Theatre COVID-19 Processes RHC Glasgow

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Objectives

This guideline details new procedures within the theatre department during the COVID-19 epidemic

Scope

Some of these processes differ from measures in ED or other hospital areas due to the different patient processes & patient flow through theatre. Much of the information will NOT apply outside of theatres.

It is probable this guidance will change several times over the course of the next few weeks as the clinical situation and recommendations on PPE evolve.

Audience

All theatre personnel & staff preparing patients for theatre

Summary Table

 

Aerosol Generating Procedures

The UK has reached the stage of sustained community transmission of COVID-19. New guidance relating to PPE has been released by Public Health Agencies to reflect this.

The main change is that use of FFP3 masks is now recommended for those performing (or assisting with) an aerosol generating procedure in ANY patient.

The following procedures are currently considered to be potentially infectious AGPs for COVID-19:

  • intubation, extubation and related procedures, for example manual ventilation and open suctioning of the respiratory tract (including the upper respiratory tract)
  • tracheotomy or tracheostomy procedures (insertion or open suctioning or removal)
  • bronchoscopy and upper ENT airway procedures that involve suctioning
  • upper gastro-intestinal endoscopy where there is open suctioning of the upper respiratory tract
  • surgery and post mortem procedures involving high-speed devices
  • some dental procedures (for example, high-speed drilling)
  • non-invasive ventilation (NIV); Bi-level Positive Airway Pressure Ventilation (BiPAP) and Continuous Positive Airway Pressure Ventilation (CPAP)
  • High Frequency Oscillatory Ventilation (HFOV)
  • induction of sputum (cough)
  • high flow nasal oxygen (HFNO)
Case selection

Case definition

Local paediatric case definition is acute onset of any of the following symptoms:
• Fever
• Persistent cough (with or without sputum),
• hoarseness,
• nasal discharge or congestion,
• shortness of breath,
• sore throat,
• wheezing,
• sneezing
Fever alone may be attributable to the surgical condition and should be considered in that context.

See HPS guidance for general case definition: https://www.hps.scot.nhs.uk/web-resources-container/covid-19-guidance-for-secondary-care/

Don't delay going to theatre because of an outstanding COVID test. Although this might help to stratify risk and reduce use of COVID theatre, it has to be balanced against delaying the procedure. Consultant to consultant discussion may help with risk assessment.
ID can be contacted too if necessary


Referrals for patients for Emergency or Urgent Surgery

Known or suspected cases will be referred from ED PICU or general wards. There is a policy of graded use of ward areas for COVID-19 patients. 3C, 3B and 6A/4A will be maintained as “clean” wards for vulnerable patients including dialysis and LTV. Ward 1E is being prepared as expansion space for PICU.

All surgical services have altered their treatment protocols to minimise the volume of surgery being performed and also the type of procedures done to minimise the risk to our staff.
All patients referred for surgery should be checked against the case definition for COVID-19. Careful MDT discussion is required to decide which patients should and should not be coming for surgery, i.e. only those requiring emergency or urgent surgery. Ideally surgery should be delayed until patient has recovered from COVID-19 illness.

Although FFP3 masks will now be worn by staff much more frequently in theatres, we will continue to take those patients with the highest risk (known or suspected COVID or contact) to theatre 2. Other patients will be managed in standard theatres with enhanced PPE measures.

Theatre Location & Plan for PPE

 

Test symptomatic patients as per standard guidelines. Testing of asymptomatic patients is not indicated except in the context of cardiac bypass surgery.

Theatres must be informed in advance if patient being booked for theatre has COVID-19 infection – phone theatre booking extension 84852

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Test symptomatic patients as per standard guidelines. Testing of asymptomatic patients is not indicated except in the context of cardiac bypass surgery.

 

Theatres must be informed in advance if patient being booked for theatre has COVID-19 infection – phone theatre booking extension 84852

 

Known or suspected COVID patients; Pathway A

Patient must use designated COVID theatre.

Patient will be anaesthetised and fully recovered in theatre.

Patient must not go to theatre recovery room.

Theatre 2 in the Theatre 1-3 corridor will be used as the designated COVID.

Theatre location has been discussed with IPC team and chosen to minimise exposure within the theatre suite and provide best separation from non-infected patients while accepting that the route to Theatre 1-3 is relatively complex.

DSU has been closed to patients to allow transfer of COVID-19 patients via DSU and the rear part of the Recovery Room into theatre 1-3 corridor. Physical barriers have been erected to prevent cross-contamination. These are such that they can be removed in case of fire.

 

In the event that emergency O-NEG blood is required from the theatre blood fridge, this will be taken round the outside corridor, via DSU to COVID theatre area.

Theatre Suite Preparation

Advance preparation

All unnecessary equipment removed from theatres 1-3 and corridors.

Area in recovery adjacent to theatre 1 cleared.

Drager anaesthetic machines in COVID theatre.

All automatic doors in theatres 1-3 switched off.

Signage at entrances to theatre 1-3 corridor indicating COVID-19 theatres.

Is image intensifier required?

