Operating Room Preparation and Guidance for COVID-19 Patients

Guideline · Apr 2020 · 5 min read

In brief

Clinical protocols for preparing operating rooms and managing surgical procedures in COVID-19 positive patients, covering infection control measures, PPE requirements, and perioperative safety guidelines.

Written by the GCMD Library team from the guideline.

Operating Room Selection and Infrastructure

A dedicated negative-pressure OR located at the corner of the operating complex with separate access is designated for all confirmed or suspected COVID-19 cases. The suite consists of five interconnected rooms with controlled pressure gradients: negative pressure in ante room and induction room, positive pressure in OR proper, preparation, and scrub rooms. Understanding airflow patterns is crucial for infection control.

Anesthesia Equipment and Circuit Management

The same OR and anesthesia machine are dedicated exclusively to COVID-19 cases throughout the epidemic. Additional HME filters are placed on both inspiratory and expiratory limbs, with filters and soda lime changed after each case. All required drugs and equipment are pre-staged on a tray before each procedure to minimize handling of the drug trolley during the case.

Airway Management Protocol

A fully stocked airway trolley with disposable equipment is maintained in the induction room. Video-laryngoscopy is recommended to maximize first-pass success and avoid repeated airway instrumentation. Limited-supply equipment like BIS monitors requires thorough decontamination after use.

Patient Transport and Transfer Procedures

Hospital security clears the route from ward/ICU to OR including elevators. Ward nurses perform transport in full PPE including N95 mask, goggles/face shield, splash-resistant gown, and boot covers. For ICU patients on mechanical ventilation, gas flow is turned off and endotracheal tube clamped during ventilator switching to prevent aerosolization, with ICU personnel wearing PAPR during transfer.

Personal Protective Equipment Requirements

PAPR is worn by all personnel within 2 meters of the patient during induction and reversal of anesthesia. For operative airway procedures like tracheostomy, all staff maintain PAPR throughout the entire procedure. For non-airway procedures, regional anesthesia is preferred when feasible.

Intraoperative Communication and Supply Management

A dedicated runner stationed outside the OR handles requests for additional drugs or equipment, placing items on a trolley in the ante room for OR team retrieval. The same reverse process is used for sending out specimens including arterial blood gases and frozen sections. The runner wears PPE when entering the ante room.

Doffing Protocol and Exit Procedures

Personnel exiting the OR discard used gowns and gloves in the ante room and perform hand hygiene before leaving. PAPR is removed outside the ante room. Patients not requiring ICU care are fully recovered within the OR itself before transport.

Post-Case Decontamination and Turnover

Minimum one-hour interval is scheduled between cases for patient transport and thorough decontamination of all surfaces, equipment, monitors, and anesthesia machine. All unused items on drug tray and airway trolley are assumed contaminated and discarded. After confirmed COVID-19 cases, hydrogen peroxide vaporization is used for terminal decontamination, and all staff must shower before resuming regular duties.

