, thoracic, etc.) and patients with many comorbities or treatment are obstacles to the development of this technique. Similarly, patients must be able to connect to a platform and know how to use the software. Failure to undergo a preoperative anaesthesia evaluation may contribute to day of surgery cancellation, which has a negative financial impact on both patients and hospitals. Up to 25% of day of surgery cancellations are due to inadequate preoperative workup, and it is well established that preoperative clinics reduce risk of such cancellations and delays. With telemedicine, we found a 1.3% last minute cancellation rate, consistent with the international average, in patients who underwent telehealth evaluation as opposed to an in-person visit, thus suggesting an equivalent performance between the 2 evaluation options.
Teleconsultation is carried out using tools that guarantee the security of patient data. It is carried out in conditions that must guarantee : Authentication of the healthcare professionals involved in the procedure; Identification of the patient; Access by healthcare professionals to the patient's medical data required to perform the procedure; Access by the patient to the patient's medical data required to perform the procedure. Informed consent is an important factor in surgery and telemedicine itself is no different.
The evaluation of the practices is advised to optimise these new modalities.

MODALITIES OF ANAESTHESIA AND ANALGESIA
As stated in the introduction, in the context of the COVID-19 pandemic, the resumption of surgical activity is subject to several major limitations: the strain on the supply of certain anaesthesia drugs, the change in hospitalisation capacities, the risk of contamination of healthcare providers and patients and the application, throughout the patient's journey, of the "distancing" principle. In addition, some peculiarities of COVID-19 patients (risk of drug interactions, worsening of the condition, etc.) are to be taken into account.
These limitations lead us to propose an adaptation of anaesthesia procedures. Favour strategies that reduce the exposure of health professionals to a risk of contamination while maintaining optimal safety conditions for the patient is one of the most important objectives. When safety conditions are met (especially for postoperative follow-up), outpatient management should probably be prioritised.

R5.1.1 -In a context of resumption of surgical activity and COVID-19 pandemic, experts suggest that drug-saving anaesthetic strategies (for propofol, midazolam, myorelaxants) should be preferred in adults and children.
R5.1.2 -Experts suggest giving priority whenever possible to regional anaesthesia. Regional analgesia and infiltration techniques should also be considered.

Rationale
Tensions on drug stocks and even shortages of drugs such as propofol, midazolam, atracurium, cisatracurium or rocuronium require the choice of anaesthesia protocol that spares these drugs, which are otherwise subject to quotas.
To do so, the experts propose several principles: -Prefer regional anaesthesia (RA) for anaesthesia and analgesia, rather than general anaesthesia. In the context of -Peripheral and topical local anaesthesia allow postoperative follow-up directly in the room or in a dedicated space, without going through the recovery room in accordance with regulations. This facilitates compliance with distancing measures specific to the current epidemic context. 65 In children, since RA techniques are regularly associated with general anaesthesia or sedation, they do not make it possible to bypass the recovery room.
-When GA is required, inhaled anaesthesia should probably be preferred in this context to intravenous targetcontrolled anaesthesia.
-Monitoring of the depth of anaesthesia when possible, and of curarisation may be required in order to best adapt drug dosages. 66 These recommendations apply to both elective and emergency care. In conjunction with the institution's pharmacy, it is important to monitor local stock trends.

R5.2.1 -Regarding airway management during intubation of a COVID+ or highly suspicious patient, the experts refer to the "expert recommendations on the resuscitation management of patients during SARS-CoV-2
epidemics" published by the SRLF-SFAR and to the "airway management principle" sheet, which are also applicable in the operating theatre.

Rationale
During the COVID-19 pandemic period, the intubation of a COVID+ patient in the operating theatre is based on the same rules as those issued in critical care units, due to the risk of spraying of the virus during this risky procedure. In order to minimise the risk of aerosolisation and contamination of personnel, it is necessary to: -Limit the number of staff present in the operating theatre -Avoid ventilating the patient with a face mask during the preoxygenation phase.
-Stop oxygen before removing the bag valve mask.
-Intubate the patient by the most experienced senior using a video laryngoscope -Connect the ventilator after inflating the intubation tube balloon.

R5.2.2 -Experts suggest that rapid sequence induction is preferred for airway management of a COVID+ or
highly suspected patients.

R5.2.3 -The experts suggest performing induction according to usual airway management for a non-COVID
patient.

