COVID 19 Recommendations and Resources

Procedural Recomendations:

  • UPDATED 4/4/2020
  • All APC employees must read and be familiar with published APC Covid19 Protocols and check back frequently as this document is updated on a regular basis as we learn more. (This is a more comprehensive and detailed document.)

General Principles:

  • Adherence to checklists should be evaluated in-person and in real time by a second individual to reduce gaps.
  • Patients with confirmed or suspected COVID19 should utilize procedures as outlined below.
  • Early controlled induction and intubation is preferable to crash intubation.
  • An appropriate high-quality filter (HEPA) should be placed immediately between the ETT or mask and any connecting circuit or ventilating bag/device, including the CO2 detector at all times.
  • Only experienced personnel should intubate patient. or manipulate the airway (Only experienced providers or students at this time at discretion of anesthesiologist.)
  • Only essential personnel present in room during intubation.
  • Anesthetic should be geared to minimize coughing.
  • All extra supplies should be removed from video laryngoscope cart prior to being taken into room
  • Required Basic PPE
    • Hospital provided scrubs, head covering, and shoe covering before entering OR environment
    • Double gloves, eye protection, a N95 mask and a second mask
    • optional: gown, full face shield, boot covers
    • obtain approval of any non-hospital provided PPE with hospital prior to using in the hospital setting.
  • Full PPE
  • Perform frequent hand hygiene and sanitize surfaces that may have possibly been touched or contaminated.
  • Change outer gloves and sanitize after any interaction with the airway

Suspected or Confirmed COVID 19 Patients

  • Do not bring to the HOLDING room or PACU areas unless specifically directed and coordinated with OR leadership / Anesthesiology / Proceduralist.
  • Follow General Principles outlined above.
  • Full PPE protection as outlined in General Principles section utilizing second observer and checklist
  • Potentially utilize PAPR if available.
  • Be intubated and extubated in a negative-pressure room if at all possible
  • Minimize circuit disconnects and keep HEPA filter on ETT at all times
  • Ventilator utilized for transport under sedation.
  • Utilize Glidescope for intubation (remove extra supplies)
  • Utilize 2 experienced providers for every intubation.
  • Full paralysis (check with nerve stimulator) and minimal ventilation of patient (rapid sequence intubation)
  • Have rescue plan and equipment as needed.
  • Designate a dedicated supply runner with available n95 mask to be outside the intubation room and available via Vocera to obtain any necessary supplies for anesthesia or surgical teams.
  • Wait 20 minutes before opening any doors to the intubation room, including entrance of surgical team, to allow regular air exchanges to near-eliminate airborne/aerosolized particles.
  • Potentially allow surgical team to avoid use of n95 during the procedure subject to hospital policy for other groups. (APC members are required to wear n95 mask at all times in contact with COVID19 positive patients.)
  • Upon exit of room remove all PPE and immediately sanitize hands per Ballad Health PPE Doffing Procedure utilizing observer.
  • If patient is already intubated prior to the procedure, the patient should remain intubated at the conclusion of that procedure and be transported directly back to their room (ICU).
  • Pre-prepare operating room as outlined in APC Covid19 Protocols 
    • Obtain all supplies, drugs, fluids, etc and have in room before case if possible.
    • Seal drawers to anesthesia cart and Omnicells with tape.
      • Only enter the drawers in the event of true emergency.
      • Remove any supplies from tops of carts from room.
    • For additional drugs/supplies utilize designated personnel outside operating room and follow appropriate handoff procedures.
    • Ensure anesthesia machine circuit has appropriate filters.
    • HME/HEPA filter at end of circuit should be taken with provider for use when patient intubated.
    • If heavy ETT suction anticipated during case, utilize ICU ventilator with in-line suctioning and perform TIVA.
  • Extubate in a negative pressure environment. Patients who are to be extubated at conclusion of procedure:
    • Should be transported directly to PACU negative pressure room for extubation. After confirmation of stable patient, anesthesia provider will handoff to PACU nurse in full PPE inside negative pressure room.
    • If patient must be extubated in OR, the room must be closed to all personnel, until there has been 99.9% air turnover (20 minutes for ORs with no room traffic).

Standard/Routine OR Case Precautions:

