COVID-19 and Anesthesia FAQ

Updated January 20, 2021

Disclaimer: These guidelines were developed using the best judgement of clinicians with experience using anesthesia machines short-term in operating rooms. They are being frequently updated based on experience using anesthesia machines long-term for intensive care ventilation. The information and materials provided herein are provided only for information and educational purposes and do not establish a standard of care or constitute medical or legal advice. Readers are reminded to consult with their own institutions and medical/legal advisors.

These FAQs have been developed in a collaborative effort between the Anesthesia Patient Safety Foundation (APSF) and the American Society of Anesthesiologists (ASA). This APSF version is a slight variation of the version that appears on the ASA website. Viewers of this material should review these FAQs with appropriate medical and legal counsel and make their own determinations as to relevance to their particular practice setting and compliance with state and federal laws and regulations. The APSF and ASA have used their best efforts to provide accurate information. However, this material is provided only for informational purposes and does not constitute medical or legal advice. This response also should not be construed as representing APSF or ASA policy (unless otherwise stated).

Please submit your clinically related questions to [email protected]

TABLE OF CONTENTS

General
Hospital / Facility Administration
Anesthesia Machines and Equipment
Personal Protective Equipment (PPE)
Clinical Care
Wellness

GENERAL

1. Where can I find anesthesia-related recommendations on treating COVID-19 and suspected COVID-19 patients?

Recommendations on treating COVID-19 and suspected COVID-19 patients are available online. Additional recommendations, statements and other resources are available on our APSF/ASA FAQs and the ASA’s “In the Spotlight” COVID-19 webpage.

2. What are the various positions on cancelling or rescheduling elective surgeries?

All major medical societies including ASA and ACS as well as federal agencies recommend deferring elective/non-time-sensitive cases, regardless of patient age. Please see the ASA, ACS and AORN statement on surgical triage decision making.

3. My facility is starting to talk about restarting elective cases. Do professional societies have any suggestions?

On April 17, 2020, the ASA, ACS, AORN and American Hospital Association (AHA) released a Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic. The document contains a list of principles and considerations to guide physicians, nurses and local facilities in their resumption of care in operating rooms and all procedural areas.

4. What is the position of the ASA, APSF, AAAA and AANA on the use of Personal Protective Equipment, including an N95 mask?

The ASA, APSF, AAAA and AANA have released a joint statement on the use of Personal Protective Equipment. The ASA also supports anesthesia professionals purchasing and wearing alternate approved respirators, if they choose to do so. On April 19, the ASA issued an additional statement on “Facility Requirement for Personal Protective Equipment.” This statement is endorsed by the APSF.

5. What is the position on placing multiple patients on a single mechanical ventilator?

The APSF, ASA, the Society of Critical Care Medicine (SCCM), American Association for Respiratory Care (AARC), American Association of Critical‐Care Nurses (AACN) and American College of Chest Physicians (CHEST) issued a consensus statement on the concept of placing multiple patients on a single mechanical ventilator on March 26.

6. Where can I find information on purposing anesthesia machines as ICU ventilators?

PSF and ASA are working together to help anesthesiologists purpose anesthesia machines as ICU ventilators.

7. Where can I find resources for training on critical care medicine?

In response to the rapidly evolving COVID-19 pandemic, ASA, in collaboration with the Society of Critical Care Anesthesiologists (SOCCA), SCCM and APSF have developed the COVID Activated Emergency Scaling of Anesthesiology Responsibilities (CAESAR) ICU Project. This library of ongoing resources, educational materials and information includes informational statements from leaders in critical care medicine, presented to you in a written format, and as brief audio recordings.

We also recommend you visit the ASA resources from other organizations website for additional critical care medicine materials.

8. How do we consider restarting elective cases?

Facilities will have multiple contingencies to work through when restarting elective surgery. ASA has consolidated a number of resources and materials resuming elective surgery for your consideration.