 

Prior to surgery

Designate a senior nurse controller for the area to ensure the following:

  • Adequate and appropriate staffing including for substitution:

minimum - 2 anaesthetists, 2 anaesthetic assistants, 5-6 theatre nurses

  • PPE understood and trained
  • Roles understood
  • Environment controlled
  • Thorough Team Brief
  • Patient transfer route
  • Log staff undertaking case on Opera. Include COVID-19 status in free text.
  • Control and log breaches of PPE on Datix – phone 84315 which will prompt for dataset.

Use Checklist to help with this.

 

Theatre Brief

Theatre team to meet in theatre 1 for team brief. Surgeon to provide copies of completed consent and checklist to be used for WHO checks then destroyed. Originals in patient record. Senior anaesthetic and surgical staff in order to expedite procedures. Consider regional / local anaesthetic to avoid AGPs.

 

 

Personal Protective Equipment

 

Use full respiratory PPE whenever attending to the patient in theatre:

  • Double gloving – disposable gloves (not required to be sterile unless performing aseptic or sterile practices)
  • Long-sleeved, fluid resistant disposable surgical gown
  • FFP3 respirator mask – fit check after applying (cover filter and breath in, holding breath for 10 seconds. You should be aware of mask sucking on to your face with no air coming in round the seals while you hold your breath)
  • Eye protection - full face visor

 

All staff are required to train in the donning and doffing of PPE and will be fit tested for a FFP3 mask. Donning and doffing of PPE must be done in the correct order and in an unhurried manner guided one-to-one by a buddy.

Posters are displayed throughout theatres: https://www.nhsggc.org.uk/media/259081/ppe-donning-and-doffing-poster-for-covid-19-mar-20.pdf

In theatres 1-3, all steps of donning are carried out before entering the COVID theatre.

For doffing, note the location of different stages.

The FFP3 respirator must always be removed outside the patient’s room or after leaving theatre disposal room. Signage is displayed.

If outer gloves become contaminated, including after intubation, they can be removed and replaced. Apply alcohol gel to inner gloves before putting on new outer gloves.

An area in DSU and 2nd Stage Recovery will be designated for changing, washing and showering.

 

Pre-op Assessment

By anaesthetist, on ward.

Consider collecting a mask (Fluid Resistant Surgical Mark, FRSM), gown and gloves before leaving theatre suite.

Check paper and computer records first.

PPE: FRSM, apron and gloves to enter patient room. Also wear a gown to provide some protection of theatre scrubs at this stage. Maintain distance of >2m from patient and parent. Avoid touching surfaces in room. Inform family of changes to normal theatre practice re parental presence in anaesthetic room and during recovery period.

Careful doffing of PPE to exit patient room.

Complete anaesthetic chart and bring to theatre.

Low threshold for premedication.

 

 

 

Anaesthetic Preparation

BE PREPARED - EVEN MORE THAN USUAL!

Airway

The COVID airway trolley has equipment organised by age group and will remain in the anaesthetic room of COVID theatre.

Checklists in each drawer tell you what equipment is in the drawer and what is to be found elsewhere.

Select age appropriate equipment/materials and place on trolley inside theatre.

Use cuffed endotracheal tube for intubation, but consider LMA if that would be appropriate and would minimise coughing.

Have available and consider using clamp for ETT to minimise aerosol generation.

Plan to use videolaryngoscopy – McGrath or C-mac depending on requirements.

IV access & Drugs

Prepare anaesthetic drugs in anaesthetic room, including vasoconstrictor and fluid boluses. Minijet syringes of adrenaline are kept inside Theatre 1. Two syringe pumps are available in theatre and one alaris infusion pump. A calculator is available in theatre.

Err on side of preparing more than you think you will need.

Trolley in theatre for drugs.

Consider using clonidine or dexmedetomidine.

Dexamethasone is controversial - steroids prolong the period of viral shedding but are used in adults with COVID for airway oedema.

Single dose of NSAIDs is likely to be OK if no other contraindication.

Don’t forget local anaesthetic if appropriate.

Select range and ample supply of IV cannulae, syringes, needles, dressings.

Place all airway and IV equipment, and drugs inside theatre before patient arrives.

After a patient is in theatre, drugs and other items can only be passed in on a tray onto a trolley. Avoid all touch contact. A member of the team in full PPE will be in the anaesthetic room throughout the case for this purpose.

Any single-use equipment and all drugs (including CDs) must be disposed of in theatre. They must not be returned to the anaesthetic room. A Griff bin with orange waste bag will be placed in theatre for easy disposal of clinical waste.

 Transfer to Theatre

PPE will be worn by team undertaking transfer: theatre gown, apron, fluid-resistant surgical mask with visor, gloves.

It is expected that a ward nurse and a member of theatre reception staff will transfer the patient to theatre. A theatre trolley will be used for transfer.

Route cleared to minimise exposure.

Shortest route used.

Note lift used as cleaning will be required.

Patient should wear a fluid-resistant surgical mask where appropriate/possible a Hudson mask on the patient as an alternative may also provide some protection of staff

Accompanying parent should wear a fluid-resistant surgical mask.

Patient should be transferred directly into theatre via DSU (not through reception).

Theatre anaesthetic team will meet transfer team in DSU area adjacent to Theatre Recovery, and complete theatre checklist. Parent will leave at this point returning to ward with ward nurse. Parent must not access other areas of the hospital unless specifically allowed by ward staff.

