Korean J Anesthesiol > Volume 73(6); 2020 > Article |
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Author Contributions
Sharon Ong (Conceptualization; Data curation; Formal analysis; Methodology; Project administration; Supervision; Validation; Writing – original draft; Writing – review & editing)
Wan Yen Lim (Data curation; Formal analysis; Methodology; Validation; Writing – original draft; Writing – review & editing)
John Ong (Data curation; Formal analysis; Methodology; Supervision; Validation; Writing – review & editing)
Peter Kam (Conceptualization; Formal analysis; Investigation; Methodology; Supervision; Validation; Writing – review & editing)
Country | Australia [10,11] | Canada [12,13] | China [14–16] | India [17] | Italy [18,19] | South Africa [20] | South Korea [21] | Taiwan [22] | UK [23,24] | US [25–28] |
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Training | Donning & doffing PPE | Donning & doffing PPE | Donning & doffing PPE; Streaming lectures online | Donning & doffing PPE | Donning & doffing PPE | Donning & doffing PPE | Donning & doffing PPE | Donning & doffing PPE | Donning & doffing PPE | Donning & doffing PPE |
Simulation | e.g. Category 1 Caesarean delivery, airway crisis, major hemorrhage | e.g. airway emergency | e.g. Category 1 Caesarean delivery | Intubation/ extubation drills wearing PPE | Possible scenarios and multi-disciplinary teams | Not stated | Not stated | Not stated | e.g. Category 1 Caesarean delivery | e.g. Category 1 Caesarean delivery & airway crisis |
Prioritization | Postpone elective surgery. Pandemic surgical framework | Not stated | Postpone elective surgery | Defer elective/ semi-emergency surgery | Not stated | Surgery based on acuity. Postpone elective surgery | Not stated | Not stated | Postpone elective surgery | Postpone elective surgery, surgical review committee |
Patient screening | History taking including respiratory symptoms; appropriate triage & prompt isolation of patients | Perform airway assessment with PPE on | Elective cases | History taking (including fever, cough, sore throat and travel history) should be elicited | Not stated | Preoperative screening for acute respiratory illness, pneumonia, contact and travel history, contact with healthcare facility managing COVID-19 patients | Not stated | Not stated | MACOCHA score to predict difficult intubation and prepare strategy | Screen patient for fever, cough, dyspnea, diarrhea & contact history |
Telemedicine for anesthesia consult | History (travel & contact history, respiratory symptoms) & examination | Actively counsel patient to postpone elective surgery | Phone or video assessment for pre-anesthesia encounter | |||||||
Referral to infection control if temp > 37.3℃ | PCR Testing based on population prevalence | |||||||||
Emergency cases | ||||||||||
As above plus Chest Xray or CT | ||||||||||
Resource planning | Team-brief | Not stated | Smaller group to lead airway management in COVID-designated hospitals | Multiple tracheal intubation teams | Team-brief | Team of 5 : 3 in OT and 2 outside as runners | Replace anesthesia team every 2 hours to avoid fatigue | Not stated | Team-brief; Communication checklist; Cognitive aid | Team-brief; Communication checklist |
Smaller group to lead airway management | Standby doctor with donned PPE outside chamber | COVID cart with equipment & drugs | Exclude high-risk staff during airway management | |||||||
OT | Negative pressure isolation room | Negative pressure isolation room | Negative pressure isolation room | Designated OT with filters (lack of negative pressure OT) with dedicated anesthesia machine | Negative pressure isolation room | Negative pressure OT | Negative pressure OT | Not stated | Negative pressure OT with > 12 air changes | Designated negative pressure isolation OT |
Warning signs on OT doors | Warning signs on OT doors | Warning signs on OT doors | Warning signs on OT doors | Warning signs on OT doors | Warning signs on OT doors | |||||
