Anesthesia

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Anesthesia SARS

• British Journal of Anesthesia
• Volume 90 , Number 6 , June 2003

2
SARS

• Outbreak in Toronto (Canada)
• 267 people were admitted
• 21 deaths
• gt 50 healthcare workers
• 3 Anesthetists , 1 Intensivist

3
Infection control in Anesthesia

• Highly infectious disease
• Transmitted by coronavirus via contact or droplet
• Can live in environment up to 24 hour
• Malaise , Myalgia , Respiratory symptoms from dry
  cough to respiratory failure

4
Hand washing

• Routine hand washing
• Hand mediated transmission major factor to
  cross infection
• Effective hand decontamination significant
  reduction in pathogens infection
• Alcohol based hand rubs effective

5
Gloves

• 14.5 routine use of gloves
• Blood contamination of surgeons hands decrease
  from 13 to 2 with the use of double gloves
• Advises double gloves
• Hands must be washed after degloving

6
Face Masks

• 2 Functions
• Patient protetion by reduction risk of iatrogenic
  infection
• Self protection by reducing risk of nosocomial
  infection
• Standard surgical face masks 50 leak
• N95 masks protecting 95 of particles gt 0.3
  microns , require routine fit testing
• PCM 2000 Tuberculosis masks , not require fit
  testing

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N 95 mask
PCM 2000 mask
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Face mask (2)

• N95 masks 8 hours
• PCM 2000 masks 4 hours
• Uncomfort increase work of breathing
• Masks must not be reused

9
Extra protection

• Theatre caps
• Disposable fluid-resistant long sleeved gowns,
  goggles , disposable full-face shields
• Hand washing after touching or removing items

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The SARS patient

• Regarded as ultra high risk
• Attending anesthetist should wear N95
  mask,goggles,face shield,double gown,double
  gloves,protective overshoes.
• Powered respirator

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Powered respirator

• 3M AirMate powered air purifying respirator
  (PAPR) in bronchoscopy
• AirMate consist belt-mounted motor-driven fan,
  HEPA filter , rechargeable battery pack
• 3M R-Series Tyvek head cover
• 98-100 protection at 0.3-15 microns , flow rate
  180 Litre/min
• Major advantages completely covers the head
  ,eliminating risk of respiratory ,ocular,skin
  contamination

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Air-Mate 12 PAPRHead Cover System
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HEPA Filter
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OR Management of Potential SARS patient
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Patient transfer

• Patients must be transferred directly into OR
• Transfer route should be discussed with
  Infection control team member
• Patient must wear a face mask (N95)
• Transporters should adopt full droplet/contact
  precautions
• Assistance (respiratory therapist) should be
  provided for the anesthesiologist
• Ambu bags should be equipped with a small
  volume heat and moisture exchange filter

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Staff precautions

• Staff should wear clean surgical scrubs laundered
  by the hospital (no personalized hats)
• Minimize the number of individual staff members
  present
• Hand washing for 15 seconds before and after
  patient care
• Communicate with all levels of staff involved in
  the pt.s care regarding the pt.s SARS status
• Clear the room of unnecessary or over stocked
  equipment
• Post a Droplets/Contacts sign on OR doors to
  minimize traffic. Keep doors closed

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On entry to OR

• Maintain full droplet / contact precautions
• Gowns (front and back protected)
• Double gloves. Remove first pair after providing
  direct patient care and before touching other
  areas of the room/ anesthesia machine
• N95 or PCM 2000 mask must be worn with adequate
  seal
• A full face disposable plastic shield for eye
  protection(goggles).
• It is recommended that staff stay minimum of 2
  metres from the patient to avoid droplet
  contamination

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Intubating SARS patient

• Apply all barrier precautions
• Apply N95 mask,goggles,disposable protective
  footwear,gown and gloves.Put on the belt-mounted
  AirMate
• Experienced anesthetist available to perform
  intubation
• Standard monitoring , IV , instruments, drugs ,
  ventilator and suction checked avoidnasal or
  esophageal probes , use axillary temp probe

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Intubating SARS patient (2)

• Avoid awake fiberoptic intubation
• RSI technique in high A-a gradient , unable to
  tolerate 30s of apnea or has C/I to
  succinylcholine
• If manual ventilation small TV applied
• Preoxygenation 5 minutes with 100 oxygen
• Hydrophobic filter between facemask and bag

22
Intubating SARS patient (3)

• Intubate and confirm correct position
• Institute mechanical ventilation and stabilize
  patient.
• After removing protective equipment , avoid
  touching hair or face before washing hands

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At the end of the case

• Remove gloves , followed by gown decontaminate
  hands with alcohol for 15 seconds
• Remove face shield , followed by hair cover and
  wash hands again
• Remove goggles then mask and wash hands again
  with alcohol for 15 seconds
• Re-gown,glove,hair cover,mask goggles
• Transfer patient to Post anesthesia Care Unit
  (Isolation room)
• Remove gown,gloves,goggles and mask prior to
  exiting the isolation room
• Change surgical scrub suit as soon as practically
  possible

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Anesthesia equipment

• Filters
• Small-volume heat and moisture enchange filter
  (PAL filter) hydrophobic membrane
• Anesthetic circuits
• Disposable circle system,reservoir bag ,mask, BP
  cuff , temp probe
• Soda lime
• Soda lime does not need to be changed but EtCO2
  sample line with trap must be changed after the
  case

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Anesthesia equipment (2)

• Drug cart
• Consider necessary for the entire case
• Place at least 2 metres from the operating table
• Avoid contamination
• Machine / surfaces
• Place as far from the patient as practically
  possible
• Avoid placement of contaminated equipment
• Discard needles and syringes immediately

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Intensive care

• Requires full precautions
• Strict isolation in negative-pressure room
• Venturi-type masks should be avoided
• CPAP and BiPAP must be avoided
• Avoid procedures that induce coughing

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Conclusions

• Anesthetists must be rigorous about the
  application of standard precautions in everyday
  practice
• In known or suspected SARS patient, full droplet
  and contact precautions must be applied.