Measuring depression and anxiety level and determining concerns regarded to pandemic in doctors and nurses working in operating room Anxiety and depression level of health care workers in the operating room

Aim: One of the most important conditions for healthcare professionals to work efficiently during the pandemic is to ensure complete physical and mental well-being. This study was planned to measure the depression and anxiety levels of nurses and doctors working in the operating room during the COVID-19 pandemic, and to determine the causes of anxiety related to the pandemic. Material(s) and Method(s): This study is a cross-sectional, descriptive and region-stratified survey study. This study was conducted with operating room nurses and doctors who volunteered to participate. Participants were administered a survey consisting of 13 questions that questioned the reasons for concern about COVID-19 in addition to the Beck Anxiety Scale and Beck Depression Scale. Result(s): There was no difference between doctors and nurses regarding anxiety and depression symptoms. Anxiety level was higher in men. Depression and anxiety levels were high in those who worked for sixteen years and over, while depression and anxiety levels were significantly lower in the 18-35 age group. The most worrisome situation for healthcare professionals was the possibility of working in a unit where they had never worked before. The working area that the participants considered the most risky one in relation to COVID-19 was the emergency operating room. Discussion(s): We observed that participants showed mild depression symptoms and moderate anxiety. Also, psychological conditions of the younger participants were better.Copyright © 2022, Derman Medical Publishing. All rights reserved.

Would you like a charcoal-filtered coffee break? Use of 'tea trolley' teaching to familiarise staff with new guidelines and equipment for the management of malignant hyperthermia crisis

During 2020, updated guidelines for management of malignant hyperthermia (MH) were published. These guidelines now recommend the use of activated charcoal filters [1]. We suspected that the disruption and redistribution of staff and resources during the coronavirus pandemic may have resulted in staff being unaware of these updated guidelines, threatening the ability of a theatre team to respond effectively to a MH crisis. We implemented a quality-improvement project to rectify this. Methods Prior knowledge of the updated guidelines, location of emergency equipment (activated charcoal filters, dantrolene and printed copies of guidelines) and confidence in using activated charcoal filters was established by online questionnaire. We subsequently designed and delivered a 'tea trolley' teaching session to theatre staff (Fig. 1). Teaching sessions were evaluated with an electronic survey. Results Fifty-nine theatre staff responded to the initial questionnaire, with 39% stating they had read and understood the new MH guidelines. Forty-four per cent of respondents were unsure whether our Trust had access to activated charcoal filters, with only 20% knowing where the nearest supply was kept and 14% saying they would be confident using the filters. We subsequently delivered 'tea trolley' teaching to 73 theatre staff (including 28 anaesthetists, 15 operating department practitioners and 24 members of nursing staff) across several weeks, to demonstrate safe usage of activated charcoal filters and dantrolene in an emergency. Feedback was excellent, with all agreeing that their confidence and knowledge had increased. Discussion The multiple benefits of 'tea trolley' training have been documented widely [2] and subsequently established in many departments. Departmental disruption due to the pandemic response and ongoing clinical pressures as we attempt to recover our services can lead to staff working in unfamiliar areas. We suggest that 'tea trolley' teaching should be utilised in ensuring comprehensive knowledge of updated emergency guidelines and equipment, and have shown that it is an excellent method of embedding emergency preparedness. (Figure Presented).

Using Extracorporeal Membrane Oxygenation for COVID-Positive Urgent Tracheostomy

Introduction: Extracorporeal membrane oxygenation (ECMO) can be used during difficult airway surgery because it provides an unobstructed operative field while ensuring adequate oxygenation without need for ventilation. We present a case of utilizing ECMO to perform urgent tracheostomy on a COVIDpositive patient with a large oropharyngeal mass causing critical airway narrowing. Method(s): A 62-year-old man presented with 6 months of worsening dyspnea. Computed tomography imaging and flexible laryngoscopy showed a large oropharyngeal mass extending into the nasopharynx and larynx causing critical airway narrowing and severely distorted upper airway anatomy. Traditional methods to secure the airway including transnasal vs transoral intubation vs awake tracheostomy were considered inadequate due to tumor location/friability, trismus, inability to lie flat, and unclear tracheal landmarks on palpation. In addition, on the day of surgery, the patient tested positive for COVID. We decided ECMO was the safest method to safely perform tracheostomy while minimizing COVID aerosolization. Result(s): The thoracic surgery team proceeded with bifemoral cannulation, and ECMO was initiated in less than 30 minutes. Standard tracheostomy was performed, and biopsies of the oropharyngeal mass were obtained. The patient was weaned off ECMO after <1 hour and awakened without any issues. There were no complications from bi-femoral venous access. Conclusion(s): Multiple methods to secure this patient's difficult airway were considered. Fiber-optic nasal intubation would require navigating the bronchoscope around the large tumor partially obstructing the nasopharynx and larynx. Awake tracheostomy was considered risky due to his large neck circumference, significant coughing episodes, and inability to lay supine. Both of these options would also be associated with high levels of COVID aerosolization. The use of ECMO allowed for apneic tracheostomy while minimizing the risk of COVID infection to all operating room personnel. In the era of COVID, ECMO is an unconventional but powerful tool that should be added to the armamentarium of highrisk airway surgery.

