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Prepared May 7, 2003
Severe Acute Respiratory Syndrome (SARS) is an
infection in which affected individuals develop a fever, followed
by respiratory symptoms such as cough, shortness of breath or difficulty
in breathing. In some cases, the respiratory symptoms become increasingly
severe, leading to respiratory failure, ventilatory dependency and
occasionally, death. The causal pathogen is believed to be a novel
coronavirus, thought to be spread by "droplet / contact".
It is possible that a patient with SARS may require
therapeutic / diagnostic procedures which require the presence of
an anesthesiologist. Evidence from the recent outbreak of SARS in
Toronto, suggests that anesthesiologists (and other health care
workers) exposed to oral secretions at the time of intubation are
at 'high risk' of acquiring the infection.
To this end, the following are recommendations
for the anesthetic management of a SARS patient (probable / "person
under investigation"). The principles and a protocol for managing
these patients (outlined below) have been developed by anesthesiologists
at six hospitals affiliated with the University of Toronto. It should
be emphasized that these recommendations are based on our current
understanding of this illness and its spread. These recommendations
are expected to change over time. Although this is presented as
a single document, it has been modified in each of the hospitals
affiliated with the University of Toronto to meet local needs and
available resources. The SARS experience has alerted the anesthesia
community to the need to review and revise our current infection
control practices for all patients in the operating room. New guidelines
for infection control for all patients are anticipated in the near
future.
Of the recommendations listed below, the use of
Personal Protection Systems may be the most unfamiliar to anaesthesiologists.
Hospitals are recommending the use of personal protection hoods
and suits for physicians and assistants involved in laryngoscopy
or other airway interventions (including extubation). Devices such
as the Powered Air Purifying Respirator system consist of a lightweight
hood (e.g. PAPR hood device) connected via a breathing tube, to
a belt-mounted air purifier. Other hospitals have purchased the
Stryker "T4 Personal Protection System" that also filters
air. No clear consensus has been reached regarding the best air
filtration system. Nevertheless, these systems are considered to
be important barriers to protect health care personnel during larygoscopy,
intubation, and other invasive airway procedures. Importantly, caregivers
need to be trained in the use of these suits in advance of airway
intervention. Procedures for safely removing contaminated suits,
gloves, boots and outer gowns must also be reviewed. Gloves should
be removed and replaced after intubation before touching any equipment.
Detailed protocols for the use of this equipment are being developed.
i) Patient transfer
- Patients must be transferred directly into the OR
- Transfer route (to OR) should be discussed with 'Infection Control'
team member
Patients must wear a face mask (N95).
- Transporters should adopt full droplet /contact precautions
(see below)
- Assistance (respiratory therapist) should be provided for the
anesthesiologist.
- Ambubags should be equipped with a small-volume heat and moisture
exchange filter (e.g. PAL filter)
ii) Staff precautions
- Staff should wear clean surgical scrubs laundered by the hospital
(no personalized hats!)
- Minimize the number of individual staff members present. There
should be minimal exchange of staff during the case
- Hand-washing (e.g. With Cida Rinse) for 15 seconds before and
after patient care.
- Communicate with all levels of staff, involved in the patient's
care regarding the patient's SARS status.
- Clear the room of unnecessary or over stocked equipment.
- Post a "Droplets/ Contacts" sign on the OR doors to
minimize traffic. Keep doors closed.
iii) On entry to the OR
- maintain full droplet /contact precautions: - Gowns (front
and back protected)
- Double glove. Remove first pair after providing direct patient
care and before touching other areas of the room/ anaesthesia
machine. Subsequent intervention must be performed with double
gloves.
- N95 or PCM2000 mask or equivalent must be worn. Ensure that
there is an adequate seal (Beards interfere with seal)
- A full face disposable plastic shield for eye protection. Neither
protective eye wear (such as goggles) nor prescription glasses
are adequate.
- It is recommended that (where possible), staff stay a minimum
of 2 meters from the patient to avoid droplet contamination.
Hospitals are recommending the use of personal
protections hoods and suits for physicians and assistants involved
in laryngoscopy or other airway interventions (including extubation).
Devices such as the Powered Air Purifying Respirator system consists
of a lightweight hood (e.g. PAPR hood) connected via a breathing
tube, to a belt-mounted air purifier. Other hospitals have purchased
the Stryker "T4 Personal Protection System" that also
filters air.
At the end of the case
- Remove gloves, followed by gown and decontaminate hands with
alcohol (Cida) hand rinse for 15 seconds.
- Remove face shield, followed by hair cover and wash hands again.
Remove goggles, then mask and wash hands again with alcohol (eg.
Cida) rinse for 15 seconds. Re-gown, glove, put on hair cover,
mask and goggles.
- Transfer patient directly to Post-anesthesia Care Unit (isolation
room)
- Remove gown, gloves, goggles and mask prior to exiting the isolation
room.
- Change surgical scrub suit as soon as practically possible.
NOTE: Directives from the Ministry of Health
require that a 'SARS Unit' be a negatively pressurized room, which
is not available in most ORs (typically positively pressurized with
filtration to the incoming ventilation system). Some hospital protocols
advocate that intubation be performed in negative pressure rooms
where available.
Filters
Correct use of the small-volume heat and moisture
exchange filter (eg. PAL filter) provides bacterial/ viral removal
greater than 99.999%. It has a hydrophobic membrane that block the
passage of bodily fluids and aerosolized droplets (carrying pathogens).