Patient transfer | To OT with surgical mask | Not stated | To OT with surgical mask | Do not keep patient in holding area | Direct route to OT with surgical mask | Direct route to OT with surgical mask. | Plan ahead for patient transfer. | Not stated | To OT with surgical mask | To OT with surgical mask |
Porters to clear the path | Do not keep patient in holding area | Do not keep patient in holding area | Do not keep patient in holding area | |||||||
Infection control | Airborne precautions | Airborne precautions | Airborne precautions | Airborne precautions | Airborne precautions | Airborne precautions | Airborne precautions | Airborne precautions | Airborne precautions | Airborne precautions |
PPE | N95 mask, face shield or goggles, gown, hat, double gloves for airway procedures | N95 mask or PAPR, face shield or goggles, gown, hat, double gloves | N95 mask or PAPR, face shield or goggles, gown, shoe covers, hood, and double gloves | N95/N99 mask, eye protection, gown, boot covers, hat, double gloves | N95 mask or PAPR device, face shield or goggles, gown, shoe covers, and double gloves | N95 mask, face shield or goggles, gown, shoe covers, and double gloves (PAPR for intubation & extubation) | N95 mask, face shield or goggles, protective coverall/ body suit, shoe covers, and double gloves (PAPR for intubation & extubation) | N95 mask or PAPR device, face shield or goggles, gown, and double gloves | N95 mask, eye protection, gown, double gloves | N95 mask or PAPR device, face shield or goggles, gown, and double gloves |
PAPR only for trained staff or if performing multiple procedures | Buddy System when donning PPE | Buddy System when donning PPE | Hand hygiene is essential before donning and after doffing PPE | Buddy System when donning PPE | Use “anti-fog” for goggles | Not stated | Buddy System when donning PPE | Buddy System when donning PPE | Buddy System when donning PPE | |
Buddy System when donning PPE | Hand hygiene is essential before donning and after doffing PPE | Hand hygiene is essential before donning and after doffing PPE | Hand hygiene is essential before donning and after doffing PPE | Buddy System when donning PPE | Hand hygiene is essential before donning and after doffing PPE | Hand hygiene is essential before donning and after doffing PPE | Hand hygiene is essential before donning and after doffing PPE | Hand hygiene is essential before donning and after doffing PPE | ||
Hand hygiene is essential before donning and after doffing PPE | Hand hygiene is essential before donning and after doffing PPE | |||||||||
Staff to handover all personal belongings to buddy/runner to avoid them becoming fomites | ||||||||||
Equipment | 2 viral filters placed in circuit | Hydrophobic/ HEPA filter between circuit & ETT | 2 viral filters placed in circuit (between ETT & circuit; & between circuit & machine) | 2 viral filters placed in circuit (between ETT & circuit; & between circuit & machine) | Filter placed in circuit | High efficiency Hydrophobic filter on every oxygen interface | HEPA filter between circuit & ETT | HEPA filter between circuit & ETT | HME filter between catheter mount & circuit | HEPA or HME filter between circuit & ETT, gas sampling tubing protected by HEPA filter |
Forced air warming blankets only in intubated patients | Use disposable equipment if possible | Use disposable equipment if possible | Dedicated equipment | Preload closed suction device on anesthesia circuit | Use disposable equipment if possible | Use disposable equipment if possible | Create a COVID-19 tracheal intubation trolley | Use disposable equipment if possible | ||
Use disposable equipment if possible | Use disposable equipment if possible | Use disposable equipment if possible | Use disposable equipment if possible |
PPE: personal protective equipment, MACOCHA: Mallampati III/IV, sleep apnea, decreased cervical mobility, mouth opening < 3 cm, Coma GCS < 8, severe Hypoxemia, practitioner not an Anesthetist. CT: computed tomography, PCR: polymerase chain reaction, OT: operating theatre, PAPR: powered air-purifying respirator, HEPA: high-efficiency particulate air, ETT: endotracheal tube, HME: heat and moisture exchanger.