Management in Theatre

  • Patient should wear a surgical face mask if appropriate/possible before start of anaesthetic induction.
  • Minimise transfers. Transfer from trolley to table, anaesthetise on table. Trolley will remain in theatre. For adult-sized patients it may be safer to anaesthetise on the trolley then transfer after pause time following on from induction.
  • HMEF filters at machine and patient ends of circuit (as is usual in RHC theatres).
  • Avoid regular NSAIDs
  • Consider using Dexmedetomidine or Clonidine
  • Consider use of transwarmer for induction to avoid switching on bair hugger prior to AGP
  • Suctioning and procedures that risk breaking circuit and aerosol generation should be avoided. In-line suction for ETT suction should be used and will be available in theatre.
  • Minimise point of care testing for these patients (blood glucose or ABGs). Risk assessment by Clinical Biochemistry, RAH dated 02/03/20 advises full PPE for this. We will place a dedicated blood gas analyser and glucometer in COVID theatre. Write down results on anaesthetic chart if analyser not connected to Portal.
  • Ideally, set up surgical instruments in advance and cover appropriately. This will reduce the time scrub staff need to wear PPE.

Induction & Intubation

Intubation is an aerosol generating procedure (AGP), so full respiratory PPE as above must be used. See list at end of document. Minimise the number of staff in the theatres at intubation while recognising that additional members cannot be added at short notice.

  • Have 2 anaesthetists present at induction, one for airway, one for IV access & drugs, and one anaesthetic assistant. Additional anaesthetic assistant in full PPE in anaesthetic room to assist if required.
  • Use circle in preference to T-piece. Don’t use high fresh gas flow.
  • Preoxygenate if possible.
  • Don’t switch on bair hugger until after all AGP’s and patient is fully draped.
  • Consider IV induction vs gas induction - choice should aim to minimise coughing / distress. Premedication will help.
  • LMA may be used if judged to minimise coughing.
  • Give generous dose of muscle relaxant if using.
  • Minimise bag-mask ventilation and tidal volume as this might generate aerosols
  • Use Videolaryngoscopy (McGrath or C-Mac) to maximise anaesthetist distance from patient. Watch ETT distance through cords carefully.
  • Do not ventilate until ETT cuff is inflated. Use cuff pressure monitor to inflate cuff. Do not get close to patient to listen for a leak. If an uncuffed ETT is used, place a throat pack to minimise droplets from any leak.
  • Confirm ETT placement with ETCO2 trace and chest wall movement. There are single-use stethoscopes, but these are best avoided as difficult to use with PPE and risk of self-contamination.
  • Use in-line endo-tracheal suction.
  • PPE must be continued after intubation.
  • Tray and plastic bag are provided to store airway equipment until end of procedure.

Intraoperative Management

  • Minimise traffic
  • Aim to keep time wearing PPE to 45-60 minutes - avoiding fatigue reduces likelihood of breaching PPE – plan for replacement during longer cases. Government guidance recommends PPE be worn for sessional use – generally up to 4 hours – but don’t expect to last this long.
  • Anaesthetic chart – complete pre and post-op in Theatre 1 for short cases. For longer cases can be passed into theatre after 11 minute wait post intubation AGP. It can be passed back into the anaesthetic room prior to extubation. (Or it can be covered or put more than 2 metres away from AGP.) Use white board in theatre as an aid.
  • Computers will be available in theatre for documenting care, viewing x-rays. Keyboards will have protective covers.
  • Communication via phone in theatre should be kept to a strict minimum. Walkie-talkies are available for easier communication. Use phones on loud speaker to reduce self-contamination. Use anaesthetic room runner to communicate with those outside theatre during case.
  • Plan and avoid time critical manoeuvres with associated risk of PPE breach.
  • Generous use of muscle relaxants to avoid coughing.
  • Avoid ventilator disconnections.
  • Use plastic sheets/drapes to enclose patient during AGPs if possible.

Minimising aerosol generation when changing between ventilators/circuits

  • Turn off gas flow
  • Ventilator to manual
  • APL fully open
  • Consider clamping ETT
  • Disconnect circuit leaving HME connected to ETT
  • Reconnect new ventilator to HME
  • Unclamp ETT

Care if there are different CO2 sampling systems

Minimising Aerosol Generation during suctioning

  • Only suction if required
  • Turn off fresh gas flow
  • Ventilator to manual, APL fully open
  • Clamp ETT connect in line suction circuit
  • Unclamp ETT
  • Suction
  • Restart ventilator

Extubation and Recovery

  • Transfer patient to trolley before extubation.
  • Only keep minimum staff in theatre.
  • Attempt to minimise coughing and spluttering to minimise generation of aerosols
  • Use sugammadex if appropriate
  • Minimise suctioning
  • Extubate to facemask & circle or T-piece
  • Full recovery of patient in the same theatre, minimum 11 minutes to allow aerosol dispersal
  • Patients sent back to the ward via agreed routes after appropriate coordination with receiving ward

Transfer from Theatre to Ward

  • Contact ward prior to transfer.
  • Patient to be transferred directly to their ward room, not through recovery.
  • Extubating anaesthetist and assistant can transfer patient from theatre exit to DSU reception area.
  • Ward nurse and reception staff member will transfer patient to ward.
  • Handover to ward staff will be done by phone from theatre during recovery period to avoid time spent in reception area of DSU.