Rationale
If general anaesthesia is required, the patient's clinical condition and COVID-19 status should be considered in the airway management strategy.
-If the patient is COVID+ or highly suspected: the procedure described by SFAR 46 should be followed with rapid sequence induction and intubation. Special attention should be paid to tracheal extubation with the same barrier precautions as for intubation. This applies to patients under emergency management when the COVID-19 status is unknown. Special attention should also be paid to hand hygiene.
-If the patient is non-COVID or asymptomatic, there is no need to modify usual procedures because of the COVID-19 pandemic. Routine airway management is recommended. If intubation is chosen, conventional induction is recommended according to standard recommendations, with adaptation of the induction sequence according to haemodynamic conditions, drug contraindications, and compliance with fasting conditions and the patient's age.
The frequency of anaphylaxis related to atracurium has been estimated to be 1/22451 administrations. The frequency of anaphylaxis due to fast-acting myorelaxant is about 10 times higher (succinylcholine: 1/2080 and J o u r n a l P r e -p r o o f 27 rocuronium: 1/2499). 67 The severe over-risk of allergy to the patient linked to a rapid sequence induction does not seem to be justified by the sole risk of SARS-CoV-2 contamination of the caregivers, this risk being low when protective measures are well respected (Cf. item 1). Readers are invited to refer to "Guidelines on muscle relaxants and reversal in anaesthesia". 66 In a non-COVID patient, spontaneous ventilation anaesthesia or the use of supraglottic devices such as laryngeal masks is possible.
We insist on the importance during the preoperative checklist to share with the operating theatre staff, in addition to the usual information, the COVID status of the patient which will determine his perioperative circuit and the strategy adopted by the anaesthesia team for airway management.

COVID+ patients are likely to be treated with antivirals. A table of drug interactions with drugs used against SARS-
CoV-2 is available online from the University of Liverpool. 68 A summary is provided below for drugs frequently used in the perioperative period ( Table 3). The hydroxychloroquine has multiple cardiac adverse events, including significant QT prolongation. Combinations with other drugs that prolong the QT interval, frequently used in the perioperative period such as halogenated drugs, droperidol, ondansetron, or hypothermia related to surgery and anaesthesia may increase the risk of developing a serious arrhythmia, such as ventricular fibrillation. The combination of hydroxychloroquine and azithromycin, proposed by some, carries a risk of additive/synergistic QT interval prolongation. ECG monitoring is essential.
In addition, the combination of lopinavir/ritonavir carries a risk of overdosage with amide type local anaesthetics (lidocaine, levobupivacaine, bupivacaine, prilocaine, mepivacaine, ropivacaine), ketamine, midazolam, sufentanil, oxycodone or tramadol due to ritonavir-related cytochrome P3A inhibition, but also to underdosage of propofol and morphine due to increased biotransformation of products metabolised by cytochrome P2C9 and P2C19 or by glucuronidation. Remdesivir, tocilizumab, and interferon beta do not show significant interactions with drugs normally used perioperatively, nor do they have cardiac effects. NSAIDs may be associated with worsening of symptoms during respiratory viruses, with an increased risk of empyema. 70 Despite recent alerts, there is no scientific evidence to date linking NSAID use to the aggravation of SARS-CoV-2 infection. A precautionary principle applies. 71 Thus, in a patient with an established or strongly suspected SARS-CoV-2 infection, the prescription of NSAIDs will be avoided. However, in asymptomatic patients, there appears to be no contraindication to their use if their benefit is established. 72,73 Discontinuation of corticosteroids is not recommended in patients on long-term therapy. 70 Steroid treatment of patients with COVID-19 is controversial and is not currently recommended. 74 The single intraoperative injection of dexamethasone, at the usual recommended doses, does not appear to present an over-risk in the asymptomatic patient.

R5.5.4 -Experts suggest that neuraxial anaesthesia should be preferred for caesarean section. If general
anaesthesia is indicated, experts suggest that rapid sequence anaesthesia be performed regardless of the patient's COVID-19 status.

Rationale
In the context of COVID-19 pandemic, obstetric patients present two particularities.
First, unlike scheduled surgical activities, obstetrical activity in essence cannot be postponed and therefore remained at its usual level at the peak of the pandemic. The organisation of care had to be adapted, with the establishment of specific care channels for women infected with SARS-CoV-2 or suspected of being infected, not only to optimise the care of these women, but also to avoid the contamination of other pregnant women and of caregivers working in maternity wards. These COVID-positive or suspected COVID-positive/non-COVID channels are logically maintained as long as the pandemic persists.

