Pandemic Flu and Anesthesia

1
Pandemic Flu and Anesthesia

• Proper use of personal protection equipment
  during intubation inside and outside the
  operating room

2
Overview

• History of Pandemic Influenza
• Modes of Transmission for Infectious Disease
• Personal Protection Equipment Review
• Donning/Doffing a PAPR
• Protocol for Intubation Outside the O.R.
• Intra-op Management of Pandemic Flu Patients

3
History
4
HistoryPandemic Flu

• credit Office of the Public Health Service
  Historian

• 1918 worldwide influenza A pandemic
• Spanish Flu (H1N1)
• 675,000 U. S. deaths
• 50 million deaths worldwide
• Original source of the virus waterfowl or pigs

5
HistoryPandemic Flu

• 1957 Asian flu (H2N2)
• 70,000 deaths in the U.S.
• 1-2 million deaths worldwide
• 1968 Hong Kong flu (H3N2)
• 34,000 deaths in the U.S.
• 700,000 deaths worldwide

6
HistoryPandemic Flu

• 1976 Swine Flu outbreak at Fort Dix, New Jersey
• 13 soldiers infected 1 dies
• Intensive epidemiologic study and isolation limit
  spread
• More Americans perish from complications due to
  the vaccine than from swine flu

Courtesy The Gerald R. Ford Library
7
HistoryPandemic Flu

• 1997 Avian Flu (H5N1)
• Discovered in Hong Kong
• 18 infections 6 deaths
• 2004 Avian Flu moves to Thailand
• 47 cases 34 deaths

8
History--Avian Flu

• Image from Jan Conroy, UC Davis Graphics 8/2008
  Courtesy of UC Davis Newsletter

• 2006 spreads to Turkey, China, Iraq,
  Azerbaijan, Egypt
• 2007 cases reported in Nigeria

9
History Avian Flu

• Currently, transmission requires contact with
  infected birds or their secretions
• When the strain becomes transmissible via
  human-to-human contact, how quickly would the
  pandemic spread?

10
Avian Flu Model

• Estimates of an Avian Flu pandemic three months
  after the arrival of 10 infected people to Los
  Angeles.
• Blue color 1 or fewer cases per 1000 people
• Red color 100 or more cases per 1000 people
• Courtesy Los Alamos National Laboratory News
• April 4, 2006

11
History--SARS

• 2003 Worldwide spread of Severe Acute
  Respiratory Syndrome (SARS)
• Novel Coronavirus A
• 29 countries affected
• 8400 cases 900 fatalities
• In Toronto, of 31 health care workers performing
  36 intubations, 3 (all anesthesiologists)
  contract SARS

12
Modes of Transmission
13
Modes of Transmission

• Influenza A
• Multiple routes of infection
• Droplet transmission 50-100 microns in diameter
  travel less than one meter arent suspended in
  air
• Direct contact of contaminated hands ones to
  nose, mouth or eyes
• Auto-inoculation via fomites (objects
  contaminated with virus)
• ?Potential for small droplets (less than 5
  microns diameter) to aerosolize (airborne),
  transmitting virus beyond 1-2 meters

14
Modes of Transmission

• Influenza and SARS may by transmitted through
  aerosol generating procedures
• Nebulizer treatments
• High flow oxygen
• Non-invasive ventilation (CPAP or BiPAP)
• Bronchoscopy
• High frequency oscillatory ventilation
• Bag-valve ventilation
• Intubation and suctioning

15
Personal Protection Equipment (PPE)
16
Personal Protection Equipment

• Hand washing
• Either soap and water or alcohol based cleansing
  solutions are effective in controlling influenza
  or SARS virus.
• Must be done prior to patient contact, after
  removing masks, gloves and gowns
• Health Care Workers (HCW) who consistently washed
  their hands during care for SARS patients had
  lower infection rates
• Shaw,K Public Health, (2006) 120,8-14.

17
Personal Protective Equipment

• Masks
• Facemasks (surgical masks)
• Loose fitting disposable masks that stop
  droplets, skin or hair particles falling onto the
  patient from the HCW
• Prevent splashes from contacting the HCWs face
• Respirators
• Air filtering devices that protect against
  inhalation of both large and small particles
• OSHA requires their use as part of a hospital
  respiratory protection program

18
Personal Protection Equipment

• OSHA Respiratory Protection Plan requirements
• Qualified program administrator
• A written protocol including
• Appropriate respirator selection
• Medical certification for the PPE wearer
• Fit testing
• Maintenance and cleaning of equipment
• Program review
• Pandemic Influenza Preparedness and
  Response Guidelines for Healthcare Workers and
  Healthcare Employers www.osha.gov/Publications/OS
  HA_pandemic_health.pdf accessed 8/18/08

19
Personal Protection Equipment

• Respirators1
• --Air-purifying respirators
• Remove contaminants by filtration or absorption
• May be passive or powered
• N-95 (filtering face mask)
• Powered Air Purifying Respirator (PAPR)
• Atmosphere-supplying respirators
• Provide clean breathing air from an
  uncontaminated source
• Self-contained breathing apparatus (SCBA)
• Allow entry into an oxygen depleted environment
• 1Szeinuk J et al Am Jour Indust Med (2000)
  37142-157

20
N-95 Respirators
21
PPE N-95 Respirators

• Passive air filtration
• Industrial uses also require identification of
  resistance of filter degradation to oil
• N means not oil resistant
• R means somewhat oil resistant
• P means strongly oil resistant
• Respirators are also classified by the percent of
  small particles are filtered (95, 99, or 99.97)
• Thus N-95 respirators are not oil resistant and
  filter about 95 of small particles.

