COVID Operation Theatre- Advisory and Position Statement of Indian Society of Anaesthesiologists (ISA National)

Abstract

Corona virus disease 2019 (COVID-19) caused by SARS-CoV-2 has spread worldwide and has affected millions of people. Patients with COVID-19 may have to undergo elective or emergency surgical procedures under local or general anaesthesia. It is advisable to postpone elective surgeries in such patients, even if they are asymptomatic, till the time they test negative for this virus. There are reports of higher incidence of morbidity and mortality in COVID infected patients following surgery. However, emergent surgeries would be required to be carried out, like cesarean sections, acute abdominal conditions, pediatric and neonatal emergencies, trauma, tracheostomies in Intensive Care Unit (ICU) and the like. Such emergency surgical procedures necessitate setting up of dedicated COVID OPERATION THEATRES (COVID OT). SETTING UP COVID OT Name of Operation Theatre Dedicated Operation Theatres are to be used for all confirmed or suspected COVID-19 infected patients These operation theatres should be labeled as “COVID-19 Operation Theatre (COVID OT)” Large clear bill boards and signage in local language and/or english, visible from a distance, should be placed outside such OTs Number of Operation Theatres Ideally, there should be 2 COVID OTs: One for obstetrical surgical procedures Second for general surgery/orthopaedics/other surgical procedures for all age groups Location The operation theatres should be located in the dedicated COVID Block/Centre There should not be any adjoining inhabited buildings within 20 meters COVID OTs should be preferably located near to COVID ICU, High Dependency Unit (HDU), Isolation ward and Emergency ward Changing Room There should be separate changing rooms for male and female heath care workers with attached toilet and shower facilities Ideally, independent changing rooms with toilet and shower facility should be there for doctors, nurses and support staff There should be provision for opening the doors with feet or elbow without touching the handles Donning Area There should be a dedicated donning room adjacent to the scrub room The pre-sterilized Personal Protective Equipment (PPE) Kits should be available in adequate number in donning area. It should have chairs and hand sanitization facility. Doffing Area There should be a dedicated doffing room with hand sanitization facility and waste collection bins Used PPEs should be disposed as per the Bio Medical Waste Management guidelines Separate Entry and Exit The entry to the donning area and the exit from the doffing area should be separate so that there is no “mixing up” of the health care workers entering and leaving the operation theatres Air Conditioning of OT Airborne infection isolation requirements (AIIR) have to be strictly enforced The most important factor in COVID -19 pandemic is to ensure that the virus laden airborne particles do not leak out of the rooms occupied by COVID-19 patients and also to maintain the concentration of virus laden particles inside the COVID-19 patient room at a minimum. This is required to control the spread of infections and also to protect the healthcare workers As it is in normal practice, most of the OTs would be served by a Heating, Ventilating, Air Conditioning (HVAC) system that would be of a recirculatory type, wherein the air from the OT is taken back to the air handling unit (AHU) for thermal conditioning and brought back The same HVAC system can also be connected to a few other areas of the hospital. In some cases, there may be no dedicated return air duct but only a ceiling return system. If a COVID-19 patient has to be operated in such an OT, it will present a significant risk of the virus laden particles spreading out from the designated COVID OT Since, majority of operation theatres in India are not negatively pressurized, the positive pressure system and central air conditioning must be turned off To convert an existing OT into a COVID OT, it is first necessary to convert the OT into a non-recirculatory system (100% once through system) On an emergency basis, this can be achieved by blanking (blocking) off the return air vents in the OT. It is important to make sure that the AHU will have provision to receive adequate outdoor air supply. The outdoor air source for the AHU shall not be from within the building and all care shall be taken to avoid intake of outdoor contaminants, to the best possible extent. Additionally, an independent exhaust blower shall be provided to extract the room air and exhaust out into the atmosphere, preferably, after suitable “exhaust air treatment” The exhaust air quantity should be greater than the supply air quantity so that a negative pressure of minimum 2.5 Pa (preferably >5 Pa) is achieved in the room. The supply air quantity should provide a minimum of 12 air changes per hour. The position of the extract air duct in the OT should be just above the head of the patient As a next best possible option, the COVID OT can have stand alone room air-conditioners. Room air