The ASA, American College of Surgeons, American Hospital Association and the Association of periOperative Registered Nurses (AORN) released a “Roadmap for Resuming Elective Surgery after COVID-19 Pandemic” that includes multiple principles and considerations for beginning the discussion on resuming elective surgeries. The Centers for Medicare & Medicaid Services (CMS) also released guidance for restarting elective surgeries. In addition, the ASA and APSF have released a statement on perioperative testing for COVID-19 virus.

9. When restarting surgery, what are some tactics or actions we can take to develop a rational priority for patient backlog?

The ASA, ACS, AHA and AORN in our “Roadmap for Resuming Elective Surgery after COVID-19 Pandemic” includes strategies for resuming surgeries and considerations for prioritizing patients. Planning for resuming surgeries should take into account the perspectives of multiple stakeholders, including those from surgery, anesthesia, nursing and facility administration.

10. The ASA, AORN, ACS, AHA Joint Statement “Roadmap for Resuming Elective Surgery after COVID-19 Pandemic” includes a principle that “there should be a sustained reduction in the rate of new COVID-19 cases in the relevant geographic area for at least 14 days.” Who determines a “sustained reduction rate” (i.e. state or local authorities, health department, hospital)?

There is no one definition of “sustained reduction rate” and can vary by locality as well as situation. State and local health authorities would be the most objective source. Ideally, facilities, in coordination with local and state authorities, would determine when there is a sustained reduction in new COVID-19 cases.

11. Should anesthesiologists cancel or delay cases when patients refuse preoperative COVID-19 testing?

There are many contingencies that anesthesiologists should consider when patients refuse to take a COVID-19 test prior to surgery. The ASA/APSF Statement on Perioperative Testing for the COVID-19 Virus states that patients showing symptoms of COVID-19 should undergo further evaluation and those with COVID-19 should have their elective surgical procedures delayed until the patient is no longer infectious and has demonstrated recovery from COVID-19.

When patients refuse to take a preoperative COVID-19 test, anesthesiologists must work with their surgical colleagues, perioperative nurses, and local infection prevention experts to assess the surgical and anesthetic risk to the patient, and the risk to healthcare workers of contracting the virus. It is important for anesthesiologists to understand why patients refuse to be tested and offer to reschedule procedures when the testing mandate is no longer in effect. When there is an unknown or elevated risk of infection, we recommend delaying their procedures until the risk is either better known (i.e., negative test result) or patients are asymptomatic for at least 10 days.

Patients who refuse preoperative COVID-19 testing put their health and safety at risk. Recent studies and physician experience have indicated that COVID-19+ patients have increased risks of complications and adverse events. ASA, APSF and other organizations recommend that anesthesiologists delay the care of these patients either until they have tested negative for the virus or all symptoms have abated for 10 or more days.

Patients who refuse to take a preoperative COVID-19 test place healthcare workers at risk. Their care can also waste valuable resources. Patients who have not undergone preoperative COVID testing, or who have undergone testing but their test results are not yet available, and in whom clinical assessment of potential infection is not possible, should be cared for as COVID-19+ with all appropriate precautions. This also is true for patients presenting for urgent or emergent surgery when there is insufficient time to obtain COVID-19 tests.

We recommend anesthesiologists and their groups review the ASA Statement on Perioperative Testing for the COVID-19 Virus.

12. Should perioperative testing occur on patients who received the COVID-19 vaccine?

As of January 19, 2021, there are no studies regarding whether someone who received a vaccination could still carry COVID-19 viral material in their naso- or oropharynx and still be considered infectious while not manifesting symptoms. In the absence of data to answer this question, perioperative testing for COVID-19 should continue for patients scheduled for surgery, until we have either definitive studies or the Centers for Disease Control (CDC) offers different guidance. All patients should be screened for symptoms prior to presenting to a healthcare facility.

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HOSPITAL / FACILITY ADMINISTRATION

1. What are APSF and ASA’s recommendations for the safe anesthesia care of COVID-19 patients?

Virus-carrying droplet particles become aerosolized into finer particles by airway procedures such as laryngoscopy, intubation, extubation, suctioning, and bronchoscopy, as well as by coughing and sneezing. These airway procedures and exposures carry a higher risk of infection for anesthesia professionals and other healthcare workers and require the use of rigorous PPE and environmental protection.

