By Michael Vlessides

In a little more than three months, the novel coronavirus has disrupted lives, financial markets, medical meetings and travel plans around the world. And chances are the disease has likely already made an appearance in your OR.

So how can anesthesiologists and the institutions in which they work protect themselves and other patients from the novel virus? In a recent communication, the Anesthesia Patient Safety Foundation (APSF) published a series of perioperative considerations for COVID-19.

“We honestly don’t know where this could end up,” said Michael Aziz, MD, an author of the APSF communication. “We’re getting reports from northern Italy, from doctors at well-running institutions in a reasonably well-running health care system, and it’s quite disastrous.


“I don’t think anyone’s assuming we’re going to get there, but a lot of physicians are preparing for that same situation, and I think we have to,” said Dr. Aziz, a professor of anesthesiology and perioperative medicine at Oregon Health & Science University, in Portland.

Anesthesiologists at Risk

As the APSF noted, human-to-human transmission of the virus is commonplace, presenting a serious risk for health care professionals. For their part, anesthesia providers and intensivists are at greatest risk for exposure if there is direct contact with respiratory droplets when managing patients’ airways, primarily during intubation and extubation. As such, the APSF noted that it is “imperative to implement measures to mitigate perioperative transmission.”


With that in mind, the foundation presented a series of perioperative safety measures that should be standard practice in the anesthesia work environment, beginning with hand hygiene. The foundation reminded clinicians that frequent handwashing—the single most important hygiene measure to protect against cross infection—must be actively enforced. Hand hygiene must be meticulously performed in accordance with standard guidelines; alcohol-based gels should be located on or near every anesthesia workstation.

“I think it always comes back to the basics with contact precautions and hand hygiene,” Dr. Aziz said. “Of course, you don’t want to get coughed on, but patients rarely cough into our faces. What’s much more common is that our hands are in our faces after we’ve touched things that may be contaminated. That’s why it always comes back to the hands—it’s a probability game.”


PPE Protocols Emphasized

With respect to personal protective equipment (PPE), the APSF recommended that these be made available to all providers and appropriate protocols should be reviewed. PPE includes the following:

  • N95 masks, although powered air-purifying respirators provide superior protection and may be called for during airway procedures in patients with known or suspected COVID-19.
  • Disposable OR caps and beard covers should be worn, which can help protect against possible contamination from hair that may have been exposed to infected droplets.
  • Disposable fluid-resistant long-sleeved gowns, goggles and full-face shields should be the norm for front-line medical staff at highest risk for exposure.

Of note, the APSF advised that consideration be taken to avoid intubations in rescue or crash situations where PPE protocols cannot be fully maintained. The foundation also suggested a lowered threshold for planning elective or semielective intubations in relevant cases. “Given the risk of transmission with non-invasive ventilation,” they wrote, “we recommend proceeding early directly to endotracheal intubation in patients with acute respiratory failure.”

The APSF also offered advice regarding intubation and extubation, noting that PPE, including double gloving, should be worn and the number of staff present for these procedures limited. Intubating equipment should be prepared and disposed of directly beside the patient to limit the possible distance that contaminated equipment may travel. Finally, clinicians should consider the use of prophylactic antiemetics, which will help reduce the risk for vomiting and possible viral spread.

Airway Precautions

The foundation made a series of recommendations in patients with suspected COVID-19, which they adapted from an editorial by Kamming et al (Br J Anaesth 2003;90[6]:715-718). In brief, the recommendations begin with two general precautions:

  • Suspected or confirmed cases should not be brought to holding or PACU areas, but instead an OR designated for such cases. Infected people should be recovered in the OR or transferred to a negative pressure room.
  • Make your own personal protection a priority by wearing PPE and taking careful steps to avoid self-contamination.

These recommendations are followed by eight precautions to be taken during airway manipulation:

  • Apply an N95 respirator or powered air-purifying respirator along with other PPE, including double gloving.
  • If possible, have the most experienced anesthesia provider perform the intubation; trainee intubations of sick patients should be avoided.
  • Unless indicated, avoid awake fiber-optic intubation, as atomized local anesthetic will aerosolize the virus.
  • Preoxygenate patients for a minimum of five minutes with 100% oxygen, which will help avoid manual ventilation and potential aerosolization of the virus from the patient’s airways.
  • Perform rapid sequence induction or modified rapid sequence induction as indicated. For manual ventilation, apply small tidal volumes.
  • Ensure placement of a high-quality heat and moisture exchanger rated to remove at least 99.97% of airborne particles of at least 0.3 mcm, either between the face mask and breathing circuit or between the face mask and reservoir bag.
  • Resheath laryngoscopes immediately after intubation, and seal all used airway equipment in a plastic double reclosable zipper bag. This equipment must then be decontaminated and disinfected.
  • Wash hands before touching your hair or face after removing PPE.

As Dr. Aziz explained, institutional initiatives also may help to protect the health of practitioners. “I think every hospital at this point needs some kind of central command center and a source of communication that shares messages and keeps clinicians updated. The CDC is changing things every day, and it’s hard to keep on top of the updates. Each institution needs a single message source so they can be in line with the authorities.

“The other big thing is equipment,” he added. “Someone needs to keep count of how many ventilators and dialysis machines there are, how much personal protective equipment is on hand. Because if you look at the projections, it’s likely that something is going to run out.”

An International Perspective

D. John Doyle, MD, PhD, explained that the Cleveland Clinic Abu Dhabi has established a corporate COVID-19 task force and hotline to prepare for the possibility that the pandemic will substantially affect the institution.

“A separate anesthesia task force was set up to identify best practices regarding intubation,” commented Dr. Doyle, a consultant in the Department of Anesthesiology at the United Arab Emirates institution. “We based our COVID-19 response planning on the APSF document regarding perioperative considerations for coronavirus, as well as on several other published resources.”

At the institution, instructional videos and educational posters regarding the appropriate use of PPE, powered air-purifying respirators, and other relevant information were distributed widely. “Additionally, we have been in telephone contact with a number of Italian physicians working in the clinical trenches to get up-to-date practical advice,” Dr. Doyle continued. “Everyone is handwashing obsessively. Handshakes have been largely replaced with other forms of greeting. We are taking the whole business very seriously.”

The complete text of the APSF communication can be found at www.apsf.orgdsrqwxywecevuxyyvsdcrxyz. The APSF also made an infographic available for clinicians and institutions to distribute freely.