Anesthetic Circuits
Circle circuit: Use a disposable circle system,
reservoir bag and mask as well as BP cuff and temperature probe
(all found on the SARS cart); A PAL filter should be placed on the
inspiratory and expiratory limbs of the circuit. The PAL filter
should be discarded, with the circuit, reservoir bag and tubing,
at the end of the case. Place another filter at the machine end
of the fresh gas flow outlet. Continue to use the gas-scavenging
device as usual.
Soda lime
The Soda lime does not need to be changed but
the end-tidal C02 sample line with trap must be changed after the
case.
Drug Cart
Prior to patient arrival, remove from the cart
what you consider necessary for the entire case and place it at
least 2 meters from the operating table. During the case, avoid
contamination of the cart by either double gloving (double glove
for patient contact /single glove for cart contact) or requesting
a colleague (not touching the patient) to obtain what you need from
the cart.
Machine /surfaces
Place the anesthetic machine as far from the patient
as practically possible. Consider using a surface away from the
anesthetic machine for placement of contaminated equipment (eg laryngoscope).
Discard needles and syringes immediately.
General aim to minimize patient coughing before,
during and after intubation and/or induction of anesthesia.
Choice of Airway
- Cuffed endotracheal tubes.
- LMA's are permitted (may be preferred to reduce airway irritation)
if appropriate considering patient's respiratory status.
Discard LMA or endotracheal tube after use, along
with oral and nasal airways.
Choice of Anesthetic
Tailor to the patients' needs.
Monitoring
Use axillary temperature probes. Avoid nasal or
esophageal probes.
No additional measures have been implemented for
the cleaning of anesthesia equipment. However particular attention
should be focused on the exterior surfaces of the anesthesia machine
(including dials / vaporizers), ventilator and laryngoscope handles.
Disinfection with a hospital-approved agent, (eg. virox) should
be used.
- 1) Communicate with laboratories FIRST before sending samples.
Indicate "SARS SPECIAL INVESTIGATION" on form.
- 2) Do not send specimens in the pneumatic tube. Send in biohazard
bags, in biohazard screw top bottles and have hand delivered to
the lab.
Policy for emergency tracheal intubation of SARS
patients outside the OR
When patients with suspected SARS require tracheal
intubation, the Intensive Care or Emergency Department Staff physician
may request the assistance of the On-Call Staff Anesthesiologist.
As for all patients, a careful assessment of the airway should be
performed and the possibility of difficulty during intubation anticipated
before an urgent airway intervention is required.
Pagers
The On-Call staff Anesthesiologist can be located
via the Hospital Switchboard or OR desk.
Equipment Available in the ICUs and SARS units
- a. Manual resuscitation bag with viral filter
- b. In-line suction catheters
- c. PAPR hoods*
- d. Intubation equipment*
- e. Anesthesia and Resuscitation drugs*
*The top of the Cardiac Arrest cart will contain
3 additional packages
- a. PAPR hoods (2 - for anesthesiologist and RT)
- b. Intubation equipment (laryngoscope, ETT 7.0, 8.0 mm, oral airway,
Yankauer sucker, stylette, ties/tape, PAL filter)
- c. Drugs/Syringes - (midazolam 5 mg, succinylcholine 200 mg, rocuronium
100 mg, ephedrine 50 mg, atropine 0.6 mg). Syringes 1- 20 ml, 3
- 10 ml, and 3 - 5 ml. Injection port adaptor.
Procedure
- a. After hand-washing, both Intubator and RT
will put on double gloves, gowns, goggles, boots and PAPR hoods
or Stryker hoods in the ante-room or outside the patient's room.
- b. Intubation will preferably be performed in patients who are sedated
(midazolam) and paralysed (succinylcholine or rocuronium) to prevent
coughing, and facilitate the intubation.
- c. After intubation, the gowns, boots, hoods, and gloves will be
removed in the ante-room or inside the patient's room, first by
the RT who will then assist the anesthesiologist.
List of drugs stocked in a separate SARS intubation
kit
| TOP SHELF (Intubation Medications) |
QUOTA |
| Atropine 1mg/10ml |
1 |
| Ephedrine 50mg |
1 |
| Glycopyrolate 0.2mg |
1 |
| Ketamine 100mg |
1 |
| Midazolam 5mg/5ml |
1 |
| Narcan 0.4 mg/1 ml |
1 |
| N/S 250cc |
1 |
| Propofol 200mg |
1 |
| Succinylcholine 100mg |
1 |
| Rocuronium 50 mg |
1 |
| BOTTOM SHELF
(Cardiac Medications) |
|
| Adenosine 6mg/2ml |
1 |
| Amiodarone 150mg/3ml |
2 |
| Atropine 1mg/10ml |
2 |
| Calcium Chloride 1gm/10ml |
1 |
| D50W 25gm/50ml |
1 |
| Diltiazem 50mg/10ml |
1 |
| Epinephrine 1mg/10ml 1:10,000 |
3 |
| Lidocaine 100mg/5ml |
2 |
| Magnesium Sulphate 5gm/10ml |
1 |
| Metoprolol 5mg/5ml |
1 |
| Sodium Bicarbonate 50mEq/50ml |
1 |
| Verapamil 5mg/2ml |
1 |
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