APSF and ASA’s recommendations for the safe anesthesia care of COVID-19 patients are updated. Specifically, they address known or suspected (PUI, “person under investigation”) patients in several clinical situations:

When caring for a patient with known or suspected COVID-19 infection
When considering a procedure for a patient with known or suspected COVID-19 infection
When patients with known or suspected COVID-19 infection need to be transported
When performing procedures on patients with known or suspected COVID-19 infection

See also the CDC set of guidances for infection control, use of PPE and hand hygiene.

2. Do we need N95s and full PPE working at the airway for all patients, even if we don’t know their COVID-19 status? For all procedures? What if the facility doesn’t have enough?

ASA, APSF, AAAA and AANA have provided PPE recommendations addressing contingencies that anesthesiologists face at their local facilities.

Due to close patient contact and the need for airway instrumentation, anesthesia professionals are at increased risk of exposure and infection for all diagnostic, therapeutic, and surgical procedures. Also, identification of who is COVID positive or negative with certainty is not possible in the setting of clinical care, especially if there is community transmission. Therefore, APSF and ASA recommends as optimal practice that all anesthesia professionals should utilize full PPE appropriate for aerosol-generating procedures for all patients when working near the airway.

Ideally, anesthesia professionals should use properly fitted N95 masks or powered air purifying respirators (PAPRs). If a facility has existing or projected shortages of N95 masks or PAPRs, however, temporary mitigation plans based on current CDC recommendations should be enacted. CDC offers guidance on conserving N95 respirators within the broader context of engineering and administrative control strategies to decrease personnel risk, in “Strategies for Optimizing the Supply of N95 Respirators.” In addition, CDC offers guidance to extend use/reuse of N95 respirators as a strategy to conserve supply in “Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings.” The National Institutes of Health also released a study on the efficacy of decontamination methods. We encourage physicians to discuss the availability of PPE and other resources with your local leadership and to develop a plan to balance resource constraints with need to protect all providers.

3. What if my facility is unable to supply me with appropriate PPE because of supply chain issues? Can I buy and wear my own?

COVID-19 community transmission is becoming widespread, and reports of health care workers becoming infected are increasing. The APSF and ASA support that anesthesia professionals may purchase and wear alternate approved respirators, if they choose to do so. There are no regulatory prohibitions that forbid health care professionals from wearing PPE when not required to. It is inappropriate for facilities to prohibit their employees from purchasing and wearing approved PPE. The ASA statement “Purchase and Wearing of Personal Protective Equipment by Anesthesiologists and other Anesthesia Professionals” also includes CDC references that identify and support the use of alternate approved respirators. The Joint Commission similarly supports “allowing staff to bring their own standard face masks or respirators to wear at work.”

4. Our hospital administrators will not allow us to wear PAPR in the operating room. How do I address this issue?

APSF and ASA recognize that some hospitals are reluctant to allow the use of PAPRs in the operating room based upon CDC guidance that states, “Powered Air-Purifying Respiratory (PAPR) use in the Operating Room (OR) has not been recommended as there is a lack of scientific evidence to support safe usage of this type of device and the possible impact (contamination of wearer’s exhaled, unfiltered air) onto the sterile field.” AORN’s recommended practice, due to the lack of evidence, is to use a fit tested NIOSH-approved N95 respirator. Scientific studies are currently under way. A 2017 pilot study published in the American Journal of Infection Control details some considerations for PAPR use in the operating room. Prudent practice suggests adherence to CDC guidance of N95 use until more evidence is available. Also, CDC encourages inquirers to seek further guidance from the PAPR manufacturers.”

APSF and ASA have issued several recommendations and published FAQs related to the wearing of appropriate PPE when caring for a patient with known or suspected COVID-19 infection. APSF and ASA strongly support that anesthesia professionals may purchase and wear alternate approved respirators that are equivalent to or better than N95 respirators, if they so choose. On April 19, the ASA issued an additional statement on “Facility Requirement for Personal Protective Equipment.”

