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Anesthesia Considerations of a Pregnant Woman With COVID-19

Undergoing Cesarean Delivery: A Case Report

Article · July 2020

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COVID-19 Resources
Anesthesia Considerations of a Pregnant Woman
With COVID-19 Undergoing Cesarean Delivery:
A Case Report
Jennifer L. Harenberg, MS, CRNA
Robert Church, DNP, CRNA
Tito D. Tubog, DNAP, CRNA
Physiologic changes during pregnancy may increase
the risk of coronavirus disease 2019 (COVID-19) infec-
tion. Limited data show serious complications of
COVID-19 infection and pregnancy. Severe adverse
maternal and perinatal outcomes such as preterm
delivery, intensive care unit admission, and neonatal
and intrauterine death have been reported. Our knowl-
edge of the epidemiology, pathogenesis, disease pro-
gression, and clinical course of COVID-19 is continually
changing as more information and evidence emerge.
The present case adds further insights on COVID-19
and anesthesia considerations for patients undergoing
cesarean delivery. In this case report, we describe a
T
he outbreak of the novel coronavirus disease
2019 (COVID-19) infection has become a
global health crisis. Exposure to this pathogen
predisposes both the mother and fetus to an
increased risk of infection and severe adverse
maternal and perinatal outcomes.1 The physiologic and
immunologic changes during pregnancy increase mater-
nal morbidity and mortality.2 Because current data on
COVID-19 and its impact on pregnancy are not entirely
understood, researchers draw on experiences from previ-
ous coronavirus outbreaks as a guide to infer the severity
of COVID-19 to pregnant women. For instance, during
the 2009 influenza A virus subtype H1N1 pandemic,
infected pregnant women experienced more severe com-
plications compared with the general population.3 Simi-
larly, the case fatality rates for severe acute respiratory
syndrome (SARS) and Middle East respiratory syndrome
(MERS) were significantly higher in pregnant women
compared with nonpregnant women.2 Severe sequelae
such as preterm deliveries, stillbirths, respiratory compli-
cations, and maternal mortality were common during the
SARS and MERS epidemics.2
Case reports show serious complications of COVID-19
infection and pregnancy. Mullins and colleagues4 ana-
lyzed 23 case reports or case series and reported adverse
morbidity to include intensive care unit (ICU) admis-
sions. In the same narrative review, 47% of pregnant
women admitted to the hospital had preterm delivery.
www.aana.com/aanajournalonline AANA Journal
successful spinal anesthetic in a pregnant woman with
confirmed COVID-19. To prepare for the likelihood of
caring for women during labor and cesarean delivery,
anesthesia professionals must know how to provide
safe, patient-centered care and how to protect every
member of the obstetric team from exposure to the
virus. In addition, it is paramount that our profession
shares our experiences and practices to help guide our
multidisciplinary approach in delivering the best care
possible to these women.
Keywords: Anesthesia, cesarean delivery, COVID-19,
pregnancy, spinal anesthetic.
Similar findings were described in a systematic review
and meta-analysis of 19 studies showing that 41% of the
pregnant women infected with COVID-19 deliver prema-
turely at less than 37 weeks.5
There is variability in the rate of cesarean delivery in
COVID-19–infected patients. An analysis of 108 preg-
nancies shows that 91% delivered via cesarean delivery.6
In addition, most women undergoing cesarean delivery
have thrombocytopenia and elevated C-reactive protein,
which may increase the severity of COVID-19 and neuro-
logic complications.7-9 There are known maternal deaths
of patients with COVID-19 due to respiratory complica-
tions after delivery.10 Neonatal and intrauterine death
have been reported in reviews of numerous studies.6,11
Our knowledge of the epidemiology, pathogenesis,
disease progression, and clinical course of COVID-19 is con-
tinually changing as more information and evidence emerge.
The limited knowledge of the impact of COVID-19 on preg-
nant women and the limited clinical experience in managing
COVID-19 in pregnant women pose a potential anesthetic
challenge during labor and delivery. Professional societies
have issued interim guidance regarding the evaluation and
management of pregnant women with COVID-19.12-19
The purpose of this case report is to present additional
information on COVID-19 and anesthesia considerations
for patients undergoing cesarean delivery. In this case
report, we describe a successful spinal anesthetic in a
pregnant woman with confirmed COVID-19.