Theatre Cleaning

  • See Public Health document COVID-19 Guidance for infection prevention and control in healthcare settings”. Joint document issued by UK Public Health Agencies including HPS (Key document 3 – see above for link) for additional information including cleaning and disposal of waste.
  • The positive pressure in theatres means that the corridor is potentially contaminated after theatre use and requires cleaning, in addition to the theatre cleaning. 
  • Recommendation is to leave theatre empty for 11 or 18 minutes after patient leaves before going in to clean. Wear basic PPE (surgical mask with eye protection, gown/apron and gloves to clean.
Aerosol Generating Procedures in Asymptomatic Patients; Pathway B

The most recent Infection Prevention and Control guidance (6/4/20) recommends full PPE with FFP3 masks for AGPs in ANY patient. In RHC where patients are asymptomatic, surgery and procedures will be carried out in standard theatres (4-9, cath lab, IR, MRI), but with additional precautions.

The following procedures are currently considered to be potentially infectious AGPs for COVID-19:

  • intubation, extubation and related procedures, for example manual ventilation and open suctioning of the respiratory tract (including the upper respiratory tract)
  • tracheotomy or tracheostomy procedures (insertion or open suctioning or removal)
  • bronchoscopy and upper ENT airway procedures that involve suctioning
  • upper gastro-intestinal endoscopy where there is open suctioning of the upper respiratory tract
  • surgery and post mortem procedures involving high-speed devices
  • some dental procedures (for example, high-speed drilling)
  • non-invasive ventilation (NIV); Bi-level Positive Airway Pressure Ventilation (BiPAP) and Continuous Positive Airway Pressure Ventilation (CPAP)
  • High Frequency Oscillatory Ventilation (HFOV)
  • induction of sputum (cough)
  • high flow nasal oxygen (HFNO)

Certain other procedures/equipment may generate an aerosol from material other than patient secretions but are not considered to represent a significant infectious risk. Procedures in this category include: administration of pressurised humidified oxygen; administration of medication via nebulisation.

There is no specific mention of other surgical procedures (e.g. laparoscopy), but these may also carry a risk of aerosol generation. Diathermy alone is not considered an AGP by the current national guidelines or evidence in literature.

Theatres, Air Changes & AGPs

Air changes / pause times after AGP’s in RHC Glasgow

Area

Air changes/ hour (data from estates)

Time (minutes) for 99% airborne contaminant removal

Laminar flow theatres1

25

11

Standard theatre or Cath lab and IR

25

11

Anaesthetic rooms     

15

18

MRI / CT anaesthetic rooms

15

18

Theatre recovery

6

46

Theatre reception

6

46

Staff Rest areas

2.5

138

PICU clinical area

10

26

ED Resusc

6-8

46

Although laminar flow creates a very high flow under the canopy, the total theatre air flow may not be very different to a standard 25 air change per hour.

 

 

As Per above Table:

If no further AGP is planned, it is safe to be with the patient while wearing a FRSM and other PPE as appropriate for your task. Surgery may involve multiple AGPs and mean that FFP3 masks should be worn throughout. Minimise staff present in theatre during an AGP and pause time.

UK Public Health Agencies guidance on reducing risk of transmission states that only those within 2m of an AGP need to wear FFP3 masks. Outside that distance, a FRSM is required. In most of our theatres a 2m radius from the patient encompasses the entire theatre, so in practice, it may not reduce use of FFP3 masks. The important issue is an awareness of AGP occurrence.

Laminar flow further complicates theatre air changes and it is difficult to determine if it is of benefit or harm. It will add to theatre noise levels when communication is already difficult because of PPE and so we recommend switching it off. If laminar flow is thought to be of particular benefit for surgery, this can be discussed at the theatre brief.

For theatres, Cath lab and IR, the pause time is 11 minutes

For MRI and anaesthetic rooms the pause time is 18 minutes

Theatre Preparation

Advance preparation

All unnecessary equipment removed, covered or put outside a 2 metre zone of any expected AGP.

All automatic doors switched off.

Theatre Brief in theatre to allow social distancing

To include the following:

  • AGPs to be performed and timing
  • Consider regional / local anaesthetic to avoid AGPs.
  • Adequate and appropriate staffing including for substitution
  • PPE understood and trained
  • Locations for donning and doffing
  • Roles understood
  • Environment controlled
  • Patient transfer route
  • Log staff undertaking case on Opera. Include COVID-19 status in free text.
  • Control and log breaches of PPE on Datix – phone 84315 which will prompt for dataset.

Use Checklist to help with this.

Case records will accompany patient to theatre, but remain in the anaesthetic room or prep room until pause time has elapsed following induction.

Consider covering the anaesthetic machine and other equipment to minimise contamination.

