Episode #5 Perioperative Considerations for COVID-19

Hello and welcome back. I’m your host, Alli Bechtel. Today, we are going to return to the APSF’s Novel Coronavirus Resource Center. I hope that you have found your way to the resource center already and if not, I will include a link to it in the show notes.  The APSF has put together resources related to patient safety amidst the current coronavirus pandemic and this information is updated frequently so we hope that you will visit the site often for the most up-to-date information. We are going to tackle a big topic today and it is, “An Update on the Perioperative Considerations for COVID-19 Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2)” by Zucco and colleagues. As we review this important topic, please keep in mind that we are making our best efforts to provide accurate information on this podcast and on our website, but this material is provided only for informational purposes and does not constitute medical or legal advice. I will link to the article in the show notes.

As we all know, the COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus-2 continues to have a significant impact on everyday life as well as patient care in the hospital and patient safety during anesthesia care.

Information related to this pandemic is constantly changing. At the time of this recording, the fatality rate is approximately 2-20% for hospitalized patients and over 80% for patients who are intubated and require mechanical ventilation. We have seen quite a bit of community transmission in the United States especially since a single person has the potential to spread the infection to 2 or more additional people…and with this risk for human to human transmission, we see that SARS-CoV-2 portends a high risk to all health care professionals in the perioperative setting.  It is so important that perioperative and hospital leaders develop strategic steps for interventions on patients with either suspected or confirmed COVID-19 infection.

Let’s talk about safety measures that may be taken during this current pandemic in the perioperative setting. At this point, we recognize that non-pharmacological interventions and public health measures are very important to help fight this pandemic.

Safety measures need to take into account pathogen transmission which may occur via inhalation of infected respiratory droplets and this is more likely to occur with closer distance to the droplets or within 6 feet. Additional risks for exposure include long exposure to high aerosol counts in an indoor or closed environment as well as close contact with mucous membranes and through the digestive tract. Transmission may also occur from direct or indirect contact with contaminated surfaces leading to self-contamination or further transmission of the virus. SARS-CoV-2 is able to survive for 12-72 hours outside of the body depending on the type of surfaces.  The most effective public health effort includes preventing transmission and some of the important components includes rapid identification of cases through testing, contact tracing, isolation or quarantine of infected and exposed individuals and supportive care.  The APSF acknowledges that healthcare professionals are at risk for perioperative exposure and it is really important that hospital-wide guidelines should be available to mitigate and manage exposure and further virus transmission.

Since the beginning of the current pandemic, we have learned a great deal about disease transmission especially from the experiences in China, Italy, the United Kingdom, and the US.  Community spread of the disease is the most common form of viral transmission, but there are still concerns for nosocomial transmission in the perioperative environment especially in the setting of high community prevalence and decreased testing availability and reliability.  In addition, viral shedding likely occurs prior to onset of symptoms which can lead to increased transmission potential in asymptomatic  patients. The authors report that it is important for the safety of patients and healthcare professionals to have a coordinated effort to minimize disease transmission along with a unified approach and clear communications with all staff members in the organization.  This will help a great deal in terms of anxiety, fear, confusion, and tension among team members when it comes to utilizing PPE correctly and implementing appropriate protocols.

Okay, now let’s move into the OR environment where there are many surfaces for droplet contamination. In addition, many aerosolizing procedures take place in the operating room which may lead to aerosolization of sputum from a patient with Covid-19 and this may be a potential exposure for healthcare professionals in the OR.  The highest risk time periods are during intubation and extubation. Inside and outside the OR, it is important to keep in mind that inadequate PPE as well as improper use of PPE and poor hand hygiene are risk factors for viral transmission.

Let’s get into the recommendations for the perioperative practice of anesthesia in patients with Covid 19.  First, for hand hygiene, it is recommended to continue to practice frequent handwashing according to standard protocols.  Next up, for personal protective equipment it is important that all providers have access to appropriate PPE including a fit-tested N95 or the equivalent or a powered air-purifying respirator plus eye protection with goggles or a face shield, a disposable head cover, and impermeable fluid-resistant gown, shoe covers, and 2 sets of gloves.  Remember that disposable OR caps may also be helpful to reduce contamination by touching hair that has been exposed to droplets after the procedure and of course, hand washing is vital before and after doffing PPE. A fit-tested N95 is an essential piece of equipment to protect against airborne and droplet precautions for Covid-19 since it is approved for protection against droplet and airborne transmission of 95% of particles greater than 0.3microns and likewise the PAPR may be used since it provides equal protection but has the added benefit of versatility for providers with different face sizes and facial hair, and in different situations. Safety for healthcare professionals when using PPE depends on protocols for correct donning and doffing and availability of trained observers as well as simulation training when possible for high risk activities such as intubation and extubation. Simulation training is an important safety activity that has been used by many organizations for donning, doffing, intubating, extubation, and managing unanticipated events in Covid-19 patients. Has the perioperative workflow at your institution changed  during the pandemic? Some of the changes may include workflow redesign, checklist implementation, and testing. For example, institutions may need to designate specific ORs for Covid-19 patients to minimize contamination of the anesthesia and OR equipment by covering any non-mobile equipment and removing any unnecessary equipment.