We recommend that you work with your anesthesia department, infection prevention personnel and other facility-level stakeholders on a common policy. As noted above, such considerations may take into consideration availability of N95s, failure of N95 fit testing and other contingencies that may affect healthcare worker safety and patient care.

5. How long should surgical personnel wait to enter the room after a patient has been intubated? Should the unnecessary staff who leave the operating room at the time of intubation (aerosolizing procedure) stay out for roughly 20 minutes until the air turnover is adequate to clear potential viral particles? Or can staff, if they have N95 masks, return and begin working right after intubation?

For example, in the referenced CDC table, if your operating room has a typical 15 air changes per hour (ACH), one can see that 99% of the airborne pathogens will be removed from an operating room in 18 minutes. In that scenario, unnecessary staff who leave the operating room before the time of intubation can safely reenter wearing a surgical mask in 18 minutes to participate in a non-aerosol generating surgical procedure. Staff wearing N95 masks and other PPE for aerosol generating procedures identified in the ASA recommendations linked above can remain in the room during the aerosol generating procedures, including intubation and extubation.

6. Should our hospital convert our PACUs into makeshift ICUs?

If the pandemic overcomes the capacity of a hospital ICUs, the PACUs can serve as overflow. Given the fact that PACUs are open units, the institution must decide if all the patients housed in the PACU will have COVID19 or non-COVID19 patients (but not both). Institutions will also need to draft a plan on who will provide medical care to these patients (e.g., Critical Care Anesthesiologists, Internists, Surgeons, ED Physicians, or combination).

7. Does the APSF or ASA have any kind of algorithm or decision tree on how to handle patients coming through for elective, urgent and emergent surgery? We are trying to maintain operations while having the ability to scale back as the situation around us may require.

We have not produced an algorithm on how local hospitals should handle elective, urgent and emergent surgery. There are many contingencies that a hospital must consider, including, but not limited to, patient population, community COVID-19 spread, social distancing, equipment availability and type of elective procedure (will a delay cause more harm?). Hospitals, anesthesiology departments and other healthcare workers should work together to create their own institutional algorithm or decision tree based on these factors. Please also consider the “ASA-APSF Joint Statement on Non-Urgent Care During the COVID-19 Outbreak”. Groups should also consider the CMS guidance on non-essential planned surgeries (PDF) and the Joint Statement from ASA, ACS and AORN on Surgical Triage Decision Making.

8. What is the definition of elective cases? I am receiving pushback from my hospital, surgeons and others who believe that many of their cases are urgent or emergent.

We are concerned that elective and non-essential surgeries appear to be continuing in locations where community spread is significant. While the Anesthesia Quality Institute definition of elective surgery is “a surgical, therapeutic or diagnostic procedure that can be performed at any time or date between the surgeon and patient,” this definition doesn’t reflect nuances that exist in scheduling operative procedures at the current time.

Please review the ASA-APSF Joint Statement on Non-Urgent Care During the COVID-19 Outbreak as well as the Centers for Medicare and Medicaid Services (CMS) guidance on non-essential planned surgeries PDF.

When working with surgeons on scheduling cases, consider reviewing the ACS statement that includes an Elective Surgery Acuity Scale (ESAS) that balances a patient’s need or impact of a surgical procedure with available resources. Many cancer cases are considered time-sensitive. We recommend close collaboration between surgeons, anesthesiologists, and hospital administration to balance individual patient needs with system resource constraints.

9. I am concerned about intubating and extubating patients who could be asymptomatic carriers. I am concerned that current PPE guidelines do not reflect the transmission risks from asymptomatic individuals.

ASA, APSF, AAAA and AANA have provided PPE recommendations highlighting the uncertainty of patients’ COVID-19 status and the need for practitioner safety, addressing contingencies that anesthesiologists face at their local facilities. The decision on whether a patient is suspected of COVID-19 infection should be made individually based on clinical, history and testing criteria where possible. The suspicion of asymptomatic COVID-19 infection should be considered in areas with community spread. Ideally, anesthesiologists and other members of the healthcare team should have an adequate supply of N95 masks for caring of all patients whether symptomatic or not.