Country | Australia [10,11] | Canada [12,13] | China [14–16] | India [17] | Italy [18,19] | South Africa [20] | South Korea [21] | Taiwan [22] | UK [23,24] | US [25–28] |
---|---|---|---|---|---|---|---|---|---|---|
Anesthesia Technique | Regional technique where possible | Not stated | Regional technique where possible | Regional technique where possible | Not stated | Not stated | Not stated | Not stated | Not stated | Regional technique where possible |
Induction | Limit staff present due to potential aerosolization | Limit staff present due to potential aerosolization | Limit staff present due to potential aerosolization | Limit staff present due to potential aerosolization | Limit staff present due to potential aerosolization | Limit staff present due to potential aerosolization | Not stated | Not stated | Limit staff present due to potential aerosolization | Limit staff present due to potential aerosolization |
Airway Management | Most experienced clinician | Most experienced clinician | Most experienced clinician | Most experienced clinician | Most experienced clinician | Most experienced clinician | Most experienced clinician | Not stated | Most experienced clinician. | Most experienced clinician |
Intubation | Use of video- laryngoscope; optimize position | Use of video- laryngoscope | Use of video- laryngoscope (Asleep fiberscope intubation by trained staff) | Use of video- laryngoscope | Use of video- laryngoscope | Use of video- laryngoscope with pre-loaded introducer | Use of video- laryngoscope | Use of video- laryngoscope | Use of video- laryngoscope; optimize position | Use of video- laryngoscope |
Clear plastic cover over patient | ||||||||||
R냐 | RSI | RSI | RSI | RSI | (modified) RSI | RSI | RSI | RSI | RSI | |
(Intubation recommended over SAD) Introducer for intubation (stylet/bougie) | Consider induction with Ketamine or use vasopressors in hemodynamic instability | Consider induction with Ketamine or use vasopressors in hemodynamic instability | ||||||||
Neuromuscular blocker | Neuromuscular blockade | Neuromuscular blockade | Neuromuscular blockade | Neuromuscular blockade | Neuromuscular blockade | Neuromuscular blockade | Neuromuscular blockade | Neuromuscular blockade | Neuromuscular blockade | |
Avoid PPV until ETT cuff inflation. Disconnect mask & HME from circuit to avoid ongoing flow of oxygen out through filter | Avoid PPV until ETT cuff inflation | Avoid PPV until ETT cuff inflation | Avoid PPV until ETT cuff inflation | Avoid PPV until ETT cuff inflation | Avoid PPV until ETT cuff inflation | Not stated | Avoid PPV until ETT cuff inflation | Avoid PPV until ETT cuff inflation | Avoid PPV until ETT cuff inflation | |
Ensure tracheal tube cuff pressure ≥ 5 cmH2O above peak inspiratory pressure | ||||||||||
Awake fiberoptic intubation | Avoid | Not stated | Avoid | Avoid | Avoid aerosol with topicalization | Not stated | Avoid; Avoid aerosol with topicalization | Avoid | Avoid | Avoid |
Rescue – Insert SAD if failed 2nd attempt | ||||||||||
Difficult Airway | Vortex approach | Not stated | Not stated | Not stated | Intubate through SAD with flexible endoscope | After failed intubation Plan B: 2nd generation SAD; Plan C: Two-handed mask ventilation | Not stated | Not stated | Safe, Accurate, Swift; emergency FONA (Scalpel bougie); Consider intubation via SAD (blind/ bronchoscope assisted) | Not stated |
Surgical airway if cannot intubate and oxygenate | CICO, for early cricothyroidotomy | Plan D: emergency FONA | ||||||||
Supraglottic airway device (SAD) | Insert SAD if failed intubation (2nd generation SAD preferred) | SAD for airway rescue | SAD preferred to intubation to minimize coughing at extubation | For airway rescue | Insert SAD if failed intubation (2nd generation SAD preferred) | SAD for airway rescue | For manual ventilation instead of face mask ventilation | SAD for airway rescue | 2nd generation SAD preferred. | Not stated |
Careful patient selection; controlled ventilation & low peak airway pressures; Intubate if leak is significant | ||||||||||