22
PPE N-95 Respirators

• Advantages
• Readily available
• No interference to using a stethoscope
• Not powered, noiseless
• Disadvantages
• Requires fit testingonly works with a tight seal
• Leaves some of the face and neck exposed to
  droplets
• Increases the work of breathing, uncomfortable
• Not generally reusable
• Cant be used for men with beards

23
PPE Powered Air Purifying Respirators--PAPRs
24
PPE Powered Air Purifying Respirators (PAPR)

• Advantages
• Doesnt require fit testing
• Completely covers the face some also cover the
  neck
• Doesnt increase the work of breathing
• Most components reusable

25
PPE PAPR

• Disadvantages
• Requires ongoing training to put on (Don), use
  safely, and take off (Doff)
• Fan noise impedes conversation
• Cant use a stethoscope
• May cause claustrophobia
• Limited availability, some models cant be used
  in an OR
• More challenging to use during a difficult
  intubation

26
PPE Comparing N-95 vs. PAPR

• Most of the HCWs in Toronto who contracted SARS
  did so before N-95 masks/droplet precautions were
  utilized1
• One intensivist contracted SARS during a
  difficult intubation in spite of wearing a
  N-95/goggles/gown and gloves
• PPE only work when used appropriately
• 1Nicolle L, Can J Anesth (2003) 50983-988.

27
PPE Comparing N-95 vs. PAPR

• Prospective, randomized, controlled crossover
  study of 50 subjects comparing contamination
  following use of PAPR vs. N-95 respirator
• Subjects using the N-95 had more frequent and
  larger areas of skin contamination
• Subjects using the PAPR had increased risk of
  self-contamination while doffing their PPE
• Zamora J et al. CMAJ (2006) 175249-254.

28
PPE Comparing N-95 vs. PAPR

• Unanswered Questions
• Minimal infective dose of viruses
• Safe distance away from patients to prevent HCW
  infection
• Issues of PAPR use
• Claustrophobic reactions to HCW wearing a PAPR
• Difficulty in communication due to Blower noise
• Scary appearance of PAPR wearer to pediatric
  patients
• Increased complexity of PPE increasing confusion
  and thus self-contamination of HCW

29
PPE Comparing N-95 vs. PAPR

• Recommendations
• The CDC and OSHA mandate using a N-95 respirator
  as the minimum respiratory protection when in
  close contact with SARS/pandemic flu patients
• The CDC and OSHA note that further respiratory
  precautions are warranted (but not mandated)
• California and some hospitals have required using
  a PAPR during aerosol-generating procedures
• Rushs policy also states that a PAPR will be
  used in aerosol-generating procedures

30
Donning and Doffing a PAPR
31
Whats a PAPR?

• Breathing Tube and airflow indicator

• Air-Mate Blower

32
Whats a PAPR?

• Tyvek Head Cover--Rascal

• Tyvek Hood

33
PAPR Head Covers in Use

• Rascal Headgear

• PAPR Hood

34
Donning/Doffing a PAPR

• Prior to entering the patients room
• Put on shoe covers
• Put on hair cover (if Rascal is being used)
• Prepare the Air-Mate blower

35
Preparing the Air-Mate Blower

• Remove the back cover
• Check the filter is clean
• Ensure the filter arrows point into the unit
• Replace the back cover

36
Preparing a PAPR

• Attach the air hose to the Air-Mate Blower by
  inserting the male end of the hose and turning it
  clockwise until a click is felt.

37
Preparing the Air-Mate Blower

• Turn on the power
• Check the airflow with the airflow indicator
• The indicator should float on the air coming out
  the lower band of the indicator should be visible
• If this test fails do not attempt to use the unit

38
Donning a PAPR

• Attach the breathing tube into the headgear
• If present, remove the tissue covering the
  faceplate
• Place the Air-Mate on mid-back attach and secure
  belt around waist

39
Donning a PAPR

• Pull the face piece over your head
• Adjust the headpiece for comfort
• Verify adequate airflow
• Remove PAPR if
• Breathing becomes difficult
• You feel dizzy or anxious
• You smell or taste contaminants
• Your eyes, nose, or mouth become irritated
• Remove a PAPR only outside a contaminated room

40
Donning a PAPR

• Put on gown and gloves
• If using a hood, the inner shroud tucks inside
  the gown the outer shroud hangs outside the
  protective clothing.
• You may now enter the patients room

41
Doffing a PAPR

• Before leaving the room
• Remove shoe covers
• Remove gown by grasping the shoulders pull
  forward, rolling the outside of the gown inward
  and keeping the contaminated surface away from
  your body remove gloves
• Discard gown and gloves in the red biohazard bag

42
Doffing a PAPR

• Wash your hands!
• Put on new gloves
• Exit the room, close the door

43
Doffing a PAPR

• Assistant (wearing gloves) supports the PAPR
  power source while the wearer takes off the belt
• Take off the hood from the inside, disconnect the
  breathing tube (from the inside of the hood)
• Place hood in reprocessing bag or waste

44
Doffing a PAPR

• The assistant places the breathing tube and Air
  Mate in a biohazard bag for reprocessing
• Both remove their gloves
• Wash your hands!!