We know that PPEs are in short supply in many areas of the country. Therefore, limiting surgical case volume should help reduce the frequency of provider exposure. We further encourage physicians to discuss the availability of PPE and other resources with your local leadership and to develop a plan to balance resource constraints with need to protect all providers.

Please review the Personal Protective Equipment FAQ section for additional details on reusing N95 masks. In general, The CDC and NIOSH have released guidance on reusing PPE. Anesthesiologists should also contact the manufacturer of devices and PPE to ensure that cleaning and reusing such devices and materials are safe and maintain their effectiveness. Please also see the APSF recommendations for processes to eliminate coronavirus from N95 masks.

10. We are currently using CDC guidelines for at-risk patients. Is there any data on at-risk caregivers, such as those who are older or are immunosuppressed?

Data indicate that older individuals and those with co-existing conditions are at increased risk of severe disease and have higher mortality if infected. There is reasonable concern about these anesthesiologists for providing care to COVID-19 patients and suspected COVID-19 patients. There are no national recommendations on mitigating exposure of higher risk physicians, and neither does APSF or ASA. These discussions need to occur on the local level addressing the specific issues and concerns, and might include deploying those physicians into lower risk clinical situations if this can be accommodated.

11. Do APSF and ASA have guidelines or recommendations for physicians who are pregnant? We are concerned about our increased risk for exposure.

We do not have specific guidance on pregnant anesthesiologists, their risk of contracting COVID-19 or if it will affect their pregnancy. Please review the CDC website. Please review the American College of Obstetricians and Gynecologists for additional information on COVID and pregnancy. Please make sure to regularly check these websites for new information.

While pregnant women are more susceptible to viral infections like influenza, their susceptibility to SARS-CoV is unclear. At this time, pregnant women do not appear to be more affected.

The CDC recommends that “facilities may want to consider limiting exposure of pregnant healthcare providers to patients with confirmed or suspected COVID-19, especially during aerosol-generating procedures.” Over time, we hope to have more data on this important issue.

12. How should the operating room be decontaminated following surgery on a COVID-19 patient?

We do not have specific guidance on how to decontaminate the operating room after a procedure with a COVID-19 patient. The current CDC guidance states that routine cleaning and disinfection procedures using an EPA-registered, hospital-grade disinfectant from List N, are appropriate for SARS-CoV-2 in healthcare settings. Upon patient leaving the room, entry should be delayed until sufficient time has elapsed for enough air changes to remove aerosolized infectious particles. The AORN Guideline for Environmental Cleaning outlines recommended cleaning procedures that should be monitored for quality and consistency. Linen and medical waste should follow the routine established practices as outlined by local, state and federal regulations.

Please contact your local infection disease and environmental management personnel for information. Please review APSF recommendations for more information.

13. What are some elements of patient blood management that I should consider?

The ASA Committee on Patient Blood Management has developed a resource for anesthesiologists with regard to pandemics and patient blood management. The resource also includes references and links to relevant literature.

14. I’m trying to set up an intubation team to do all intubations for the entire hospital to minimize staff exposure and PPE used. Has this been done and what is the optimal number of persons or teams that my hospital should designate?

Several team-based models have been implemented in hospitals within the United States – including those for intubation/extubation, patient positioning and other features of COVID-19 care. There are many examples based upon local need and resources. At one hospital, an initial team is made of five physician anesthesiologists are working a 12-hour shift. This team and others use PPE that follows CDC guidance, including the use of N95 masks, gloves, gowns and eye protection. Equipment also includes the use of a video laryngoscope while performing an RSI. A powered air-purifying respirator (PAPR) can also be used for intubation if individuals have received training for donning and doffing for the device.

15. For a patient who has tested negative for COVID-19 as per the ASA statement, should we adhere to the Air Exchange Rate calculation for healthcare workers entering the operating room who are not wearing an N95 or other PPE?