Methods of oxygenation | Avoid HFNO; minimize sedation & supplemental oxygen; lung protective ventilation | Avoid HFNO & non-invasive ventilation | Not stated | Avoid high flow oxygen | Use nasal apneic oxygenation 3 L/min Balance risk of viral transmission vs HFNO | Avoid high-flows and extreme positive pressure ventilation | Avoid high flows and HFNO | Avoid HFNO & non-invasive ventilation | Avoid HFNO & non-invasive ventilation | Not stated |
Extubation | Closed loop suctioning; | Prophylactic antiemetics to minimize vomiting | Closed-loop suctioning | Closed-loop suctioning; prophylactic antiemetics to minimize vomiting | Closed-loop suctioning | Consider antiemetics | Not stated | Consider glycopyrrolate or atropine to minimize secretions | Closed-loop suctioning; consider opioids, lidocaine/ dexmedetomidine | Closed-loop suctioning; Prophylactic antiemetics to minimize vomiting and possible viral spread. |
Deep extubation, Consider opioids, lidocaine/ | Cover patient’s nose and mouth with wet gauze | Plastic sheet to reduce droplet dispersion | ||||||||
Dexmedetomidine | ||||||||||
SAD exchange to avoid coughing | ||||||||||
Recovery of patient | Recover in OT; Surgical mask placed over oxygen mask | Not stated | Recover in OT | Patient to wear surgical mask; oxygen mask over surgical mask | Not stated | Recover in OT | Recover in OT | Not stated | Recover in OT | Recover in OT |
Surgical mask placed over oxygen mask/nasal prong | Surgical mask placed over oxygen mask/nasal prong | |||||||||
Ventilators on standby for circuit disconnection |
Country | Australia [10,11] | Canada [12,13] | China [14–16] | India [17] | Italy [18,19] | South Africa [20 | South Korea [21] | Taiwan [22 |
---|---|---|---|---|---|---|---|---|
Patient transfer | ICU transfer plan; minimize circuit disconnection; clamp ETT, paralyze before disconnection | Minimize circuit disconnection, clamp ETT | Single-use Ambu bags preferred for intubated patients, avoid ventilator use | Single-use Ambu bag preferred for intubated patients; | Minimize circuit disconnection, clamp ETT; ventilator on standby | Not stated | Not stated | Not stated |
Use dedicated lift and lobby | ||||||||
Post-operative cleaning & disinfection | OT cleaning as per local protocol | As per hospital terminal cleaning protocol | Environmental disinfection | Environmental disinfection | Not stated | Not stated | Not stated | OT cleaning as per local protocol |
Maintain airborne precautions for staff entering OT for at least 30 min | (2–3% hydrogen peroxide spray disinfection, 2–5 g/L chlorine disinfectant/75% alcohol wiping of solid surfaces of equipment & floor) | (2–3% hydrogen peroxide, 2–5 g/L chlorine disinfectant/75% alcohol wiping of solid surfaces of equipment & floor) | ||||||
Post-op handling of equipment | Waste disposal in labelled bins | Waste disposal in labelled bins | Waste disposal in labelled bins (double-bagged) | Waste disposal in labelled bins (double-bagged) | Waste disposal in labelled bins | Dispose all used airway equipment in double zip-locked bag | Dispose all used airway equipment in double zip-lock bag | Dispose all used airway equipment in double zip-lock bag |
Replacement of filters & breathing circuits; seal equipment in zip-lock bag | Replace end-tidal carbon dioxide sample lines & traps | Replace end-tidal carbon dioxide sample lines & traps | ||||||
Debriefing | Debriefing post event | Timely feedback, encourage incident reporting | Not stated | Not stated | Debriefing post event | Not stated | Not stated | Not stated |
Staff monitoring & welfare | Staff: complete logbook of clinical exposures | Not stated | Daily temperature check: monitor respiratory symptoms and inform occupational med team. | Social distancing measures for staff | Not stated | Not stated | Not stated | Not stated |
Regular communication updates | Wellness resources | May require blood tests and chest CT, consider isolation | Wellness resources on mental health and communicating with empathy | |||||
Consider influenza vaccination | ||||||||
Pregnant staff deployed to areas away from COVID-19 patients | ||||||||
Wellness resources |