A quantitative evaluation of aerosol generation during supraglottic airway insertion and removal.

Many guidelines consider supraglottic airway use to be an aerosol-generating procedure. This status requires increased levels of personal protective equipment, fallow time between cases and results in reduced operating theatre efficiency. Aerosol generation has never been quantitated during supraglottic airway use. To address this evidence gap, we conducted real-time aerosol monitoring (0.3-10-µm diameter) in ultraclean operating theatres during supraglottic airway insertion and removal. This showed very low background particle concentrations (median (IQR [range]) 1.6 (0-3.1 [0-4.0]) particles.l-1 ) against which the patient's tidal breathing produced a higher concentration of aerosol (4.0 (1.3-11.0 [0-44]) particles.l-1 , p = 0.048). The average aerosol concentration detected during supraglottic airway insertion (1.3 (1.0-4.2 [0-6.2]) particles.l-1 , n = 11), and removal (2.1 (0-17.5 [0-26.2]) particles.l-1 , n = 12) was no different to tidal breathing (p = 0.31 and p = 0.84, respectively). Comparison of supraglottic airway insertion and removal with a volitional cough (104 (66-169 [33-326]), n = 27), demonstrated that supraglottic airway insertion/removal sequences produced <4% of the aerosol compared with a single cough (p < 0.001). A transient aerosol increase was recorded during one complicated supraglottic airway insertion (which initially failed to provide a patent airway). Detailed analysis of this event showed an atypical particle size distribution and we subsequently identified multiple sources of non-respiratory aerosols that may be produced during airway management and can be considered as artefacts. These findings demonstrate supraglottic airway insertion/removal generates no more bio-aerosol than breathing and far less than a cough. This should inform the design of infection prevention strategies for anaesthetists and operating theatre staff caring for patients managed with supraglottic airways.

Portable negative pressure environment to protect staff during aerosol-generating procedures in patients with COVID-19.

Patients with COVID-19 often need therapeutic interventions that are considered high aerosol-generating procedures. These are either being performed by healthcare providers with potentially inadequate personal protective equipment or the procedures are being delayed until patients clear their viral load. Both scenarios are suboptimal. We present a simple, cost-effective method of creating a portable negative pressure environment using equipment that is found in most hospitals to better protect healthcare providers and to facilitate more timely care for patients with COVID-19.

Impact of COVID-19 Pandemic on Ambulatory and Operating Room Rhinology Practice in the US.

INTRODUCTION: The pandemic caused by the novel coronavirus virus has altered all facets of clinical practice in the United States. The goal of this study is to better understand the impact of COVID-19 on rhinologic ambulatory and operative practice. METHODS: A 27-item survey to assess these objectives was created and approved by the Division of Rhinology faculty at Rush University Medical Center in April 2020. The survey was then distributed to rhinologists in a web based format via www.surveymonkey.com from April 10 through April 23, 2020. RESULTS: A total of 277 U.S based rhinologists responded to the survey (23.04%). The most common practice types were single specialty private (44.9%) and academic (24.6%). 90.2% practice in a state under a shelter in place order. Comparing pre-COVID baseline to during-COVID, there was statistically significant reduction in the number of patients of seen daily in clinic (p < 0.001). The number of nasal endoscopies in the office and surgical procedures fell dramatically. Overall, 5 respondent rhinologists have been infected with COVID-19 and 27 have been furloughed. CONCLUSION: COVID-19 has drastically affected rhinologic practice. There is a dramatic reduction of in person care in the office setting and surgical management of sinonasal and skull base disease. Enhanced PPE is being used in only half of potentially aerosolizing procedures which represents an area of further education. Novel approaches such as use of virtual encounters and point of care testing should be considered as options to facilitate care.

Practical considerations for performing regional anesthesia: lessons learned from the COVID-19 pandemic.

Coronavirus disease (COVID-19) was declared a pandemic by the World Health Organization on 11 March 2020 because of its rapid worldwide spread. In the operating room, as part of hospital outbreak response measures, anesthesiologists are required to have heightened precautions and tailor anesthetic practices to individual patients. In particular, by minimizing the many aerosol-generating procedures performed during general anesthesia, anesthesiologists can reduce exposure to patients' respiratory secretions and the risk of perioperative viral transmission to healthcare workers and other patients. To avoid any airway manipulation, regional anesthesia should be considered whenever surgery is planned for a suspect or confirmed COVID-19 patient or any patient who poses an infection risk. Regional anesthesia has benefits of preservation of respiratory function, avoidance of aerosolization and hence viral transmission. This article explores the practical considerations and recommended measures for performing regional anesthesia in this group of patients, focusing on control measures geared towards ensuring patient and staff safety, equipment protection, and infection prevention. By doing so, we hope to address an issue that may have downstream implications in the way we practice infection control in anesthesia, with particular relevance to this new era of emerging infectious diseases and novel pathogens. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is not the first, and certainly will not be the last novel virus that will lead to worldwide outbreaks. Having a well thought out regional anesthesia plan to manage these patients in this new normal will ensure the best possible outcome for both the patient and the perioperative management team.

