anesthesia & sars british journal of anesthesia volume 90, number 6, june 2003
TRANSCRIPT
Anesthesia & SARS
British Journal of Anesthesia
Volume 90 , Number 6 , June 2003
SARS
Outbreak in Toronto (Canada) 267 people were admitted 21 deaths > 50 % = healthcare workers 3 Anesthetists , 1 Intensivist
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
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
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
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 >
0.3 microns , require routine fit testing PCM 2000 Tuberculosis masks , not
require fit testing
N 95 mask
PCM 2000 mask
Face mask (2)
N95 masks : 8 hours PCM 2000 masks : 4 hours Uncomfort & increase work of breathing Masks must not be reused
Extra protection
Theatre caps Disposable fluid-resistant long sleeved
gowns, goggles , disposable full-face shields
Hand washing after touching or removing items
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
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
Air-Mate™ 12 PAPRHead Cover System
HEPA Filter
OR Management of Potential SARS patient
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
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
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
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
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
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
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
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
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
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
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.