SPECIFIC HOSPITALISATION PATHWAYS
The resumption of surgical activity during the COVID-19 outbreak exposes no-COVID-19 patients and healthcare workers to contamination. The following expert proposals should be discussed within each institution in a collegial manner (Extended Executive Board, Operating Theatre Committee, Healthcare Infection Control Practices Advisory Committee) and lead to protocols that take into account the specific characteristics of each institution (architectural constraints, recruitment) and the local incidence of COVID-19 infection. Appropriate signage has to be applied throughout the specific COVID-19 pathway.

Rationale
In the context of non-COVID patients management in the operating theatre, the aim of this guideline was to avoid both the occurrence of nosocomial SARS-CoV-2 infection 87 and the contamination of caregivers by asymptomatic patients 88 . For any planned surgical procedure, the risk/benefit balance must be discussed in a multidisciplinary manner, given the probably high postoperative morbidity and mortality in this epidemic context. 88 Management of "non-COVID" patients must be considered in a specific pathway. 89 This pathway covers the entire patient's hospitalisation day: from the anaesthesia consultation to discharge from the hospital after surgery, following the guidelines for protection (chapter 1).

R6.2.2 -Experts
suggest that for both adults and children, priority should be given to outpatient treatment and enhanced recovery after surgery as much as possible.

Rationale
In the context of COVID-19 outbreak, outpatient management should be considered and preferred to conventional hospitalisation when feasible. Outpatient management reduces the length of stay, thereby reduces the risk of patient exposure and the risk of contamination in case of asymptomatic infection. 90 Outpatient management of surgical emergencies should be considered whenever possible. 91 Outpatient pathways for resumption of activity during the pandemic period need to consider several points: 1/ the planning and convocation schedules should be staggered to avoid waiting times and gathering of patient; 2/ the use of single or isolated rooms should be preferred to wait or exit lounges; 3/ Limit admissions in the postoperative recovery room must be applied as much as possible, in particular after performing locoregional anaesthesia.
Depending on the local outpatient surgery units, this recommendation may limit the number of patients treated. Finally, waiting areas for companions should be arranged in order to respect the safe distances. 91,92 The number of companions should be limited to one person per patient (adult or child).
In case of conventional hospitalisation, enhanced recovery after surgery should be preferred as far as possible in order to reduce, once again, the length of stay. In the same way, hospitalisation on the day of surgery should be considered if the healthcare institution ensures that there is no risk of infected patient by the COVID-19 (for example by a phone call the day before hospitalisation).

Rationale
The rapidly changing COVID-19 pandemic situation requires a periodic review of the measures taken and an analysis of the clinical, social and economic context derived from each decision.
The resumption of surgical activity will be gradual and spread over time. The objective is to summarise, as a priority and progressively, those activities that prove decisive in limiting the loss of chance for patients awaiting cancer or non-cancer surgery. 93 The gradual deployment of surgical activity in a controlled number of operating theatres will make it possible to achieve efficiency in open operating theatres and facilitate compliance with reinforced hygiene rules to ensure the safety and protection of patients and caregivers.
Experts suggest that public and private facilities agree to propose a common approach to the provision of care adapted to the population and regional conditions of the COVID-19 pandemic.
The pace of rescheduling elective surgery in children and adults will vary according to geographical location, epidemiological pressure, and the possibility of redeploying staff from critical care to operating theatres. Elements to be evaluated for the resumption of surgical activity are the following:  Timing of resumption: There should be a sustained reduction in the rate of new COVID-19 cases in the geographical area concerned for at least 14 days before the resumption of elective surgery. 94  Any resumption must be authorised by the relevant regional and national health authorities.
 Facilities are able to safely treat all patients requiring hospitalisation without the need for a crisis care organisation.
 The facility has an appropriate number of critical and non-critical non-COVID and COVID+ beds, PPE, ventilators, drugs, blood products and all necessary medical and surgical equipment.
The facility has a number of trained and educated staff appropriate to the planned surgical procedures, the patient population and the facility resources. Health care staff fatigue and the impact of stress must be considered in order to perform planned procedures without compromising patient safety or staff safety and well-being.

How to coordinate within each institution the resumption of surgical activity after the end of lockdown?
(Role and operation of the regulation cell)