RéSUMé: Le 11 mars 2020, l'Organisation mondiale de la Santé déclarait que la nouvelle maladie du coronavirus 2019 (COVID-19) était une pandémie en raison de sa propagation mondiale rapide. En salle d'opération, dans le cadre des mesures de réponse aux épidémies, les anesthésiologistes doivent prendre des précautions supplémentaires et adapter les pratiques anesthésiques au cas par cas selon chaque patient. Plus particulièrement, en minimisant les nombreuses interventions générant des aérosols pendant la réalisation de l'anesthésie générale, les anesthésiologistes peuvent réduire l'exposition aux sécrétions respiratoires des patients et le risque de transmission virale périopératoire aux travailleurs de la santé et aux autres patients. Afin d'éviter toute manipulation des voies aériennes, il convient d'envisager la réalisation d'une anesthésie régionale si une chirurgie est prévue chez un patient sous enquête de COVID-19 ou confirmé, ou chez tout patient posant un risque infectieux. L'anesthésie régionale comporte des avantages en matière de maintien de la fonction respiratoire et ce, tout en évitant la production d'aérosols et par conséquent la transmission virale. Cet article explore les considérations pratiques et les mesures recommandées pour réaliser une anesthésie régionale dans ce groupe de patients, en se concentrant sur les mesures de surveillance visant à garantir la sécurité des patients et du personnel soignant, la protection des équipements et la prévention des infections. Ce faisant, nous espérons répondre à des interrogations qui pourraient avoir des implications à plus long terme dans la manière dont nous pratiquerons la prévention de la contagion en anesthésie, avec une pertinence toute particulière pour cette nouvelle ère de maladies infectieuses émergentes et de nouveaux pathogènes. Le coronavirus du syndrome respiratoire aigu sévère 2 (SARS-CoV-2) n'est pas le premier et ne sera certainement pas le dernier nouveau virus qui entraînera des épidémies mondiales. En disposant d'un plan bien conçu d'anesthésie régionale pour prendre en charge ces patients dans cette nouvelle ère, les meilleures issues possibles seront assurées tant pour le patient que pour l'équipe de prise en charge périopératoire.

Open tracheostomy for COVID-19-positive patients: A method to minimize aerosolization and reduce risk of exposure.

BACKGROUND: The COVID-19 virus is highly contagious, and thus there is a potential of infecting operating staff when operating on these patients. This case series describes a method of performing open tracheostomy for COVID-19 patients while minimizing potential aerosolization of the virus using typically available equipment and supplies. METHODS: This is a case series of 18 patients who were COVID-19-positive and underwent open tracheostomy in the operating room under a negative pressure plastic hood created using readily available equipment and supplies. Patients had to be intubated for at least 14 days, be convalescing from their cytokine storm, and deemed to survive for at least 14 more days. Other indications for tracheostomy were altered mental status, severe deconditioning, respiratory failure and failed extubation attempts. RESULTS: There were 14 men and 4 women with severe SARS-CoV2 infection requiring long-term intubation since March 23 or later. The mean age was 61.7 years, body mass index was 32.6, and the pretracheostomy ventilator day was 20.4 days. The indications for tracheostomy were altered mental status, severe deconditioning and continued respiratory with hypoxia. Failed extubation attempt rate was 16.7% and hemodialysis rate was 38.9%. All patients were hemodynamically stable, without any evidence of accelerating cytokine storm. To date there was one minor bleeding due to postoperative therapeutic anticoagulation. CONCLUSION: This report describes a method of performing open tracheostomy with minimal aerosolization using readily available equipment and supplies in most hospitals. LEVEL OF EVIDENCE: Therapeutic/care management, Level V.

Infection Prevention Strategy in Operating Room during Coronavirus Disease 2019 (COVID-19) Outbreak.

A novel coronavirus that emerged in late 2019 rapidly spread around the world. Most severe cases need endotracheal intubation and mechanical ventilation, and some mild cases may need emergent surgery under general anesthesia. The novel coronavirus was reported to transmit via droplets, contact and natural aerosols from human to human. Therefore, aerosol-producing procedures such as endotracheal intubation and airway suction may put the healthcare providers at high risk of nosocomial infection. Based on recently published articles, this review provides detailed feasible recommendations for primary anesthesiologists on infection prevention in operating room during COVID-19 outbreak.

Laparoscopic or robotic intraoperative management to minimize aerosol dispersion: Adaptations to the context of the COVID-19 pandemic. / Manejo intraoperatório em cirurgia laparoscópica ou robótica para minimizar a dispersão de aerossóis: Adaptações ao contexto da pandemia por COVID-19.