Education -Supporting redeployed staff during the covid-19 pandemic

Introduction: The COVID-19 pandemic required a significant increase in Critical Care bed capacity resulting in many non-Critical Care staff being redeployed to work in Critical Care.1 There were a variety of professions redeployed as ITU 'nurses' including non-critical care nurses, Operating Department Practitioners (ODPs) and medical and dental staff. Training was developed for these members of staff in order for them to support the critical care team during the surge. Objectives: NHS England produced a guide to provide principles for increasing the workforce in response to exceptional demand in adult critical care services. In it they stated that staff moved from other areas will be required to be supported to ensure safe practice, safe patient care and staff wellbeing, with appropriate supervision and delegation of care.2 These non-critical care staff needed training to care for critically ill covid-19 patients.3 During the second wave of covid-19 medical and dental staff were redeployed to act as category 'B' nurses.2 Training had been provided to prepare nurses and ODPs for these roles and this was adapted to be delivered to medical and dental staff acting as 'nurses'. Methods: Training was developed to support the development of staff redeployed to critical care to support the surge response. On completion of the training session staff were asked to complete an online survey to enable evaluation of the training, to understand their experiences, and develop any future training. Results: Post course evaluation was conducted to assess the effectiveness, quality and impact of the education intervention. Training was provided to 30 Doctors and Dentists over five sessions in the period 27 January11 February 2021. Evaluations were sent to all staff that attended the training and 19 were returned (63% response rate). 17 (89%) of the respondents said that attending the training had helped them whilst doing clinical nursing shifts in ITU. Conclusion: The integration of redeployed staff into the Critical Care team allowed the additional patients to be cared for as safely. These staff required training to provide them with the information to care for these patients safely and evaluation of this training is important to aid future planning.

I will never forget the day

Introduction: I would like to present a poem I have written about my experience of being part of the multidisciplinary team at a remote district general hospital on the day that a COVID-19 patient was retrieved for ECMO. Main Body: I will never forget the day It was late in the month of May It started in the usual way A handover with our patient lists We gathered, doctors, nurses, therapists And discussed a patient with COVID-19 infection And his clinical deterioration. He was a man of about fifty Usually well and pretty healthy Brought in by ambulance to A&E With oxygen saturations of eighty And quickly escalated to NIV. Three days alternating CPAP and high flow But progress was extremely slow And by the morning of day four He couldn't cope any more Sixty was his respiratory rate So the decision was made to intubate. He was given every treatment known Antimicrobials, paralysis and prone Epoprostenol and dexamethasone So brittle was his gas exchange with any small position change And even on APRV His FiO2 reached seventy. His only chance of salvation Was extracorporeal membrane oxygenation As the retrieval team began their journey ICU and theatre staff worked closely Nurse, consultant and operating department practitioner Helped move the patient into theatre Still proned, too unstable To even transfer to the table We waited in personal protective gear For the ECMO team to appear. From London arrived the ECMO specialist Her registrar and perfusionist A quick briefing, roles allocated, The patient was swiftly cannulated, With the largest lines I'd ever seen! And established on the ECMO machine It was a truly inspiring scene. Switching infusions, monitoring, ventilation, Ready for patient transportation But during the preparation He went into fast atrial fibrillation Requiring electrical cardioversion Amiodarone and magnesium. Sinus rhythm was restored But it was an insult he couldn't afford Increasingly hypotensive he became Chest compressions, adrenaline, all in vein, And to a difficult decision we came All agreed as a team Time to switch off the machine. I will never forget that day It was late in the month of May A life lost in a tragic way But something I can honestly say Never prouder have I been Of every person in that team We gave our all, we did our best In peace may our patient rest. Conclusion: I would like to dedicate this poem to all my ICU and theatre colleagues who shared this experience with me and, if given the opportunity, present it alongside pictures of them in their PPE as they were that day.