Statements in this guideline

An operating room with a negative pressure environment located at a corner of the operating complex, and with a separate access, is designated for all confirmed or suspected COVID-19 cases.
Recommendation
The same operating room and the same anesthesia machine are used only for COVID-19 cases for the duration of the epidemic.
Recommendation
An additional heat and moisture exchanger filter is placed on the expiratory limb of the circuit.
Recommendation
Both heat and moisture exchanger filters and the soda lime are changed after each case.
Recommendation
Before the start of each operation, the anesthesiologist puts all the drugs and equipment required for the procedure onto a tray to avoid handling of the drug trolley during the case.
Recommendation
If there is a need for additional drugs, hand hygiene and glove changing are performed before entering the induction room and handling the drug trolley.
Recommendation
As far as possible, disposable airway equipment is used.
Recommendation
The airway should be secured using the method with the highest chance of first-time success to avoid repeated instrumentation of the airway, including using a video-laryngoscope.
Recommendation
Hospital security is responsible for clearing the route from the ward or intensive care unit to the operating room, including the elevators.
Recommendation
The transfer from the ward to the operating room is done by the ward nurses in full personal protective equipment including a well-fitting N95 mask, goggles or face shield, splash-resistant gown, and boot covers.
Recommendation
For patients coming from the intensive care unit, a dedicated transport ventilator is used.
Recommendation
To avoid aerosolization, the gas flow is turned off and the endotracheal tube clamped with forceps during switching of ventilators.
Recommendation
The intensive care unit personnel wear full personal protective equipment with a powered air-purifying respirator for the transfer.
Recommendation
In the induction room, a powered air-purifying respirator is worn during induction and reversal of anesthesia for all personnel within 2 meters of the patient.
Recommendation
For operative airway procedures such as tracheostomy, all staff keep their powered air-purifying respirator on throughout the procedure.
Recommendation
For other procedures, regional anesthesia is preferable.
Recommendation
During the procedure, a runner is stationed outside the operating room if additional drugs or equipment are needed.
Recommendation
The runner wears personal protective equipment when entering the ante room.
Recommendation
Personnel exiting the operating room discard their used gowns and gloves in the ante room and perform hand hygiene before leaving the ante room.
Recommendation
Patients who do not require intensive care unit care postoperatively are fully recovered in the operating room itself.
Recommendation
A minimum of one hour is planned between cases to allow operating room staff to send the patient back to the ward and conduct thorough decontamination of all surfaces, screens, keyboard, cables, monitors, and anesthesia machine.
Recommendation
All unused items on the drug tray and airway trolley should be assumed to be contaminated and discarded.
Recommendation
All staff have to shower before resuming their regular duties.
Recommendation
After confirmed COVID-19 cases, a hydrogen peroxide vaporizer is used to decontaminate the operating room.
Recommendation
Healthcare workers are at increased risk of coronavirus infection.
Established

Full text

CORRESPONDENCE What we do when a COVID-19 patient needs an operation: operating room preparation and guidance Lian Kah Ti, MBBS, MMed, FAMS . Lin Stella Ang, MBBS, MMed, FANZCA, EDIC . Theng Wai Foong, MBBS, MMed . Bryan Su Wei Ng, MBBS, FRCA Received: 1 March 2020 / Revised: 3 March 2020 / Accepted: 3 March 2020 /C211Canadian Anesthesiologists’ Society 2020 To the Editor, We read with interest the recent review in the Journal by Wax and Christian 1 on coronavirus disease 2019 (COVID-19). The ﬁrst case of COVID-19 in Singapore was conﬁrmed on 23 January 2020. 2 In the week of February 13–19, the World Health Organization reported that Singapore had more cases of COVID-19 than any other country outside of mainland China. 3 We wish to share the protocol that we use in our hospital in preparing an operating room (OR) for conﬁrmed or suspected COVID-19 patients coming for surgery. An OR with a negative pressure environment located at a corner of the operating complex, and with a separate access, is designated for all conﬁrmed (or suspected) COVID-19 cases. The OR actually consists of ﬁve interconnected rooms, of which only the ante room and anesthesia induction rooms have negative atmospheric pressures. The OR proper, preparation, and scrub rooms all have positive pressures (eFig. 1 in the Electronic Supplementary Material [ESM]). Understanding the airﬂow within the OR is crucial to minimizing the risk of infection. The same OR and the same anesthesia machine will only be used for COVID-19 cases for the duration of the epidemic. An additional heat and moisture exchanger (HME) ﬁlter is placed on the expiratory limb of the circuit. Both HME ﬁlters and the soda lime are changed after each case. The anesthetic drug trolley is kept in the induction room. Before the start of each operation, the anesthesiologist puts all the drugs and equipment required for the procedure onto a tray to avoid handling of the drug trolley during the case. Nevertheless, if there is a need for additional drugs, hand hygiene and glove changing are performed before entering the induction room and handling the drug trolley. A fully stocked airway trolley is also placed in the induction room. As far as possible, disposable airway equipment is used. The airway should be secured using the method with the highest chance of ﬁrst-time success to avoid repeated instrumentation of the airway, including using a video-laryngoscope. 4 Equipment in limited supply, such as bispectral index monitors or infusion pumps, may be requested but need to be thoroughly wiped down after use. The Figure details the roles and responsibilities of each OR team member. Hospital security is responsible for clearing the route from the ward or intensive care unit (ICU) to the OR, including the elevators. The transfer from the ward to the OR will be done by the ward nurses in full personal protective equipment (PPE) including a well- ﬁtting N95 mask, goggles or face shield, splash-resistant gown, and boot covers. For patients coming from the ICU, a dedicated transport ventilator is used. To avoid aerosolization, the gas ﬂow is turned off and the endotracheal tube clamped with forceps during switching Electronic supplementary material The online version of this article (https://doi.org/10.1007/s12630-020-01617-4) contains sup- plementary material, which is available to authorized users. L. K. Ti, MBBS, MMed, FAMS ( &) Department of Anaesthesia, National University Health System, Singapore, Singapore e-mail: lian_kah_ti@nuhs.edu.sg Department of Anaesthesia, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore L. S. Ang, MBBS, MMed, FANZCA, EDIC T. W. Foong, MBBS, MMed /C1B. S. W. Ng, MBBS, FRCA Department of Anaesthesia, National University Health System, Singapore, Singapore 123 Can J Anesth/J Can Anesth https://doi.org/10.1007/s12630-020-01617-4