 August 2020  online content 47
Case Summary
A 34-year-old woman, gravida 2, para 1, presented to the
clinic for a scheduled nonstress test because of her gesta-
tional diabetes and increased body mass index (BMI). At
a gestation of 38 weeks and 5 days, the patient was 147
cm tall and weighed 105 kg, with a BMI of 48 kg/m2. The
patient had gestational diabetes, and her blood glucose
level was controlled with an oral hypoglycemic drug. The
patient had preeclampsia in a previous pregnancy (also
delivered by Cesarean delivery) but had only a few iso-
lated elevated blood pressures (BPs) with this pregnancy.
She had a history of a positive tuberculosis blood test
(Quantiferon-TB Gold Plus, Qiagen) with a normal chest
radiograph in 2019.
During this admission, her chest radiograph showed
probable atelectasis. The patient had no known drug
allergies. Her electrocardiogram (ECG) showed sinus
tachycardia with a rate of 100/min. She had a hemato-
crit of 39% and a platelet count of 156 × 103/μL. At this
scheduled appointment, the patient arrived wearing a
facial mask, and she reported a dry cough with occa-
sional green sputum, nasal congestion, body aches, and
mild headache. All symptoms started 2 days before this
appointment. Her temperature was 37.4 °C, and it was
recommended to send her to the emergency department
(ED) for COVID-19 testing. There, the patient’s nasal
cavity was swabbed to test for the COVID-19 virus. In
the ED, her vital signs were as follows: heart rate (HR)
of 100/min, BP of 158/83 mm Hg, respiratory rate of
23/min, oxygen saturation measured by pulse oximetry
(Spo2) of 97% on room air, and a temperature of 36.1 °C.
She was transferred back to the labor and delivery unit
for observation in case she had more elevated BPs that
would negate delivery.
Eight hours after testing, a positive COVID-19 test
result was reported. Within 4 hours after confirmation of
the positive result, she began contracting uncomfortably,
and assessment of the cervical os showed a 4-cm dilation.
The obstetric team decided to proceed with a cesarean
delivery with bilateral tubal ligation.
After the patient signed an informed consent form,
azithromycin (500 mg) was administered intravenously,
and acetaminophen (1 g) was given orally. At the same
time, the anesthesia machine was prepared with a heat
moisture exchange filter (HMEF) between the breath-
ing circuit and the patient’s airway. The patient was as-
sisted into a wheelchair, a surgical mask was applied, and
she was transported to the operating room (OR). Both
Certified Registered Nurse Anesthetists (CRNAs) and the
labor nurse each donned a yellow isolation gown, regular
gloves (double-gloved), and a standard bouffant cap. The
CRNAs also wore splash shields, N95 respirator masks,
and goggles in the event of airway manipulation.
Standard noninvasive monitors were applied on the
patient’s arrival to the OR. Baseline vital signs were as
48 AANA Journal  August 2020  online content www.aana.com/aanajournalonline
follows: BP of 153/79 mm Hg, HR of 76/min, and SpO2
of 95% on room air. Supplemental oxygen at 2 L/min was
delivered via a nasal cannula under the patient’s surgical
mask. A liter of Ringer’s lactate was infused through an
18-gauge access catheter in the patient’s right hand. The
patient was prepared and draped in the usual fashion,
and the skin was localized with 3 mL of 1% lidocaine
at the L3-L4 interspace after landmarks were identified.
The 24-gauge spinal anesthesia needle (Pencan, B Braun
Medical Inc) was placed via an introducer after the return
of cerebrospinal fluid, with good barbotage. A 1.6-mL so-
lution of 0.75% hyperbaric bupivacaine with fentanyl (15
μg) and preservative-free morphine sulfate (Duramorph,
150 μg) was injected intrathecally. The patient was placed
in a supine position with left uterine displacement. The
sensory block was assessed using pinprick testing. The
surgical incision was started when the sensory level
reached the T4 level and a Bromage scale of 3.
A lower segment cesarean delivery with bilateral tubal
ligation via the Pomeroy technique was performed. The
patient had an estimated blood loss of 700 mL and urine
output of 40 mL, and total intravenous fluids admin-
istered were 1,600 mL. Her high BP was treated with
ephedrine and phenylephrine as necessary.
The patient delivered a viable infant with Apgar
scores of 8 and 9 at 1 and 5 minutes, respectively. After
delivery, oxytocin (40 units) was added to 1 L of lac-
tated Ringer’s solution.