Because false-negatives may occur with testing, droplet precautions (surgical mask and eye covering) should be used by operating room staff for operative cases. Before performing an aerosol -generating procedure, health care providers within the room should wear an N95 mask, eye protection, gloves and a gown.

For physicians and other healthcare workers, the time to enter the room after an intubation will likely be based upon the type of PPE they are wearing and the air exchange rate of the room. A table from the CDC shows the rate that airborne contaminants are removed with various ACH. Please make sure to review the table to identify the room sizes and air exchange rates for your specific operating as well as procedural facility locations. Such information will help to guide your policy addressing when sufficient time has elapsed to clear the air of viral particles. The CDC table indicates the time required to reach 99% and 99.9% reduction in aerosolized particles. The “safe” threshold for re-entering the room wearing a surgical mask after intubation or extubation is not known. It is a local judgement to decide what threshold is considered safe.

For example, in the referenced CDC table, if your operating room has a typical 15 air changes per hour (ACH), one can see that 99% of the airborne pathogens will be removed from an operating room in 18 minutes and 99.9% in 28 minutes. In that scenario, unnecessary staff who leave the operating room before the time of intubation could reenter wearing a surgical mask in 18-28 minutes to participate in a non-aerosol generating surgical procedure depending upon the “safe” threshold decision. Staff wearing N95 masks and other PPE for aerosol generating procedures identified in the ASA recommendations linked above can remain in the room during the aerosol generating procedures, including intubation and extubation.

16. Is a single PCR negative test sufficient to recommend standard operating room attire and no N95 mask for intubation and extubation of an asymptomatic patient having surgery?

No. Because false-negatives may occur with testing, droplet precautions (surgical mask and eye covering) should be used by OR staff for operative cases. Before performing an aerosol -generating procedure, health care providers within the room should wear an N95 mask, eye protection, gloves and a gown.

Please see the APSF and ASA joint statement on Perioperative Testing for the COVID-19 Virus for additional information.

17. I’m concerned that we will be asked to proceed with more elective cases without pre-op testing of our patients or providers. What do you think is the minimum level of pre-operative testing that should be done prior to elective cases?

We believe that all patients should be screened for symptoms prior to presenting to the hospital or other location where the procedure will take place. Patients reporting symptoms should be referred for additional evaluation. Patients not reporting symptoms should undergo nucleic acid amplification testing (including PCR tests) prior to undergoing nonemergent surgery. Knowledge of whether or not patients are COVID-positive is important for guiding their postoperative management, since patients who are infected with SARS-CoV-2, the virus responsible for the COVID-19 disease, can have a higher risk of perioperative morbidity and mortality. Protection of other patients and healthcare workers is another important objective. Please see the APSF/ASA statement on Perioperative Testing for the COVID-19 Virus for additional information.

18. How long should a patient wait to have elective surgery after they have had a confirmed COVID-19 infection?

If a patient tests positive for SARS-CoV-2, elective surgical procedures should be delayed until the patient is no longer infectious and has demonstrated recovery from COVID-19. A patient may be infectious until either: they have CDC recommended test-based strategy (Resolution of fever without the use of fever-reducing medications, improvement in respiratory symptoms, and a negative results from two SARS-CoV-2 tests ≥ 24 hours apart) or via a CDC non-test based strategy (at least 72 hours since resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms and at least 7 days since symptoms first appeared.

Recommendations regarding the definition of sufficient recovery from the physiologic changes from SARS-CoV-2 cannot be made at this time; however, evaluation should include an assessment of the patient’s exercise capacity (metabolic equivalents or METS).

19. What precautions should be placed on an elective surgery patient who was exposed to COVID-19 via a positive family member and/or cohabitant?