45
Donning a PAPR
Doffing a PAPR
1. Put on shoe covers and hair cover
1. Inside the room take off shoe covers, gown
and gloves. Wash hands and put on new gloves
2. Check the HEPA filter on the Airmate blower
unit
3. Check air flow out of the blower hose using
the bullet
2. Outside the room, your assistant holds the
Airmate while you unsnap the belt
3. Disconnect the hose from the inside of the
PAPR headpiece
4. Snap the blower hose into the PAPR hood
attach the Airmate belt securely on your waist
4. Place PAPR headpiece, hose and Airmate in Red
Bag for cleaning
5. Put on PAPR headpiece or hood verify
adequate air flow
5. Waste gloves WASH HANDS!
6. Put on gown and gloves remember the gown
goes over the inner shroud of a PAPR hood
46
Rush Protocols for Intubation of SARS/Flu patients
47
Intubation Outside an O.R.

• Primary service or nursing staff notify
  Anesthesia On-Call that a patient requires
  intubation using SARS/Flu protocol
• Anesthesia PAPRs from the local room brought
  with anesthesia personnel to the patients room
• 2 on-call anesthesia providers don PAPRs for
  intubation assist with doffing PAPRs

48
Intubation Outside an O.R.

• Determine if the intubation is elective or
  emergent(i.e.. respiratory arrest)
• Perform focused H P1
• AMPLE Allergies, Medications, PMH, Last meal,
  Events
• Airway exam
• Difficult airway? Ensure a fiberoptic cart is
  immediately available
• 1Cooper A et al. CMAJ.ca Sept. 17, 2003

49
Intubation Outside an O.R.

• Anesthetic techniqueminimize coughing
• Normal airway
• Pre-oxygenate for 5 minutesavoid bag-mask
  ventilation if possible
• Use a muscle relaxant prior to intubation
• Consider giving glycopyrrolate IVP prior to
  intubation

50
Intubation Outside an O.R.

• Difficult Airway
• Experienced Anesthesia Provider to intubate the
  patient
• Have a difficult airway cart immediately
  available
• Avoid nebulized/topical/transtracheal lidocaine
• Consider deep sedation midazolam 0.05 mg/kg IVP
  and/or fentanyl 1 mcg/kg IVP every 3 to 5 minutes
  until the patient is unresponsive to deep painful
  stimuli, low spontaneous minute ventilation1
• Consider ketamine as an alternative sedative
• Lidocaine 1.5 mg/kg IVP one minute before
  intubation
• After intubation is confirmed, administer a
  muscle relaxant
• 1Cooper A et al.

51
Intubation Outside an O.R.

• For all cases
• Emergency drugs immediately available
• Disposable Capnometer
• Disposable stethoscope
• Container in the room to place laryngoscope
  (blade and handle) immediately after intubation
  second set available
• Suction ETT with closed system only

52
Operating Room Policy

• Defer elective procedures on all Pandemic
  Flu/SARS patients
• Schedule Pandemic Flu/SARS patients as last case
  of the day
• Remove any unnecessary equipment from the OR
  prior to patient arrival
• Minimize staff present for the operation

53
Intra-operative Management

• Patient Transfer1
• Transfer directly to the OR
• Infection Control determines route to transport
  the patient from a negative pressure room to the
  OR
• Patient wears N-95/ Transporters use full
  Droplet/Contact precautions
• 1www.apsf.org/resource_center/clinical_safety/sars
  .mspx accessed 6/2/08

54
Intra-operative Management

• On entry to the OR
• PAPR or N-95/full face shield and goggles full
  contact/droplet precautions
• Two anesthesia providersone stays clean
  managing the anesthesia cart and keeping the
  anesthesia record1
• Disposable BP cuff, stethoscope
• Keep anesthesia cart clean, have a small table
  available to place used/dirty laryngoscopes
• HEPA filter on inspiratory and expiratory limbs
  of the anesthesia circuit
• 1Cooper et al.

55
Intra-operative Management

• End of case
• Recover patient in a negative pressure room or
  the OR
• Transfer patient with a HEPA filter on the Ambu
  bag if assisted/controlled ventilation is
  required
• Waste all disposables in red bags circuit, CO2
  sampling line, BP cuff, tape, etc.
• Remove PPE using Rush Protocol, don new PPE prior
  to transporting patient to negative pressure room
• Clinical Engineering and Housekeeping responsible
  for disinfecting the OR and OR equipment

56
(No Transcript)