 

Personal Protective Equipment

Use full respiratory PPE during any AGP and until pause time has elapsed (11 or 18 minutes):

  • Double gloving – disposable gloves (not required to be sterile unless performing aseptic or sterile practices)
  • Long-sleeved, fluid resistant disposable surgical gown
  • FFP3 respirator mask – fit check after applying (cover filter and breath in, holding breath for 10 seconds. You should be aware of mask sucking on to your face with no air coming in round the seals while you hold your breath)
  • Eye protection - full face visor

All staff are required to train in the donning and doffing of PPE and will be fit tested for a FFP3 mask. Donning and doffing of PPE must be done in the correct order and in an unhurried manner guided one-to-one by a buddy.

Posters are displayed throughout theatres: https://www.nhsggc.org.uk/media/259081/ppe-donning-and-doffing-poster-for-covid-19-mar-20.pdf

Check where donning and doffing will be done for the theatre in which you are working.

The FFP3 respirator must always be removed outside the patient’s room or after leaving theatre disposal room. Signage is displayed.

If outer gloves become contaminated, including after intubation, they can be removed and replaced. Apply alcohol gel to inner gloves before putting on new outer gloves.

Pre-op Assessment

By anaesthetist, on ward. Consider collecting a mask (FRSM), gown and gloves before leaving theatre suite.

Check paper and computer records first.

PPE: FRSM, apron and gloves to enter patient room. Also wear a gown to provide some protection of theatre scrubs at this stage. Maintain distance of >2m from patient and parent. Avoid touching surfaces in room. Inform family of changes to normal theatre practice re parental presence in anaesthetic room and during recovery period.

Careful doffing of PPE to exit patient room.

Complete anaesthetic chart and file in case record.

Low threshold for premedication.

Anaesthetic Preparation

BE PREPARED - EVEN MORE THAN USUAL!

Airway

Select age appropriate equipment/materials and place on trolley inside theatre.

Use cuffed endotracheal tube for intubation, but consider LMA if that would be appropriate and would minimise coughing.

Have available and consider using clamp for ETT to minimise aerosol generation.

Plan to use videolaryngoscopy – McGrath or C-mac depending on requirements.

IV access & Drugs

Prepare anaesthetic drugs in anaesthetic room, including vasoconstrictor and fluid boluses.

Err on side of preparing more than you think you will need.

Trolley in theatre for drugs.

Consider using clonidine or dexmedetomidine.

Dexamethasone is controversial - steroids prolong the period of viral shedding but are used in adults with COVID for airway oedema.

Single dose of NSAIDs is likely to be OK if no other contraindication.

Don’t forget local anaesthetic if appropriate.

Select range and ample supply of IV cannulae, syringes, needles, dressings.

Place all airway and IV equipment, and drugs inside theatre before patient arrives.

Consider having a member of the team in full PPE in the anaesthetic room throughout the case if you think you might need help or access to the anaesthetic room.

Any single-use equipment and all drugs (including CDs) must be disposed of in theatre. They must not be returned to the anaesthetic room. A Griff bin with orange waste bag will be placed in theatre for easy disposal of clinical waste.

 

Transfer to Theatre

PPE will be worn by team undertaking transfer: theatre gown, apron, fluid-resistant surgical mask with visor, gloves.

It is expected that a ward nurse and a member of theatre reception staff will transfer the patient to theatre. A theatre trolley will be used for transfer.

Route cleared to minimise exposure.

Shortest route used.

Note lift used as cleaning will be required.

Patient should wear a fluid-resistant surgical mask where appropriate/possible.

Accompanying parent should wear a fluid-resistant surgical mask.

Patient will arrive in theatre reception where checklist will be completed by theatre team member before transfer directly into theatre. Unless exceptional circumstances, parents will not accompany child to theatre.

Parent will leave at this point returning to ward with ward nurse. Parent must not access other areas of the hospital unless specifically allowed by ward staff.

Management in Theatre

  • Patient should wear a surgical face mask if appropriate/possible before start of anaesthetic induction.
  • Minimise transfers. Transfer from trolley to table, anaesthetise on table. Trolley to be removed from theatre before induction. For adult-sized patients it may be safer to anaesthetise on the trolley then transfer after pause time following on from induction.
  • HMEF filters at machine and patient ends of circuit (as is usual in RHC theatres).
  • Consider avoiding Dexamethasone as an antiemetic - steroids prolong the period of viral shedding.
  • Avoid regular NSAIDs
  • Consider using Dexmedetomidine or Clonidine
  • Consider use of transwarmer for induction to avoid switching on bair hugger at this stage.
  • Suctioning and procedures that risk breaking circuit and aerosol generation should be avoided. In-line suction for ETT suction should be used and will be available in theatre.
  • Minimise point of care testing for these patients (blood glucose or ABGs). Risk assessment by Clinical Biochemistry, RAH dated 02/03/20 advises full PPE for this. Blood gas syringe should be handed out of theatre in a specimen bag. Member of staff carrying out analysis should wear FRSM, eye protection and apron/gown.
  • Ideally, set up surgical instruments in advance and cover appropriately. This will reduce the time scrub staff need to wear PPE.

 

 

Induction & Intubation

Intubation is an aerosol generating procedure (AGP), so full respiratory PPE as above must be used. Minimise the number of staff in the theatres at intubation while recognising that additional members cannot be added at short notice.

