General Anesthesia for Pediatric Radiotherapy in the Era of COVID-19

PURPOSE/OBJECTIVE(S): Managing pediatric patients (pts) requiring daily general anesthesia (GA) for radiation (RT) in the setting of COVID-19 is complex, due to both the aerosolizing nature of GA procedures and the risk of cardiopulmonary complications for infected pts. We hypothesized that deliberate management of pts requiring GA for RO during COVID-19 would allow safe operations to continue. MATERIALS/METHODS: Pediatric pts treated under GA at our tertiary hospital from 3/1/2020 to 1/29/2021 were identified; development of COVID-19 precautions began on 3/1/2020. Pts underwent COVID testing prior to their first treatment and thrice weekly (MWF) during treatment. Pts were accompanied by only one designated adult caregiver through the entire RT course; caregivers were verbally screened; and staff personal protective equipment (PPE) included surgical mask and eye protection. For COVID+ pts, RT was delivered at the end of day; a negative pressure room was used for GA induction and recovery; staff PPE included N-95 masks or powered air purifying respirators (PAPRs); and separate physician/nurse teams were designated for in-room vs. out-of-room pt management. RESULTS: 78 pediatric pts received RT under GA (vs. 69 pts over the same prior-year timeframe). From 3/1/2020-1/29/2021, mean age was 4.9 y (range 5.5 m - 19.0 y), 41/78 (52.6%) were male, and 2/78 (2.6%) received 2 courses of RT under GA, for a total of 80 courses. 24/80 (30.0%) courses were delivered to the chest, abdomen, and/or pelvis, 21/80 (26.3%) craniospinal axis, 17/80 (21.3%) brain, 9/80 (11.3%) total body irradiation, 5/80 (6.3%) head/neck, and 4/80 (5%) other. 64/80 (80%) of courses were delivered with curative intent. 39/80 (48.8%) used proton therapy, 18/80 (22.5%) photons, and 23/80 (28.8%) both modalities. Mean number of treatment fractions was 22.2 (range 1-40). 2/78 pts (2.6%) tested positive for COVID-19, both asymptomatic. Early in the pandemic (4/2020), pt 1 (a 3 yo female with neuroblastoma) had simulation delay for known household contact; after 5 weeks, COVID testing returned positive after the first day of RT. A 2 d treatment interruption was required to finalize institutional COVID guidelines, and treatment continued without incident. Because eye protection was not yet routinely used early in the pandemic, 17 staff were quarantined, but no further staff exposures occurred after precautions for the positive test were implemented. Later in the pandemic (1/2021), pt 2 (a 3 yo male with relapsed medulloblastoma) tested positive on initial COVID testing, requiring 10 d of COVID precautions for treatment; no staff exposures occurred. No caregivers screened positive, and no children presented for treatment without the designated parent. CONCLUSION: With careful multidisciplinary planning to mitigate COVID-19 risk, pediatric RT with GA was carried out for a large pt volume without widespread infection, and without increased toxicities from either GA or RT. Frequent pt COVID testing and attention to PPE limited staff exposures.