The infant was immediately taken to the neonatal ICU
and was to be quarantined from her parents for 14 days.
The mother was transferred to a negative pressure room.
The OR was disinfected after the procedure, and all anes-
thesia machine breathing circuits were discarded.
Postoperative analgesia was achieved using a standard
morphine (Duramorph) order set, which included up to
6 mg of morphine intravenously each hour. These orders
were in place for 12 hours after the preservative-free
morphine was given intrathecally in the OR. Oxygen
saturation was 96% with 2 L by nasal cannula. She was
started on hydroxychloroquine therapy at 400 mg twice
daily for 1 day and then 200 mg twice daily for 4 days.
She had serial ECGs to monitor QT intervals during hy-
droxychloroquine treatment.
Her postoperative course was uneventful until post-
operative day four, when she became febrile and desatu-
rated to the low 80% level, with new midlung to lower
lung opacities. The patient was eventually placed on
mechanical ventilation support and admitted to the ICU
with the diagnosis of COVID-19–related pneumonia.
In the ICU, the patient was given a 10-day remdesivir
regimen with convalescent plasma and tocilizumab. The
patient was extubated 16 days after the ICU admission.
Discussion
• State of the Art. The SARS coronavirus 2 (SARS-CoV-2)
that causes COVID-19 has been found to be highly
virulent and can be transmitted through droplets from
normal breathing, sneezing, and coughing, and by aero-
solization of bodily fluid discharge.20 Some of the clinical
features associated with COVID-19 include lower respi-
ratory tract infection with fever, dry cough, shortness of
breath, and malaise.20 As the COVID-19 outbreak contin-
ues, it is essential to evaluate the effects of the disease on
special populations, including the parturient.
To date, the case fatality rate for COVID-19 is rapidly
changing. Information from a small number of case
reports or series indicates that the clinical findings of
pregnant women with COVID-19 are similar to those
in nonpregnant women.21 Furthermore, the severity
of the disease in pregnant women is similar to that in
other adults.22 However, reviews of COVID-19 cases in
pregnant women reported severe and critical illness re-
quiring hospitalization and ICU admission.4,23 Although
the exact mechanism of COVID-19 transmission has
not been entirely determined, reputable agencies report
that the virus is spread through droplets.24,25 Hence,
there is a growing concern that pregnant mothers are
at risk because of physiologic changes occurring during
pregnancy. Atelectasis due to the growing fetus and con-
striction of the diaphragm, reduced functional residual
capacity, and increased oxygen consumption are likely
to affect pulmonary reserve and can result in adverse
patient outcomes.26 Intrauterine transmission is a reason-
able concern; however, current evidence suggests vertical
transmission is unlikely.27,28
The anesthesia management of the patient with a
suspected or confirmed COVID-19 infection presents a
major challenge for anesthesia professionals because of
the pathophysiologic and confirmed rapid human-to-
human transmission of the virus through symptomatic
and asymptomatic carriers. As with SARS and MERS, the
most critical goal in the OR is to prevent cross-contam-
ination by implementing stringent anesthesia guidelines
and infection control strategies in the perioperative
setting (Table). The American Association of Nurse
Anesthetists (AANA) published an infographic highlight-
ing anesthesia considerations in managing patients with
COVID-19 infection.29
Pregnant women with suspected or confirmed
COVID-19 should be triaged and their condition cat-
egorized as mild, severe, or critical. Liang and Acharya7
classified a symptomatic patient with stable vital signs
as having a mild case of COVID-19. Pregnant patients
with tachypnea and hypoxemia expressed as a partial
pressure of arterial blood oxygen /oxygen concentration
ratio less than or equal to 300 mm Hg are considered to
have severe cases. Moreover, pregnant women present-
ing with shock and multiorgan system failure requiring
mechanical ventilation have critical cases.
