Anaesthetic Management of Patients During a COVID-19 Outbreak
This document will be regularly updated and will change with progression of the outbreak. We will highlight information and advice specific to our members alongside ongoing work with the Royal College of Anaesthetists, the Faculty of Intensive Care Medicine and the ICS towards joint coordinated information.
Last updated Thursday 2 April 2020.
Protecting staff is a priority to maintain morale, maintain staffing levels and prevent ongoing transmission to other patients.
Group 1: Known or suspected COVID-19 Positive presenting in respiratory failure
- Postpone non-urgent surgery if possible until infectious status confirmed
- Direct to dedicated theatre
- HEPA filter at Y piece, and gas sampling should of filtered gas
- Droplet, direct contact and contaminated surface contact precautions
- Training in infection control and donning and doffing PPE (fit tested mask or powered hood, eye shield, gown, gloves)
- Appropriate hand hygiene (before donning and extra-care after doffing)
- Signs on entry doors to warn staff, keep doors closed
- If patient not under GA then patient should wear a surgical mask.
High Risk Procedures (eg intubation)
- 1. Ensure adequate time to prepare (donning PPE, provide checklist, supervision by buddy) - here is a useful guide from FICM
- 2. Fit tested mask or powered air purifying device, double Glove and replace outer gloves when contaminated
- 3. Minimise staff numbers in room
- 4. Experienced intubators
- 5. Avoid awake fibreoptic intubation, avoid open suctioning of the tracheal tube (closed systems available on ICU)
- 6. Avoid high flow devices/CPAP during intubation process
- 7. Consider videolaryngoscopy, sheath all equipment where possible. Ensure cleaning and disinfection. Drape none essential parts of equipment (eg ultrasound cart)
- 8. Long preoxygenation, ultrarapid RSI (or small tidal volumes with manual ventilation if needed)
- 9. Decontamination and disinfection of all equipment
- 10. Appropriately labeled bin for disposables
- 11. Remove outer gloves before touching any spaces which may be touched by others
- 12. Doffing in area designated for dirty PPE
- 13. Avoid touching hair or face before handwashing **errors in doffing are common and linked to staff infection**
- 14. Negative pressure room where possible for high-risk procedures (note theatres often positive pressure)
- 15. Seek support from local infection control expertise.
Group 2: Not expected to be COVID-19 Positive
As the outbreak progresses patients with mild symptoms may present for anaesthesia. Anaesthetists and their co-workers are at risk by wide exposure to at risk populations and particularly during airway care and intubation. Transmission can occur from asymptomatic patients. In addition anaesthetists who have mild undiagnosed COVID-19 infections can transmit to their patients.
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Consider for all patients:
- Attention to surface and equipment cleaning during and between cases (for example have a rigid protocol for anaesthetic machine interface, bag, monitors, surfaces, door handles etc, avoid unnecessary clutter)
- Wear gloves (change regularly and when soiled)
- Regular handwashing and avoid contamination of mucus membranes (gloved hands may remind you to not touch your mucus membranes)
- Avoid high flow devices especially if not wearing PPE
- Consider Videolaryngoscopy for intubation to distance your self from the airway and/or wear mask and eye protection, sheath all reusable equipment where possible and ensure appropriate disinfection procedures.
Group 3: Transfer of known or suspected COVID-19 patient
(Adapted from ASA guidance)
- Transfer only for procedures and studies essential for patient care.
- HEPA filter inserted at tracheal tube/Y piece.
- Patients who are not ventilated should wear a surgical mask
- One person should wear the appropriate PPE and ideally be accompanied by an additional member of the transport team who is not wearing a gown and gloves. The person without gloves and gown can interact with the environment. Prior to transport, the PPE clad person should perform hand hygiene and don a fresh gown and gloves to reduce potential contamination of environmental surfaces.