conditioners re-circulate air within a single occupied zone. Two split air-conditioners of 2 tons refrigeration capacity per OT are usually required. Recirculation of cool air by room air conditioners, must be accompanied by outdoor air intake through slightly open windows and exhaust by natural exfiltration. Fresh air intake through a fan filter unit will prevent outdoor dust entry (containing high levels of PM 10 and PM 2.5 particles) and exhaust fans should be kept operational. Set the room temperature between 24°C and 30°C. Maintain relative humidity between 40% and 70%. (In humid climates set the temperature closer to 24°C for de-humidification and in dry climates closer to or at 30°C and use fans to increase air movement) This will make working somewhat comfortable while wearing personal protective equipment (PPE), especially during the summers Negative pressure could be created by putting up 2-3 exhaust fans which will drive air out of the room. However, exhaust fans can lead to significant noise pollution and some compromise in OT sterility For respiratory isolation, an isolator with a filtered air supply and exhaust can be applied over the patients face Treatment of exhaust air can be done preferably by high efficiency particulate air (HEPA) filtration. When not possible, treatment of exhaust air by chemical disinfection (1% hypochlorite) is acceptable. When both the methods are not feasible, the exhaust air shall be let off into the atmosphere through an upward plume at a height of 3 m above the tallest point of the building, thereby lowering the viral load concentrations to insignificant levels by dilution. This exhaust discharge shall be well away from other air intake points and populated places. The other two options available for exhaust air treatment being Ultraviolet (UV) irradiation (15 minutes) and heating (45 min at a temperature of 75°C) Planning should be started urgently for dedicated central air conditioning for COVID OT with provision for altering the pressure in OT (making it negative pressurized). The system should have HEPA filters and there should be no leaks in exhaust ducts. Suitable renovation/modification should be carried out in this regard so that there is no mixing up of the air between COVID and non COVID operation theatres Ideally there should be central air conditioning with dedicated fresh air cycles depending upon the size of the operation theatre with HEPA filters and independent AHU. Remove all non-essential equipment and gadgets Only essential items should be inside the operation theatre They should be easy to clean and do not conceal or retain dirt or moisture within or around them Do not put extra/stand by equipment, trolleys, consumables inside the COVID OT Place all equipment and drugs essential for the anaesthetic management in a tray and avoid handling of the drug trolley during the case Similarly, the surgical equipment, linen and dressings which are essential should be kept ready on separate trolleys Transparent Plastic Sheet Covers Cover all monitors, cables, anaesthesia work station/machine, cautery, operation table, patient trolley, etc with transparent, water resistant plastic sheets. These plastic coverings should be removed and changed after each case Disposable equipmentUse disposable equipment as far as possible, like-breathing circuits, face mask, tracheal tubes, etcHeat and Moisture Exchanger with Viral Filters (HMEFs) Place two high quality Heat and Moisture Exchange Filters (HMEFs). First, between tracheal tube and breathing circuit; and the second between expiratory limb and anaesthesia machine These HME filters can remove up to 99% of airborne particles of size 0.3 microns or greater, thus helping in preventing contamination of OT atmosphere Apply a third HMEF on tracheal tube itself, if feasible Scavenging Active scavenging is not available in majority of the hospitals It is suggested that corrugated tubing can be applied to the scavenging port and that can be dipped in a bucket with 1% hypochlorite solution Suitable PPE should be used while handling the hypochlorite solution and direct contact with skin and eyes should be avoided Aerosol generating procedures (AGP) Aerosol generating medical procedures are tracheal intubation and extubation, suctioning, nebulization, CPAP, BiPAP or high-flow nasal oxygen therapy, bronchoscopy, etc Aerosolization is also increased when more than one attempt at intubation is required. The chances of exposure to the virus are maximum during such high aerosol generating procedures During AGPs, all health care workers should always wear full component of proper PPE Kit (Cover all gown, N95 mask, eye shield, cap, double gloves, shoe cover) Number of personnel inside the COVID OT There should be minimum required personnel inside the COVID OT On an average 7-8 PPE Kits are required for a surgical procedure: Surgeons: 2 (1, if feasible) Nurse: 1 Anaesthesiologists: 2 (1, if feasible) Anaesthesia Technician: 1 (if 2 anaesthesiologists, then not required) Paediatrician: 1 (for cesarean section) Resource Person: 1 (OT Master/Bearer) Sweeper: 1 Transfer