In our case, we employed rigorous contact and air-
www.aana.com/aanajournalonline AANA Journal
borne precautions because of the high transmissibility of
COVID-19. In our department, we allocated an observer
to guide proper donning and doffing of personal protec-
tive equipment (PPE). Sequential steps for donning and
doffing PPE are presented by the Centers for Disease and
Prevention (CDC; https://www.cdc.gov/niosh/npptl/pdfs/
PPE-Sequence-508.pdf). Consistent with strict anesthesia
management in cesarean delivery is the effective use of
personnel. Regardless of the type of cesarean delivery,
the current recommendation outlines the use of the most
experienced provider performing procedures such as
subarachnoid blocks or intubations. Furthermore, the
Society for Obstetric Anesthesia and Perinatology sug-
gests that the anesthesia department minimize the use
of trainees in the room of a patient with COVID-19.14 In
our case, we used 2 CRNAs for 2 reasons. First, one of the
CRNAs was a new hire to the anesthesia department and
was in his second week of orientation as a new graduate
of a nurse anesthesia program. The newly hired CRNA
had less experience than the other provider; however,
he was confident in his neuraxial technique and asked
to be part of the case as a valuable learning experience.
The institution in which this case is presented is a teach-
ing hospital, and thus the culture of education is highly
prioritized. Second, the safety of clinicians was enhanced
through a “buddy system” in the donning and doffing of
PPE. This case was the inaugural COVID-19 case in the
operating suite at this particular institution, so to proceed
as safely as possible, the providers believed that working
together was in the best interest of the patient and all
healthcare workers involved.
The diagnosis of COVID-19 in itself is not a con-
traindication to neuraxial anesthesia.12-19 The safety of
neuraxial techniques in suspected or confirmed cases of
COVID-19 has been documented. The decision to use a
particular anesthetic technique for cesarean delivery is
based on a variety of factors, including risks to the par-
turient or fetus and the skill set of the provider.30 Spinal
anesthesia was preferred to general anesthesia because
the benefits outweigh the risk.31 It is well documented
that regional anesthesia aids in the reduction of pain
scores and opioid consumption, postoperative nausea
and vomiting, and the risk of aspiration and difficult
airway associated with general anesthesia.32 During
tracheal intubation, the risk of transmission of upper re-
spiratory tract infection to healthcare providers is known
to be 6.6 times greater than those not exposed to intuba-
tion.33 Regional anesthesia offers the benefit of avoiding
airway manipulation and instrumentation; this decreases
the chance of coughing and viral aerosolization during
intubation and extubation.34 Besides, the maintenance of
pulmonary function may reduce postoperative complica-
tions in a patient with COVID-19 and associated pneu-
monia or acute respiratory distress syndrome.33
As the number of COVID-19 cases continues to rise
 August 2020  online content 49
 Perioperative Clinical considerations/management of
phase obstetric patients with COVID-19

Prehospital admission • Conduct phone screening before appointment.

• If patient is asymptomatic for COVID-19, proceed with routine prenatal care.
• Perform severity assessment if patient presents in clinic with symptoms.
• For COVID-19 testing, prioritize patients with suspected COVID-19 or those who have signs and
symptoms suggestive of COVID-19.
Preoperative • Isolate patient in negative pressure room.
• All healthcare providers involved in care should wear gown, gloves, N95 mask, and face shield (per
hospital protocol).
• Patient should wear a surgical mask.
• Use hospital’s adopted checklist for donning appropriate PPE. If possible, obtain an observer.
• Order routine laboratory studies and encourage neuraxial anesthesia in absence of thrombocytopenia.
• Avoid general anesthesia to mitigate the risks involved in aerosol-generating procedure.
• Prepare COVID-19 OR kit to avoid contaminating medication station (uterotonic agents,
vasopressors, narcotics for intrathecal administration, and antiemetics).
• Dedicate an OR for patients with COVID-19, to minimize contaminating surfaces.
• Alert necessary staff for backup coverage and assign a runner to retrieve supplies or help if needed.
Intraoperative • Use of spinal anesthesia is not contraindicated for patients with COVID-19 and should be the
preferred method of anesthesia for these patients.
• Follow standard precautions when placing neuraxial anesthetic.
• Avoid excessive or deep sedation to reduce need for any airway manipulation or instrumentation.
• Patient should wear a surgical mask at all times throughout procedure to minimize viral spread.
• If general anesthesia is indicated, all personnel in OR at time of intubation should wear PPE for
airborne precautions.
• Minimize OR to only essential personnel during intubation.
• Preoxygenation should occur with a breathing circuit extension and high-quality filter at the patient
side of the circuit.
• Maximize chance of first-pass intubation by having experienced providers manage airway.
• Use video laryngoscopy if able.