  • Induction of anaesthesia in theatre
  • Depending on complexity of patient or surgery, consider having additional anaesthetic staff in PPE at time of induction.
  • Use circle in preference to T-piece. Don’t use high fresh gas flow.
  • Preoxygenate if possible.
  • Don’t switch on bair hugger until after intubation completed.
  • Consider IV induction vs gas induction - choice should aim to minimise coughing / distress. Premedication will help.
  • LMA may be used if judged to minimise coughing.
  • Give generous dose of muscle relaxant if using.
  • Minimise bag-mask ventilation and tidal volume as this might generate aerosols
  • Use Videolaryngoscopy (McGrath or C-Mac) to maximise anaesthetist distance from patient. Watch ETT distance through cords carefully.
  • Do not ventilate until ETT cuff is inflated. Use cuff pressure monitor to inflate cuff. Do not get close to patient to listen for a leak.
  • Confirm ETT placement with ETCO2 trace and chest wall movement. There are single-use stethoscopes, but these are best avoided as difficult to use with PPE and risk of self-contamination.
  • Use in-line endo-tracheal suction.
  • PPE must be continued after intubation.
  • Use tray/ plastic bag to store airway equipment until end of procedure.

 

Intraoperative Management

 

  • Minimise traffic
  • Aim to keep time wearing PPE to 45-60 minutes - avoiding fatigue reduces likelihood of breaching PPE – plan for replacement during longer cases. Government guidance recommends PPE be worn for sessional use – generally up to 4 hours – but don’t expect to last this long.
  • Don’t start anaesthetic chart until after pause time (11 or 18 minutes) has elapsed.
  • Computers will be available in theatre for documenting care, viewing x-rays. Keyboards will have protective covers.
  • Communication via phone in theatre should be kept to a strict minimum. Walkie-talkies are available for easier communication. Use phones on loud speaker to reduce self-contamination. Use anaesthetic room runner to communicate with those outside theatre during case.
  • Plan and avoid time critical manoeuvres with associated risk of PPE breach.
  • Generous use of muscle relaxants to avoid coughing.
  • Avoid ventilator disconnections.
  • Use plastic sheets/drapes to enclose patient during AGPs if possible.

Minimising aerosol generation when changing between ventilators/circuits

  • Turn off gas flow
  • Ventilator to manual
  • APL fully open
  • Consider clamping ETT
  • Disconnect circuit leaving HME connected to ETT
  • Reconnect new ventilator to HME
  • Unclamp ETT

Care if there are different CO2 sampling systems

Minimising Aerosol Generation during suctioning

  • Only suction if required
  • Turn off fresh gas flow
  • Ventilator to manual, APL fully open
  • Clamp ETT connect in line suction circuit
  • Unclamp ETT
  • Suction
  • Restart ventilator

Extubation and Recovery

  • Transfer patient to trolley before extubation.
  • Only keep minimum staff in theatre.
  • Attempt to minimise coughing and spluttering to minimise generation of aerosols
  • Use sugammadex if appropriate
  • Minimise suctioning
  • Extubate to facemask & circle or T-piece
  • Initial recovery of patient in theatre for minimum 11 or 18 minutes pause time
  • Once stable/not coughing, patient may be transferred to recovery
  • Transfer to recovery by theatre staff or recovery staff. If this is done by theatre staff, doffing is done in recovery.
  • Recovery staff to wear FRSM, gloves, apron/gown
  • Patients sent back to the ward via agreed routes after appropriate coordination with receiving ward

Transfer from Theatre to Recovery

  • Anaesthetist and assistant will transfer patient from theatre exit to recovery, handover the patient & doff PPE in recovery

Theatre Cleaning

  • See Public Health document “COVID-19 Guidance for infection prevention and control in healthcare settings”. Joint document issued by UK Public Health Agencies including HPS (Key document 3 – see above for link) for additional information including cleaning and disposal of waste.
  • The positive pressure in theatres means that the corridor is potentially contaminated after theatre use and requires cleaning, in addition to the theatre cleaning. 
  • Recommendation is to leave theatre empty for 11 or 18 minutes after patient leaves before going in to clean. Wear basic PPE (surgical mask with eye protection, gown/apron and gloves to clean.
Asymptomatic Patients having Low risk Procedures; Pathway C

There will be a few patients who are asymptomatic and have no household contacts, and who are having procedures which do not involve AGPs. For these cases, droplet precaution PPE should be worn if within 2 metres. In practice, this 2 metre distance encompasses almost the entire theatre area. Droplet precaution PPE is a FRSM, eye protection, gown and gloves and standard infection control measures. Remember to consider the risk of conversion to general anaesthetic which would require an increase of PPE and a break in the procedure to facilitate airway maintenance, but full PPE is not required from the outset of cases intended to be done with sedation,

Examples – sedation and local anaesthetic for fingertip injury, spinal anaesthetic and sedation for testicular torsion. This could also apply to the haematology list – risk assess.

Covid Theatre Brief

Covid brief

• Print off consent and completed checklist from computer or get ward to photocopy them and pick them up from the ward to be brought down before starting the brief– these can be binned at the end of the procedure

• Minimum personnel - scrub/floor x2/AA x2/Anaes x2/Surg x2

• Staff and runners in theatre 1

• Introductions

• Surgical equipment

• Anaesthetic equipment and drugs ie local anaesthetic

• Do we need image intensifier?