  • Follow General Principles outlined above
  • Applicable for patients who are not identified as PUI (person under investigation) or confirmed COVID 19 patients.
  • Pre-op Airway exam should be done with n95 mask and second mask in place. Use gloves if touching the patient.
  • Wear at least Basic PPE
  • Perform frequent hand hygiene
  • Ask other staff not wearing n95 to move as far away as possible from airway.
  • Sedation and Regional Anesthesia Guidelines
    • Only true moderate sedation or less. Patient must be able to communicate and follow commands.
    • No deep sedation cases.
    • Patient should wear protective mask.
    • Providers need to wear at least Basic PPE in case there is a need to convert case to GA
    • Elect GA if suspected deep sedation needed.
    • If case needs to be converted to GA then stop procedure prior to conversion and communicate with room.
    • If converting case then utilize LMA guidelines or intubation guidelines below.
  • Acceptable LMA Use Guidelines
    • LMAs are acceptable if the patient is asymptomatic and has no known exposure or travel history.
    • Single attempt at LMA placement, then intubate if failure.
    • Don’t use LMA in high BMI or any other scenario where in your judgement the LMA would not work well.
    • If you expect a difficult airway, then plan to intubate safely in a controlled manner.
    • Wear your PPE even with LMAs.
    • Use LMA only on spontaneous breathing cases (no PSVPro, minimize manual positive pressure breaths.)
    • Do not use LMAs on bronchoscopy
  • Intubation Guidelines
    • Require Basic PPE for intubation for anyone within 6 feet of airway.
    • Plan to do rapid-sequence intubation.
    • Any other personnel not wearing appropriate  PPE needs to be a minimum of 6 feet away from the patient.
    • Avoid positive pressure ventilation prior to intubation.
    • If not using a stylet, place HEPA filter onto ETT before intubation (alternatively clamp tube with a hemostat.)
    • Ensure full paralysis before laryngoscopy.
    • Discard all used supplies and gloves immediately into trash.
    • Immediately perform hand hygiene before touching any surfaces within the operating room including the anesthesia machine.
    • Clean and sanitize mask, circuit, and anything that might have been touched
  • Extubation
    • Plan to extubate deep if possible so as to minimize coughing at the end of a procedure.
    • Techniques to consider: In order to minimize post procedural coughing consider using laryngeal lidocaine gels, ointments, or other topical agents. Consider opioids, dexmedetomidine for emergence. Consider TIVA to avoid irritation from inhalational agents.
    • May transport to PACU when patient is awake and coughing minimized. Do not transport deeply sedated.

Pediatric Case:

  • Follow General Principles outlined above
  • Weigh the risk of inhalation induction vs IV induction and use best judgement. (Will starting IV in upset child create a bigger risk of COVID spread or will child be able to tolerate IV without becoming agitated?)
  • Pediatric LMA use is acceptable in certain cases. See LMA guidelines above.

Cesarean Section:

  • Follow General Principles outlined above
  • For patients that are not suspected (PUI) of being positive for COVID 19 adhere to Routine Case Precautions.
  • COVID 19 Positive/suspicious (PUI) patient in Family Birth Center
    • Strongly encourage early epidural
    • If Cesarean section needed
      • Transport to negative pressure Cesarean operating room.
      • Full PPE for providers, patient to wear mask.
      • Regional anesthetic if appropriate, patient to continue to wear mask.
      • Full PPE by staff in the event intraoperative conversion to general anesthetic required. Non-airway staff should consider stepping out if able.
    • STAT
      • Transport to negative pressure Cesarean operating room. Patient wearing mask, providers in full PPE.
      • Preoxygenate for 5 minutes while patient is prepped, draped, and timeout performed.
      • Non-airway staff will then exit room
      • RSI with video laryngoscope
      • Obstetric Staff returns to perform Cesarean at their discretion of timing.
  • COVID 19 positive/suspicious (PUI) patient in ICU
    • STAT – Procedure to be done at bedside.
      • Anesthesia providers should don full PPE along with RT.
      • Surgical team will also enter and prep/drape patient per usual practice then step out of room after performing timeout.
      • RSI with respiratory therapy to assist with ventilator hookup. Plan for total intravenous anesthetic.
      • Obstetric staff to re-enter room to perform bedside Cesarean at their discretion of timing.
    • Non-STAT
      • Transport patient to negative pressure Cesarean operating room utilizing full PPE and patient with mask
      • Spinal anesthetic if appropriate
      • Full PPE for all staff

Emergency Intubation / Trauma Intubation:

  • Follow General Principles outlined above
  • Required basic PPE as outlined above
  • Rapid sequence induction and intubation. (ensure full paralysis)
  • Utilize glidescope if available (remove or cover extra supplies before entering room)
  • Change gloves, sanitize hands and equipment frequently and after any airway interaction
  • Immediate disposal of airway supplies and disposable equipment after intubation is confirmed.
  • For trauma, be prepared in required PPE before patient arrives if time allows.

Resources:

APC Documents:

APC Covid19 Protocols

Ballad Health Resources:

Ballad Health PPE Doffing Procedure

JCMC Guidelines for Anesthesia and Airway management of COVID-19 patients 04 02 2020

BalladHealth Public COVID page

BalladHealth Team Member COVID page 

APSF Resources:

APSF Perioperative Considerations 

APSF Airway Management of COVID 19 Patients

ASA Resources:

ASA Precautions for Intubating COVID 19 Patients (new)

ASA COVID 19 FAQs

Safe Airway Society Resources:

SAS Airway Managment

SAS Covid 19 Intubation Checklist

Other Resources:

Article outlining protection for healthcare workers