Personnel: 1 Personal Protective Equipment (PPE) Kit All operation theatre staff should wear PPE including anaesthesiologists, surgeons, nurses, technician, bearer, sweeper, etc Wear certified and proper Personal Protective Equipment (PPE). Use of uncertified and spurious protective gear will give a false sense of security and is hazardous Sample Specifications of Personal Protection Kit (PPE) are:A Sterile set containing- Cover All - 1 Single piece wearable coverall with head hood cap (jacket or nun type), impermeable to blood and body fluids Medium and Large size, light colour Thumb/finger loops to anchor sleeves in place Quality compliant with following standard: Meets or exceeds ISO 16603 class 3 exposure pressure, or equivalent Due to scarcity of coveralls, and risk versus benefit, and considering this as an emergency temporary measure in larger public interest, in present given circumstances, the fabric that cleared/passed 'Synthetic Blood Penetration Resistance Test' (ISO 16603) and the garment that passed 'Resistance to penetration by biologically contaminated solid particles (ISO 22612:2005) may be considered as the benchmark specification to manufacture Coveralls. The Coveralls should be taped at the seams to prevent fluid/droplets/aerosol entry. The test for these two standards (ISO 16603 and ISO 22612:2005), which can be performed in Indian laboratories are as per WHO Disease Commodity Package (Version 4.0) N-95 respirator mask- 1 Shape that will not collapse easily and can be worn with full- face shield High filtration efficiency of at least 95% against particulate aerosols of < 0.3 microns Good breathability, with expiratory valve Quality compliant with standards for medical N95 respirator: NIOSH N95, EN 149FFP2, or equivalent Fluid resistance: minimum 80 mmHg pressure based on ASTM F1862, ISO 22609, or equivalent Shoe Cover - 1 pair Made of same material as coverall Should cover the entire shoe and reach above ankles, preferably up to mid- calf. Goggles - 1 Transparent glasses, zero power, well fitting, covered from all sides Goggles should also be able to accommodate prescription glasses Goggles should have an adjustable band which should secure firmly so as not to become loose during clinical activity Face shield/visor - 1 Made of clear plastic for full face protection with padded support on fore head area and comfortable elastic band Completely covers the sides and length of the face May be re-usable (made of material which can be cleaned and disinfected) or disposable Sterile gloves-2 pairs Waste collection Bag-1All the items supplied need to be accompanied with certificate of analysis from national/international organizations/labs indicating conformity to standards 17. Communication Issues It is difficult to communicate with PPE on, so the team should practice sign language for easy, quick and correct communication 18. Telephone Facility No bag, purse, mobile phone is allowed inside the OT If intercom facilities are not available inside the OT, then one mobile phone with transparent plastic covering can be used for communicating with medical personnel and support staff outside the OT 19. Oxygen Supply There should be adequate oxygen reserve Any oxygen/nitrous oxide cylinder inside the OT should be considered as infected It should be cleaned with 1% sodium hypochlorite before being sent for refilling 20. Sterilization and Decontamination There should be enough time between two cases (approximately one hour) to allow OT staff to send the patient back to the ward, conduct thorough decontamination of all surfaces, screens, keyboard, cables, monitors, anaesthesia machine, etc The agents used in decontamination are hydrogen peroxide spray disinfection (through vaporized hydrogen peroxide generator (VHPG), 1% sodium hypochlorite solution, or 75% alcohol wiping off solid surfaces of the equipment and floor. All floors and walls to be cleaned with 1% sodium hypochlorite solution Before starting the decontamination, the staff has to remove the outer hand gloves Discard breathing circuit, mask, tracheal tube, HME filters, gas sampling line and soda lime after every surgery. Water trap to be changed if it becomes potentially contaminated All surgical linen and dressings, markers, etc. are to be discarded All unused items on the drug tray and airway trolley should be assumed as contaminated and to be discarded Seal all used airway equipment in a double zip-locked plastic bag. It must then be removed for decontamination and disinfection The histo-pathological specimens are to be kept in tight fit plastic boxes which are then sealed in plastic bags. The plastic bags are then clean before for The equipment to be kept in 1% sodium hypochlorite solution for an hour. They are then and They are put in boxes and covered with plastic bags All the equipment being sent to Sterile Supply should be covered by plastic bags which should be All such equipment should be in a dedicated area and should not be with OT equipment from areas of the hospital. It is to have an near the COVID OT The surfaces of and the should also be cleaned with sodium hypochlorite