Threats to operating room personnel's occupational safety and health: a qualitative study

Background & Objective: Every operating room has been associated with a variety of occupational hazards, but not many studies have been conducted to assess and address these hazards. We used a qualitative approach to explore operating room personnel's experiences of workplace hazards and how these hazards threaten their occupational safety and health (OSH). Methodology: This qualitative study was conducted in five teaching hospitals in the south-west of Iran from February 2019 to March 2021. The sample was 24 operating room personnel who were selected under convenient sampling technique. Data were collected using semi-structured, individual interviews, document review and non-participant observation. The collected data were analyzed according to the qualitative content analysis method using MAXQDA v. 2020. Results: After prolonged analysis of the data, the researchers extracted 644 codes, 13 subcategories, 4 categories, and 1 main theme. The main theme of the study was working in a context of occupational hazards. Conclusions: Operating rooms are full of potential dangers, which, when combined with the personnel's negligence and management inefficiencies, increase the risk of occupational health and safety. Therefore, making working conditions safe by providing adequate personal protective equipment (PPE), in-service training, and identifying and managing the causes of personnel negligence are recommended. Moreover, strategies should be introduced to manage stress and conflicts among the healthcare personnel, thus controlling psychological hazards.

COVID-19-Associated Acute Invasive Fungal Rhinosinusitis

Introduction: There have been multiple reports of acute invasive fungal rhinosinusitis (AIFRS) in patients with COVID-19 infection. Most cases were associated with high dose steroid therapy in diabetic patients. We report a case of a patient with COVID-19 infection and AIFRS. We will discuss management with the unique risks to the care team. Case: A 61-year-old diabetic woman was admitted to another facility with COVID-19 pneumonia and treated with oral dexamethasone. Three days later, she developed sharp stabbing pain in the right eye with ptosis and blurry vision. She was treated with analgesics and discharged. She returned with persistent pain and increasing right-sided hypesthesia. A CT scan did not show an acute orbital or sinus infection. She was discharged with outpatient ophthalmology follow-up. She presented to our emergency department 3 days later with 48 hours of right vision loss. Physical exam also showed disconjugate gaze and right V1/V2 hypesthesia. Nasal endoscopy showed necrotic tissue within the right nasal cavity. She was immediately started on IV amphotericin and taken to the operating room for biopsy and debridement. Pathology results were consistent with necrosis and invasive fungal hyphae. She was treated with liposomal amphotericin and was eventually discharged with permanent loss of right vision. Discussion: Management of COVID-19-associated acute invasive fungal sinusitis (CA-AIFRS) presents challenges for safety of the health care team. Diabetic COVID-19 patients' new sinonasal complaints or cranial nerve deficits must be immediately evaluated for AIFRS. The CT scan changes associated with AIFRS are nonspecific early in the disease process, therefore nasal endoscopy and biopsy are critical. This requires appropriate PPEnasal endoscopy should be performed with N95 respirator, eye protection, gloves, and a disposable gown. In patients with suspicious nasal endoscopy, immediate initiation of IV antifungals is critical. The next step is biopsy and surgical debridement. This should not be delayed in COVID-19 patients. At our institution, several steps are taken to protect the healthcare team. During intubation, only necessary anesthesia staff are in the roomwith properly worn powered air purifying respirator (PAPR). A viral filter is placed on the ET tube and the room doors are closed for 20 minutes after intubation to allow for air exchange. After 20 minutes, surgical staff may enter the room. The surgical team is outfitted with PAPRs. Powered instruments associated with aerosol generation such as high-speed drills are avoided. The surgical specimens are considered contaminated with COVID19. Therefore, frozen analysis is not used. Margins are sent for permanent analysis. Cultures are sent with appropriate labeling for laboratory precautions. The tissue is debrided to healthy tissue or natural barriers such as the skull base. Conclusion: Management of COVID-19 must include an awareness of CA-AIFRS. Diabetic patients on steroids appear to be more susceptible to CA-AIFRS. Nasal endoscopy is important for evaluation. Avoiding delays in starting antifungals and operative biopsy and debridement is critical. Safety considerations need to be prepared in advance for safe surgical debridement of these patients.