• Will we be using equipment that generates stickers?

• Print off bank of stickers


Set up theatre and return to finish brief remember the theatres are clean but advice is still to exit via double doors and enter via double doors as you would with a covid patient in theatre.

Completion of brief when all staff are back in theatre 1 prior to sending for patient.

Equipment & sample exchange with covid theatre

HOW TO:
• GET EQUIPMENT INTO THEATRE 2 ONCE PATIENT HAS ENTERED THEATRE
Covid theatre corridor is deemed relatively safe whilst a patient is in theatre.

All equipment, blood etc that needs to come into theatre 2 from either outside theatres or from the clean theatre 1 can be handed into the covid theatre via the anaesthetic room. Staff must wear a minimum of a surgical mask to do this task (not full PPE). The staff member in theatre 2 Anaesthetic room who is in PPE can then pass it through to theatre.
Staff in theatre 1 clean area can enter and leave through the double doors to the outside hospital environment via Day surgery. They can also go to the anaesthetic room door at theatre 2 but only when passing in equipment to covid theatre. They do not need to be in full PPE to do this as remember the corridor is deemed safe at this time.

Theatre reception can be runners to bring things to the handover table, they can be called in out of hours and then would take the handover table phone. (on list of numbers 84368)

STAFF COMING OUT OF COVID THEATRE MUST NOT GO STRAIGHT INTO THE CLEAN AREA IN THEATRE 1 BEFORE CHANGING THEIR BLUES

• GET SAMPLES OUT OF THEATRE 2
All samples that cannot wait until the end of the case to be sent to the lab must be bagged in theatre and handed to the staff member in the Anaesthetic room. They can then leave the sample at the handover desk to be picked up.

BEFORE ANYONE LEAVES AN AREA THEY NEED TO PHONE THE OTHER THEATRE TO LET THEM KNOW TO AVOID ACCIDENTAL CROSS CONTACT AT THE HANDOVER TABLE.

Staff who have donned PPE in theatre 1 clean room can leave only through the middle doors as marked.

Minimally Invasive Surgery

Minimally Inv Surg decision template

 

Criteria for performing minimally invasive surgery during the COVID-19 pandemic

 

SARS-CoV-2 has been isolated from the nasopharynx, upper and lower respiratory tract, the gastrointestinal tract from mouth to rectum, in blood, bile and faeces, and in the cells lining the respiratory and gastrointestinal tract. It has not been isolated in urine or CSF.1 It is likely that the virus has multiple modes of transmission.

As a department, we are committed to deliver the highest quality care for our patients and ensure we act in a way that maintains the safest possible working environment for all of our colleagues.

We believe that the best way to balance these aims during the COVID-19 pandemic is by only performing the most essential operations and to utilise non-operative strategies wherever possible. We are only offering surgery in an emergency setting, or in children who require urgent treatment (defined as where surgical treatment would normally be undertaken within 4 weeks, or when a non-operative alternative confers a high risk of patient harm in the next 3 months). In the group of patients who meet the COVID-19 case definition (or are confirmed COVID-19 on testing) we aim to avoid operating if possible. We have introduced new pathways for management of appendicitis and testicular torsion to help achieve this aim.

The potential risk of minimally invasive surgery (MIS) during the COVID-19 pandemic has received much attention. Previous research has shown that laparoscopy can lead to aerosolisation of blood borne viruses2-6, but there is no evidence to indicate that this effect is seen with COVID-19; nor that this effect would be limited to MIS procedures, or more likely compared to open surgery. The risk of aerosolisation during MIS is generally ascribed to the use of energy devices2-4 which may result in a high concentration of smoke and aerosolised particles being generated in the confined space of a body compartment. The use of any electrosurgical device can be considered to be aerosol generating7 and infectious papillomavirus has been identified in the surgical plume generated during open excision of warts.8 However, dissemination and release of any aerosolised material into the operating room, either during desufflation in an uncontrolled fashion or via port-site leakage could occur. It should be emphasised that this is a theoretical risk with little supporting evidence to date.

On the 7th April 2020, the four UK public health bodies,9 with the endorsement of the four UK and Irish Royal Colleges of Surgery10 have recommended enhanced PPE (meaning the addition of FFP3 masks) for all aerosol generating procedures (AGPs) in all patients, regardless of COVID-19 risk status. Intubation and extubation are classified as AGPs, so the majority of surgical procedures will require the anaesthetic staff to wear enhanced PPE. Although MIS is not listed as an AGP, the Colleges document states that it “is considered to carry some risks of aerosol-type formation and infection and considerable caution is advised”. Until further evidence is made available, like many other centres, we have decided to advocate that all staff within 2m of a minimally invasive procedure should also wear enhanced PPE.  We have developed a decision-making matrix to outline, in a transparent and consistent way, the criteria that should be met for us to perform minimally invasive surgery (MIS) during the COVID-19 pandemic. These will be reviewed at least every 2 weeks to take into account any new evidence or advice that is issued.

