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

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 % protection at microns, flow rate 180 Litre/min Major advantages : completely covers the head,eliminating risk of respiratory,ocular,skin contamination

Air-Mate™ 12 PAPR Head 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 EtCO 2 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.