and to be performed in COVID OT The need for a surgical will be all including surgeons, anaesthesiologists, patient and The of the team to a surgical will not be in suspected COVID-19 patients The team will on and of and in an area with high incidence of COVID-19 or etc The of team to a patient as suspected COVID positive will not be In the patient team is ready including anaesthesiologists, bearer, then COVID-19 infected patient is through a to the operation theatre The patient should be into the OT The patient should not in room at all The patient should wear operation theatre cap, and should be covered with a plastic surgical or N95 must be applied to the patient the length of in the room the patient should be done on the table, as far as possible place the surgical over the patient after tracheal The patient is in the operation theatre The patient should not be kept in room and should be to the isolation ward In isolation ward, patient should be and oxygen should be if required If tracheal is not feasible, then the patient to designated Intensive Care Unit (ICU) If the patient is kept a single patient use with HME viral filter attached must be used during Transfer of the patient to isolation The personnel the existing PPE and the then fresh PPE and the patient on a or trolley to The patient should be covered with plastic and then through a dedicated and The patient must wear a surgical or N95 during Use of Blood There have no or suspected cases of are not at risk of COVID-19 through the blood or a blood respiratory are not to be by or blood are used and ensure that blood are well and of respiratory There are no of blood to a COVID patient The to and blood bags in the COVID OT have to be regard to from to or that is the of affected and the to the is to be there are no cases of and being positive for SARS-CoV-2 It is to do neonatal after a cesarean in the second OT (if or just outside the COVID OT to the exposure to the and or used in can of surgical during or open is usually achieved On a surgical plume is created which is a source of contamination including blood and potentially There is a for viral under pressure on There is that SARS-CoV-2 is present in surgical However, other have in surgical during and other aerosol generating procedures use of may the viral load and would more to use for of must be performed by an attached to a HEPA filter to prevent into the room the COVID OT number of staff required will work in in COVID OT for of the staff working in COVID OT should be In between the the staff working in COVID OT not to will have to be given suitable by the will have to the to the risk of the two This will in separate or This can work both clinical and The staff will have to be and kept Any health care like should Do for correct donning and doffing of Personal Protective Equipment (PPE) including cover all gown, face mask, eye and gloves of a surgical from in to out the patient from operation theatre should also be done to and COVID OT putting on the OT to scrub room and scrub to the Donning Room and wear pre-sterilized Personal Protective Equipment (PPE) anaesthesia to be In case oxygen is the oxygen is applied over the surgical or N95 For general for with high oxygen to prevent the patient not to It is to cover the and with two of to some of the In and can be used The of drugs is by with or depending upon can be used for is for If no are 1 should be for tracheal intubation intubation should be done by the number of anaesthesia team personnel inside the OT. Second with PPE can be available outside the OT for and tracheal intubation to be done in the first adequate to avoid that can increase has used to prevent following with an such as before tracheal It has also used to prevent during tracheal to prevent of virus from If is the tracheal tube before starting to prevent the tracheal Apply the HMEF on tracheal tube itself, if feasible Use (made up of if available and feasible Use plastic transparent to cover the patient can be done by under the clear transparent plastic thus exposure to virus intubation with local anaesthetic will the virus is for tracheal intubation to increase the between the airway and that of the the It also intubation and at tracheal intubation the intubation with the outer worn by the of tracheal tube is confirmed by and of is to be avoided Use gas and the if do at expiratory airway if is to viral aerosol If it is not the should be done by minimum of the team airway should be used only in This will avoid and provide of drug is to the risk of and viral is usually accompanied by which to the designated Doffing Room and remove the protective the protective equipment, avoid touching or face before to the OT All staff have to shower before leaving the OT and In adequate personal protective equipment are not it is to the patient to a with such facilities The above is an and position based on and It is to that is and guidelines are being It is that wear do hand and maintain work to maintain health of support and of There are no of to The of Indian of for and

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