Preparing a COVID-19 patient for the OR

Most institutions are significantly limiting elective OR cases at this point. Let's consider the issues faced for an urgent/emergent case in which the patient has tested positive for coronavirus. This entry focuses on preparing the patient themselves, other information regarding operating room set-up or roles of physicians/staff/nurses/students in the operating room will be covered in separate entries.

One important point to note is that the N95 respirator is no longer recommended for standard PPE in instances without aerosol generation, per the March 10 updates by the CDC and NC HHS. A regular facemask is appropriate for most use. N95 or PAPR is now only deemed necessary during Aerosol Generating Procedures (AGPs). These AGPs include (but are not limited to) nebulizer administration, sputum induction, airway suctioning, intubation, bronchoscopy, positive airway ventilation (CPAP, BiPAP), and tracheostomy care.

The following are a summary of the CDC's guidance for management of COVID-19 patients last updated March 7; and the ACS Bulletin on March 20, which also discusses specifically OR preparations and considerations. You can find our summary post of those OR considerations here.

Patient transport

• Transport personnel should don PPE for standard droplet and contact precautions (gown, gloves, regular facemask) outside the patient's room, wearing PPE until the patient is situated in the wheelchair or gurney. Once the patient is situated, and before leaving the patient room, transport personnel should remove (doff) all PPE except the facemask and wash their hands.

• Use back hallways or designated patient transport hallways if available.

• If transporting through a main hallway, notify any possible staff to help clear the hallway

• On arrival, anyone assisting with transfer should don PPE prior to contacting the patient

• Patient should wear a regular facemask and be covered with a clean sheet. If patients cannot tolerate a facemask or one is not available, they should use tissues to cover their mouth and nose.

Transfer to the OR table

• Similar to directions for transport personnel above

Patient management

• Intubation/Anesthesia

1. Intubate before/outside of the OR, with N95 of PAPR for personnel, if possible in a negative pressure room

2. Extubate in a negative pressure room if possible

3. Recover patient in the negative pressure ICU/ward room. If negative pressure room unavailable, recover patient in a dedicated COVID-19 OR.

#coronavirussurgery #covid19surgery