The CDC has recommendations for those exposed to a person with symptomatic COVID-19 during period from 48 hours before symptoms onset until that person meets criteria for discontinuing home isolation. These patients should be instructed as follows: 1) Stay home until 14 days after last exposure and maintain social distance (at least 6 feet) from others at all times; 2) Self-monitor for symptoms (check temperature twice a day and watch for fever, cough, or shortness of breath) and follow CDC guidelines if symptoms develop; 3) Avoid contact with people at higher risk for severe illness (unless they live in the same home and had same exposure).

Based on these recommendations, a patient scheduled for elective surgery who has close contact with someone infected with SARS-CoV-2 should have their case deferred for at least 14 days.

20. Should we use antibody testing as part of perioperative screening and risk assessment?

Currently, the World Health Organization (WHO) recommends antibody testing only for research purposes and not for clinical decision making.

21. Do APSF and ASA have a list of aerosolizing procedures in the operating room so that we can identify which procedures require PPE?

According to the CDC there is neither expert consensus, nor sufficient supporting data, to create a definitive and comprehensive list of aerosol generating procedures (AGPs) for healthcare settings. Commonly performed anesthesia and critical care-related medical procedures that are often considered AGPs, or that create uncontrolled respiratory secretions, include tracheal intubation and extubation, manual ventilation, non-invasive ventilation (e.g., BiPAP, CPAP), bronchoscopy, open suctioning of airways, sputum induction, and cardiopulmonary resuscitation. In addition, surgical societies, including the ACS, cite procedures that are potentially aerosol-generating, including upper airway and skull base procedures, upper and lower GI endoscopies and laparoscopies. It is uncertain whether aerosols generated from some procedures may be infectious, such as nebulizer administration and high flow O₂ delivery.

22. How do we move patients to PACU? For social-distancing purposes, do we keep an empty PACU space between recovering patients?

Each facility must assess how it is able to maintain adequate space between patients. Extubated patients who are not suspected or known to have COVID-19 should be brought to the PACU with a face mask in place, and should be spaced at a distance of 6 feet apart. Patients that are coughing or sneezing repeatedly due to airway irritation may require an enclosed room with limited personnel who practice full airborne precautions with eye protection (e.g., N95 masks, gowns, gloves, and eye shields).

23. Is the APSF/ASA statement on Perioperative Testing for COVID-19 Virus applicable to the Ambulatory Surgery Center and office-based locations?

Yes. We also recommend you review the Society for Ambulatory Anesthesia (SAMBA) Statement on COVID-19 Testing Before Ambulatory Anesthesia (April 30, 2020) for additional consideration.

24. Should faculty covering potential COVID-19 cases in two different ORs follow OHSA guidelines and change PPE every time they travel back and forth between rooms?

APSF and ASA recommends working closely with your facility to determine the most appropriate strategy for PPE conservation. Prior to the COVID19 crisis, recommended practice was to completely remove PPE once you leave the immediate care of a patient. A provider would then don completely new PPE to care for the next patient.

In order to preserve PPE, anesthesia providers going between two operating rooms containing patients testing positive for SARS-CoV-2 should remove gloves, practice hand hygiene and don a new pair; change gowns, and clean any visible soil on face shields. Additionally, face masks should be changed if there is soil visible. Shoe covers, hair covering and face masks that are visibly clean do not need to be changed.

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ANESTHESIA MACHINES AND EQUIPMENT

We ask that you visit our website, Anesthesia Machines FAQs. The information in this site covers a number of important anesthesia machine and equipment issues.

1. For asymptomatic and negative COVID-19 patients, do we need to protect the CO2 sampling line with a second HEPA filter for each general anesthesia case?

Broad guidance on the approach to filtering airway gases is available on the APSF website at (https://www.apsf.org/faq-on-anesthesia-machine-use-protection-and-decontamination-during-the-covid-19-pandemic/#machine). Current guidance recommends using an HME filter at the airway and sampling gas from the machine (filtered) side of the HMEF. The viral filtration effectiveness varies with HMEFs and filtering performance at the airway is susceptible to moisture or soiling especially for electrostatic filters. Sampled gas typically enters a water trap and many of these traps have an internal filter effective for filtering viruses while some do not and for most the viral filtration effectiveness is not documented. The level of additional protection recommended for the sampling line, in addition to the HMEF, depends upon where the exhaust gas from the gas analyzer is routed.