of ventilators. The ICU personnel wear full PPE with a powered air-purifying respirator (PAPR) for the transfer. In the induction room, a PAPR is worn during induction and reversal of anesthesia for all personnel within 2 m of the patient. For operative airway procedures such as tracheostomy, all staff keep their PAPR on throughout the procedure. For other procedures, regional anesthesia is preferable, but if general anesthesia is required, the principles of management are similar to those previously published. 1,4 During the procedure, a runner is stationed outside the OR if additional drugs or equipment are needed. These are placed onto a trolley that will be left in the ante room for the OR team to retrieve. This same process in reverse is used to send out specimens such as arterial blood gas samples and frozen section specimens. The runner wears PPE when entering the ante room. Personnel exiting the OR discard their used gowns and gloves in the ante room and perform hand hygiene before leaving the ante room (ESM, eFig. 2). Any PAPR will be removed outside the ante room. Patients who do not require ICU care postoperatively are fully recovered in the OR itself. When the patient is ready for discharge, the route to the isolation ward or ICU is again cleared by security. A minimum of one hour is planned between cases to allow OR staff to send the patient back to the ward, conduct through decontamination of all surfaces, screens, keyboard, cables, monitors, and anesthesia machine. All unused items on the drug tray and airway trolley should be assumed to be contaminated and discarded. All staff have to shower before resuming their regular duties. As an added precaution, after conﬁrmed COVID-19 cases, a hydrogen peroxide vaporizer will be used to decontaminate the OR. In summary, as healthcare workers are at increased risk of coronavirus infection, a comprehensive and robust infection control workﬂow has been put into place. 5 Conﬂicts of interest None. Funding statement None. Editorial responsibility This submission was handled by Dr. Hilary P. Grocott, Editor-in-Chief, Canadian Journal of Anesthesia. References 1. Wax RS , Christian MD . Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019- nCoV) patients. Can J Anesth 2020; DOI: https://doi.org/10.1007/ s12630-020-01591-x. Figure Complete operating room workﬂow for a coronavirus disease 2019 (COVID-19) case. CD = controlled drugs; ICU = intensive care unit; NM = nurse manager; OR = operating room; PAPR = powered air-purifying respirator; PC = personal computer; PPE = personal protection equipment; pre-op = preoperative 123 L. K. Ti et al.

2. Government of Singapore . Coronavirus disease 2019: cases in Singapore. Available from URL: https://www.gov.sg/article/covid- 19-cases-in-singapore (accessed March 2020). 3. World Health Organization . Coronavirus disease (COVID-2019) situation reports. Available from URL: https://www.who.int/ emergencies/diseases/novel-coronavirus-2019/situation-reports (accessed March 2020). 4. Peng PW , Ho PL , Hota SS . Outbreak of a new coronavirus: what anaesthetists should know. Br J Anesth 2020; DOI: https://doi.org/ 10.1016/j.bja.2020.02.008. 5. Wang D , Hu B , Hu C , et al . Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. JAMA 2019; DOI: https://doi.org/ 10.1001/jama.2020.1585. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional afﬁliations. 123 What we do when a COVID-19 patient needs an operation

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