• During extubation, which has a high risk of aerosolization of the virus, minimize personnel in OR
and be sure every healthcare worker is protected with proper PPE.
• The patient should be monitored in OR until safe and before transfer to a COVID-19–designated
room following hospital guidelines.
Postoperative • Use of NSAIDs in the intraoperative and postoperative periods lacks sufficient evidence. It is
unknown if the treatment of postpartum pain with NSAIDs will worsen the trajectory of patients
with COVID-19.
• Administer antiemetics to prevent vomiting in patients undergoing cesarean delivery because
gagging and vomiting are considered aerosolization events.
• Because of potential risks of immunosuppression with corticosteroid use, avoid use of
dexamethasone in this patient population for PONV prophylaxis and treatment.
• Healthcare facilities providing inpatient obstetric care should limit visitors to those essential for the
pregnant woman’s care.
• Encourage use of communication techniques that avoid person-to-person contact, such as phone
calls and videoconference calls.

Table. Current Clinical Obstetric Anesthesia Practice and Preparedness Recommendations for Cesarean
Delivery2,12-19,38
Abbreviations: COVID-19, coronavirus disease 2019; HEPA, high-efficiency particulate air; NSAIDs, nonsteroidal anti-inflammatory drugs;
OR, operating room; PONV, postoperative nausea and vomiting; PPE, personal protective equipment

and as the knowledge of the pathogenicity of the virus sponse is necessary to optimize and provide high-quality
continues to evolve, anesthesia professionals face chal- patient care and to prevent virus transmission in periop-
lenges in the care of laboring mothers and those who erative settings. Professional organizations have outlined
will undergo a cesarean delivery. A coordinated team re- recommendations and guidelines in the delivery of care

50 AANA Journal  August 2020  online content www.aana.com/aanajournalonline

to pregnant patients.12-19 We highlight here the evidence-
based precautionary steps that are vital during the care of
a pregnant and laboring patient with COVID-19.
• Recommendations for Anesthesia Care. Preadmission
screening for potential COVID-19 exposure is conducted
over the phone, and a preanesthesia assessment is done
through video devices. According to the CDC, the
clinical presentation of COVID-19 includes fever, dry
cough, and shortness of breath.24 Other common clini-
cal manifestations of COVID-19 infection are anosmia,
hyposmia, and dysgeusia. In fact, the American Academy
of Otolaryngology-Head and Neck Surgery recommends
the screening of patients who report the loss or reduction
of taste and/or smell.35
Once admitted to the labor and delivery department,
the patient with COVID-19 is placed in a negative pres-
sure room and must be provided a face mask. All per-
sonnel with direct contact with the patient must have
PPE, which include gloves, gown, mask, and face shield
during the first and second stages of labor. Visitation of
family members during labor and delivery is limited and,
in most cases, prohibited. Signage for airborne, contact,
and droplet precautions is adequately posted in specified
locations in the labor and delivery unit.
A dedicated PPE cart is placed outside the patient’s
room for easy access to supplies for labor and delivery
to avoid unnecessary traffic and reduce contamination
of supplies and equipment. A coordinated and multi-
disciplinary approach to maternal and fetal monitoring
ensures patient safety and reduces virus transmission.
Early placement of an epidural block for laboring pa-
tients with active COVID-19 infection is recommended
to mitigate labor pain-induced respiratory sequela and
reduce the likelihood of emergency cesarean delivery.
Labor anesthesia supplies must be easily accessible
and stationed near the labor room to minimize traffic.
Anesthesia professionals and personnel assisting during
placement of a labor epidural anesthetic must wear
necessary PPE for contact and droplet precaution. It is
also essential that the patient wear a surgical mask to
limit droplet spread. Vaginal delivery is recommended in
stable patients because viral shedding during vaginal de-
livery and vertical transmission have not been reported.