The coronavirus infection, also known as SARS-COV2, has proven to be potentially fatal, representing a major global health problem. Its spread after its origin in the city of Wuhan, China has resulted in a pandemic with the collapse of the health system in several countries, some with enormous social impact and expressive number of deaths as seen in Italy and Spain. Extreme intra and extra-hospital measures have been implemented to decrease the transmission and dissemination of the COVID-19. Regarding the surgical practice, a huge number of procedures considered non-essential or elective were cancelled and postponed until the pandemic is resolved. However, urgent and oncological procedures have been carried out. In this publication, we highlight and teach adaptations to be made with commonly used materials in laparoscopy to help prevent the spread and contamination of the healthcare team assisting surgical patients.

A infecção pelo coronavírus determinante da doença COVID-19, também conhecida como SARS-COV2 foi classificada nos últimos meses como pandemia. Essa é potencialmente fatal, representando enorme problema de saúde mundial. A disseminação, após provável origem zoonótica na cidade de Wuhan, China, resultou em colapso do sistema de saúde de diversos países, alguns com enorme impacto social e número grande de mortes descritas na Itália e Espanha. Medidas extremas intra e extra-hospitalares têm sido implementadas a fim de conter a transmissão e disseminação da COVID-19. No âmbito cirúrgico, enorme quantidade de procedimentos considerados não essenciais ou eletivos foram prorrogados ou suspensos até resolução da pandemia. No entanto, cirurgias de urgência e oncológicas não permitem que o paciente espere. Nesta publicação, sugerimos e ensinamos adaptação a ser feita com materiais de uso corriqueiro em laparoscopias para evitar a contaminação ou a disseminação entre as equipes assistenciais e os pacientes.

Airway Management in the Operating Room and Interventional Suites in Known or Suspected COVID-19 Adult Patients: A Practical Review.

Current evidence suggests that coronavirus disease 2019 (COVID-19) spread occurs via respiratory droplets (particles >5 µm) and possibly through aerosol. The rate of transmission remains high during airway management. This was evident during the 2003 severe acute respiratory syndrome epidemic where those who were involved in tracheal intubation had a higher risk of infection than those who were not involved (odds ratio 6.6). We describe specific airway management principles for patients with known or suspected COVID-19 disease for an array of critical care and procedural settings. We conducted a thorough search of the available literature of airway management of COVID-19 across a variety of international settings. In addition, we have analyzed various medical professional body recommendations for common procedural practices such as interventional cardiology, gastroenterology, and pulmonology. A systematic process that aims to protect the operators involved via appropriate personal protective equipment, avoidance of unnecessary patient contact and minimalization of periprocedural aerosol generation are key components to successful airway management. For operating room cases requiring general anesthesia or complex interventional procedures, tracheal intubation should be the preferred option. For interventional procedures, when tracheal intubation is not indicated, cautious conscious sedation appears to be a reasonable approach. Awake intubation should be avoided unless it is absolutely necessary. Extubation is a high-risk procedure for aerosol and droplet spread and needs thorough planning and preparation. As updates and modifications in the management of COVID-19 are still evolving, local guidelines, appraised at regular intervals, are vital in optimizing clinical management.

Enhancing safety of laparoscopic surgery in COVID-19 era: clinical experience with low-cost filtration devices.

BACKGROUND: Surgery in the era of the current COVID-19 pandemic has been curtailed and restricted to emergency and certain oncological indications, and requires special attention concerning the safety of patients and health care personnel. Desufflation during or after laparoscopic surgery has been reported to entail a potential risk of contamination from 2019-nCoV through the aerosol generated during dissection and/or use of energy-driven devices. In order to protect the operating room staff, it is vital to filter the released aerosol. METHODS: The assemblage of two easily available and low-cost filter systems to prevent potential dissemination of Coronavirus via the aerosol is described. RESULTS: Forty-nine patients underwent laparoscopic surgeries with the use of one of the two described tools, both of which proved to be effective in smoke evacuation, without affecting laparoscopic visualization. CONCLUSION: The proposed systems are cost-effective, easily assembled and reproducible, and provide complete viral filtration during intra- and postoperative release of CO2.

Response and Operating Room Preparation for the COVID-19 Outbreak: A Perspective From the National Heart Centre in Singapore.

The outbreak of coronavirus disease 2019 (COVID-19), a respiratory disease from a novel coronavirus that was first detected in Wuhan City, Hubei Province, China, is now a public health emergency and pandemic. Singapore, as a major international transportation hub in Asia, has been one of the worst hit countries by the disease. With the advent of local transmission, the authors share their preparation and response planning for the operating room of the National Heart Centre Singapore, the largest cardiothoracic tertiary center in Singapore. Protection of staff and patients, environmental concerns, and other logistic and equipment issues are considered.