 

 

References

  1. Wang, W, Xu Y, Gao, R et al. Detection of SARS-CoV-2 in Different Types of Clinical Specimens. JAMA epub 11th March 2020
  2. Surgical smoke and infection control. Alp E, Bijl D, Bleichrodt RP, Hansson B, Voss A. J Hosp Infect. 2006 Jan;62(1):1-5
  3. Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery. Kwak HD, Kim SH, Seo YS, et al. Occup Environ Med. 2016, 73:857––863.
  4. Surgical smoke may be a biohazard to surgeons performing laparoscopic surgery. Choi SH, Kwon TG, Chung SK, Kim TH. Surg Endosc. 2014, 28 (8): 2374-80.
  5. https://www.sages.org/recommendations-surgical-response-covid-19/
  6. Zheng, MH, Boni L, Fingerhut A. Minimally invasive surgery and the novel coronavirus outbreak: lessons learned in China and Italy. Ann Surg 26th March Published ahead of print.
  7. Bree K, Barnhill S, Rundell W. The Dangers of Electrosurgical Smoke to Operating Room Personnel: A Review.  Workplace Health Saf. 2017, 65 (11): 517-526.
  8. Sawchuk WS, Weber PJ, Lowy DR, Dzubow LM. Infectious papillomavirus in the vapor of warts treated with carbon dioxide laser or electrocoagulation: detection and protection. J Am Acad Dermatol. 1989;21:41
  9. assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/877728/T1_Recommended_PPE_for_healthcare_workers_by_secondary_care_clinical_context_poster.pdf
  10. https://www.rcseng.ac.uk/coronavirus/joint-guidance-for-surgeons-v2/

 

Practical guide to mitigating any theoretical risk of minimally invasive surgery during the COVID-19 pandemic

General measures

  1. Only essential staff should be present in theatre.1
  2. Unless there is an emergency, there should be no exchange of room staff.1
  3. All staff should use PPE as recommended by current local and national guidance.1

Minimising smoke and aerosol production

  1. Diathermy units should be set to the lowest possible settings for the desired effect. 1
  2. Avoid prolonged dissecting times on the same tissue to reduce surgical smoke production.2
  3. Minimise use of aerosolizing adjuncts - monopolar diathermy, Harmonic scalpel and Ligasure. 1
  4. Use attached smoke evacuators when using external monopolar diathermy.1
  5. Keep instruments clean of blood and other body fluids to minimize contact time/ smoke.2
  6. Surgical drains should be utilized only if absolutely necessary.2

Safe Management of the artificial pneumoperitoneum

  1. Keep insufflation pressure/flow rates at lowest possible levels without compromising exposure.1,2
  2. Attach smoke evacuation filter to the designated evacuation port and outflow not exceed 7l/min
  3. Limit time in the Trendelenburg position to minimise the effect on lung function/circulation.2
  4. Avoid using two-way insufflator to prevent aerosolised particles reaching the insufflator.2
  5. Use balloon ports at every port site to minimize inadvertent gas/aerosol leak.

Prevention and management of aerosol dispersal

  1. Port site incisions should be as small as possible to create a seal around the port.1
  2. Keep port sites clean of blood and body fluids to minimize dispersal. 1
  3. Ports should not be vented.1
  4. Preformed ties should not be used – use either intracorporeal ties, clips or stapling devices.
  5. Close valves before disconnecting tubing and only open once tubing is reconnected. Insufflator should be turned “on” before new port valve opened to prevent gas back-flow into insufflator.1
  6. Use suction devices to remove smoke/aerosol during operations and before converting to open surgery or any extra-peritoneal manoeuvre.3
  7. Attach microfilter to the suction carousel to prevent smoke from the patient reaching the hospital vacuum system (not between patient and canister).

Desufflation of the abdomen

  1. Avoid explosive dispersion of body fluids when removing trocars, ports and specimens.3
  2. The patient should be supine and the least dependent port should be utilized for desufflation.3
  3. Pneumoperitoneum should be safely evacuated via an ultrafiltration system before closure, trocar removal, specimen extraction or conversion to open.1
  4. All specimens should be placed in retrieval bags prior to desufflation to aid safe removal.
  5. To desufflate, close the valve on the insufflating port before flow of CO2 on the insufflator is turned off and use suction device to desufflate.3
  6. Specimens should only be removed once all CO2 and smoke has been evacuated.3

 

Additional teaching related to this guidance should be provided for all staff involved in minimally invasive surgical cases during the pandemic.

 

References (all accessed 01/04/2020 unless stated otherwise)

  1. https://www.sages.org/recommendations-surgical-response-covid-19/
  2. Zheng, MH, Boni L, Fingerhut A. Minimally invasive surgery and the novel coronavirus outbreak: lessons learned in China and Italy. Ann Surg Published ahead of print (26th March 2020).

https://www.sages.org/resources-smoke-gas-evacuation-during-open-laparoscopic-endoscopic-procedures/

Editorial Information

Last reviewed: 10 April 2020

Next review: 08 May 2020

Author(s): Anne Goldie, Ewan Wallace, Graham Bell, Dannie Seddon

Version: 8

Author Email(s): anne.goldie@nhs.net

Co-Author(s): Minimally Invasive Surgery section courtesy of Mr G Walker

Approved By: SOP approved by existing management structures / clinical director