If cesarean delivery is necessary, surgery must be
performed in a designated negative pressure OR, and
regional anesthesia is highly recommended. Routine
assessment of platelet count must be conducted before
neuraxial anesthetic placement. In a recent cohort study
of 1,099 patients, Guan and colleagues36 found that 36%
of the patients had thrombocytopenia. In another study,
Lippi et al8 reported a decrease in platelet counts in pa-
tients with severe COVID-19 symptoms. However, no
neurologic sequelae were observed in studies with the
use of the neuraxial technique for cesarean delivery.37,38
In an emergency cesarean delivery that requires
www.aana.com/aanajournalonline AANA Journal
general anesthesia, the staff should implement the appro-
priate infection control procedures.38,39 The anesthesia
machine is prepared with an HMEF between the circuit
and the patient’s airway to avoid the virus from entering
the internal parts of the machine and to subsequently
prevent pathogen transmission to other patients.29 Two
additional high-quality filters can be used on both the
expiratory and inspiratory limbs if supplies of filters are
not limited.29,40 To prepare for these emergency scenar-
ios, we recommend creating an emergency PPE kit that
can expedite the donning process of the providers. These
kits would contain the gowns, face shields, and N95
masks. It is essential to have a variety of styles and types
of N95 masks available in these kits for each provider’s
preference. The use of a donning and doffing checklist is
useful in these emergent situations. All the OR personnel
present for induction should don the appropriate PPE.2,38
If possible, every attempt to minimize personnel in the
OR is recommended.
The most experienced anesthesia provider should be
dedicated to the intubation of a patient with COVID-19.
It might be necessary to have a colleague available for as-
sistance, whether inside the OR or immediately available
outside the room.40 The preoxygenation process should
include an HMEF between the patient and the anesthesia
circuit. A rapid-sequence induction should be performed,
avoiding positive pressure bag-mask ventilation. Video
laryngoscopy is recommended, but it is ultimately the
provider’s decision on which method would take the least
amount of time and would ensure the best possibility for
first-pass success.
Extubation in the OR should be done with limited
personnel present. This process presents increased risk
of viral transmission to others. Placing a face mask on
the patient immediately following the extubation is pre-
ferred. Adequate time must be spent in the OR before
transport to ensure the patient is exchanging air without
distress and has respiratory stability. Every effort of
obtaining a PPE observer in the recovery area should
be made. The risk of transmission is highest during the
doffing of PPE.41 After surgery, the AANA suggests dis-
carding disposable items such as the breathing circuit,
reservoir bag, gas sampling tubing, and mask.29 Cleaning
of internal parts of the machine is not necessary if appro-
priate high-quality filters were used based on the design
of the anesthesia machine.29,40 Furthermore, the AANA
endorses wiping all exposed areas after the procedure
using the anesthesia machine manufacturer’s cleaning
and disinfecting recommendations.29
So far, no data suggest transplacental transmission
of SARS-CoV-2 since no virus has been detected in the
amniotic fluid, cord blood, placenta, breast milk, and
nasal secretions of the neonate. However, there have
been confirmed cases of neonatal infection.2,10,38,42-44
Hence, newborns are separated from the infected
 August 2020  online content 51
mother for at least 2 weeks to reduce transmission.
Findings from COVID-19 cases in pregnant women
are emerging, and recommendations change as new in-
formation is appraised. To prepare for the likelihood of
caring for pregnant women in labor and cesarean deliv-
ery, anesthesia professionals must be equipped with the
knowledge to provide safe, patient-centered care and to
protect every member of the obstetric team from expo-
sure to the virus.
Conclusion
The number of positive COVID-19 cases has now sur-
passed 2.5 million worldwide. As we continue to care for
these patients, we will be faced with more challenging
obstetric cases. There are still limited data on the care
and management of the parturient with COVID-19. It is
paramount that our profession shares our experiences and
practices to help guide our multidisciplinary approach in
delivering the best care possible to these women. Every
health care institution across the world has been working
diligently to educate its employees on the current recom-
mendations that comply with the CDC and other national
organizations that we reference for our practice. Not
only is the care of patients with COVID-19 continually
changing, but also so are the safety precautions that the
anesthesia provider must take. Our national societies have
done an excellent job of educating us with the most recent
updates, such as on PPE,45 to ensure that we are providing
safe anesthesia care as well as keeping ourselves safe.
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AUTHORS
Jennifer L. Harenberg, MS, CRNA, is employed by Texas Wesleyan
University in Fort Worth, Texas, and Denver Health Medical Center in
Denver, Colorado.
Robert Church, DNP, CRNA, is employed by Denver Health Medical
Center.
Tito D. Tubog, DNAP, CRNA, is employed by Texas Wesleyan University.
DISCLOSURES
The authors have declared no financial relationships with any commercial
entity related to the content of this article. The authors did not discuss
unapproved off-label use within the article.
 August 2020  online content 53