Speaking of intubation and extubation…these are routine activities for anesthesia professionals, but the way we approach these activities has fundamentally changed during the pandemic especially when it comes to taking care of patients with known or suspected Covid-19 disease.  Some considerations during intubation and extubation depending on your organization may include donning appropriate PPE, limiting the number of staff members in the room to reduce the risk of unnecessary exposure or making sure that all staff who must be in the room have appropriate PPE and having a plan and available equipment for an unanticipated difficult airway. After intubation or extubation, it is important to have a plan for disposal of the contaminated equipment to help minimize the risk of exposure.

The article covers general precautions for airway management in patient with known or suspected coronavirus infection including the following:

1. Your personal protection is the priority. PPE for airborne, droplet, and contact precautions are required with particular attention to donning and doffing protocols to minimize the risk of self-contamination.
2. Confirmed or suspected SARS Co-V-2 infected cases should have a designated OR for the case with recovery in the OR or back up in the ICU. A clamp for the endotracheal tube may be helpful to minimize contamination during circuit disconnections.
3. Take care to have the necessary equipment for airway manipulation available.

Now, during airway manipulations, the authors reveal several important considerations such as the following:

1. Don appropriate fit-tested N95, PAPR, or the equivalent mask, eye protection, gown, 2 sets of gloves, and appropriate foot coverings. For patient monitoring, ensure that standard monitors are used along with additional monitors as needed depending on the past prior to induction of anesthesia.
2. When possible, the most experienced anesthesia professional should perform the intubation.
3. Have a plan for an unanticipated difficult airway and rescue equipment available.
4. Avoid awake fiberoptic intubation if possible due to the risk for aerosolization during topicalization with atomized local anesthetics or consider alternative topicalization techniques if absolutely necessary. A video-laryngoscope may be useful at the first choice for intubation to improve success during the first attempt.
5. Don’t forget about adequate pre-oxygenation for these patients to help decrease the time to desaturation.
6. A rapid sequence intubation may be used to avoid manual ventilation and decrease contamination, but if manual ventilation is required, it may be helpful to use small tidal volumes with a high quality viral filter in place. After intubation, ensure that the endotracheal tube cuff is inflated prior to positive pressure ventilation and make sure that there is a high quality viral filter in place.
7. Following intubation, all airway equipment should be sealed and removed from the room for decontamination and disinfection according to the institutions’ protocol.
8. During extubation, proper PPE is required as well.
9. If you are involved in an intubation of a patient with known or suspected Covid-19, consider visiting the intubatecovid.org registry to track symptoms following airway manipulation. I will link to the intubate covid registry in the show notes.

Here at the APSF, safety of patients and healthcare professionals is our priority.  As institutions across the country have resumed elective perioperative services, it is important to continue to follow evidence-based standards from local, national, and international guidelines. The combination of continued surveillance and public health efforts will likely need to continue as well.  As institutions continue to resume activities, some considerations include testing availability, local disease prevalence, surgical procedure and indication, hospital and ICU capacity, and staffing requirements. I will include the link for the Joint Statement form the American College of Surgeons, American Society of Anesthesiologists, American Hospital Association, and Association of Perioperative Registered Nurses in the show notes as well. Risk management during the pandemic likely depends on symptom-based preoperative screening. Patients who screen positive may need to be referred for testing with surgical delay and appropriate follow-up when possible.

In the article the authors highlight the importance of preoperative testing with the goals to…

• Delay elective surgery in patients who are either symptomatic or test positive.
• Trigger perioperative protocols for the appropriate care of suspected or confirmed COVID-19.
• Guide appropriate use of PPE and perioperative care protocols.

Preoperative testing depends often depends on local or regional presence of SARS-CoV2. Considerations for testing in areas with local or regional disease presence include the following:

1. All patients should be screened for symptoms prior to presenting to the hospital. Patients reporting symptoms should be referred for additional evaluation. All other patients should undergo nucleic acid amplification testing (including PCR tests) prior to undergoing non-emergent surgery. Health care systems may consider encouraging patients to self-isolate pending testing results.
2. Because false negatives may occur with testing, droplet precautions (surgical mask and eye covering) should be used by OR staff for operative cases. Before performing an aerosol-generating procedure, health care providers within the room should wear an N95 mask, eye protection, gloves, and a gown.
3. If a patient tests positive for SARS-CoV-2, elective surgical procedures should be delayed until the patient is no longer infectious and has demonstrated recovery from COVID-19.
4. Recommendations regarding the definition of sufficient recovery from the physiologic changes from SARS-CoV-2 cannot be made at this time; however, evaluation should include an assessment of the patient’s exercise capacity (metabolic equivalents or METS) to determine suitability for surgery and this is similar to how we approach patients with other viral illness as well.

Now in areas where there is little or no disease presence, a different strategy may be considered including screening all patients for symptoms and referring patients who screen positive for symptoms for additional evaluation and possible testing.

The authors leave us with a comment on the state of healthcare as this pandemic evolves and I will read it now.

“Without any current vaccinations or proven pharmacological interventions, we recommend continuous emphasis on public health efforts and nonpharmacological interventions endorsed by the Center for Disease Control (CDC), World Health Organization (WHO), and local state governments. We also advocate for the continuous leveraging of technology (telemedicine) in the perioperative setting to facilitate adequate social distancing and mitigate nosocomial transmissions.”

Thank you so much for joining me today on this journey towards improved patient safety as we continue to care for patients during the Covid-19 pandemic.  If you have any questions or comments from today’s show, please email me at [email protected].

When you get a chance, don’t forget to subscribe to the podcast through iTunes or your favorite podcast app and leave us a review. Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

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