If the analyzer is separate from the anesthesia machine, a second filter is not required if the exhaust port for sampled gas is connected directly to a scavenging system or central suction. It is not recommended for exhaust gas to enter the room directly since inhalation anesthetics will also contaminate the room. If scavenging cannot be accomplished, additional filtering is prudent to protect against viral infection.
If the analyzer is built into the anesthesia machine, it is important to understand if the exhaust gas from the analyzer goes to the scavenger, back into the circuit or into the room. If exhaust gas is routed into the breathing circuit and the effectiveness of the water trap filter for virus is unknown, additional filtering is prudent to prevent contaminating the inside of the anesthesia machine. It is not recommended for exhaust gas to enter the room directly since inhalation anesthetics will also contaminate the room. If scavenging cannot be accomplished, additional filtering is prudent to protect against viral infection.

2. What processes should I use to return an anesthesia machine that was purposed for ICU back to an operating room setting? If a machine is not used for a month or so, do we need to do any special testing prior to routine anesthesia service?

Complete guidance on how to return an anesthesia machine to service in the operating room after use for long term ventilation of patients with COVID 9 related respiratory failure can be found in the ASA website at APSF/ASA Guidance on Purposing Anesthesia Machines as ICU Ventilators (PDF Updated April 16, 2020). The current recommended steps are:

Remove and discard all disposables – circuit, filters, CO2 absorbent, mask, sampling line and associated water trap.
Following manufacturer instructions, sterilize the internal breathing system and ventilator components.
Wipe external surfaces with appropriate anti-viral cleaning solution
Replace the disposables with new clean/sterile replacements
Place a viral filter on the inspiratory limb for two to four weeks. This filter could be left in place between patients to conserve supply.

If the machine has not been used for more than a month, no special testing should be required other than the usual preventive maintenance and pre-use test procedures. It is not likely that viable virus would remain after that period of time.

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PERSONAL PROTECTIVE EQUIPMENT (PPE)

1. We don’t always know if patients are COVID positive. What PPE should we use?

The ASA, APSF AAAA and AANA have released a joint statement on the use of Personal Protective Equipment.

2. Can I reuse by N95 mask and other Personal Protective Equipment?

The CDC and NIOSH have released guidance on reusing PPE here and here. Anesthesiologists should also contact the manufacturer of devices and PPE to ensure that cleaning and reusing such devices and materials are safe and maintain their effectiveness.

Please see the APSF recommendations for processes to eliminate coronavirus from N95 masks. The inventor of the material used in the N95 mask, Dr. Peter Tsai, suggests that droplets and viable viruses will dry and no longer carry risk of transmission if the masks are not obviously soiled and are carefully stored in brown paper bags (so that air can circulate to them for drying) for at least 3 days. The CDC supports this approach if really necessary to allow re-use but suggests a 5 day period of drying. A practical application, if sufficient numbers of N95 masks are available, would be to issue 5 masks to everyone, and then have them rotate the use and storage of masks in a cycle. Information circulating through social media suggests that placing N95 masks in ovens at 70° C for 30 minutes will decontaminate N95 masks, also. The CDC explicitly does not support this approach to decontaminating N95 masks, suggesting that the dry heat may harm the protective integrity of the masks. The National Institutes of Health also released a study on the efficacy of decontamination methods.

ASA has also learned of other ways practices are reusing masks. In one case, members of the anesthesia care team are planning to reuse disposable PAPR (Powered Air-Purifying Respirator) hoods after wiping them down as well as using available reusable military grade PAPR. The PAPR filter cartridges will also be reused with care to avoid contamination. Groups have also planned to create their own ‘N95’ utilizing an anesthesia circuit mask plus a Pall Ultipor® filter plus a strap to secure a makeshift solution. This may be helpful for short, but high-risk procedures. We also are aware of hospitals and facilities using ultraviolet germicidal irradiation (UVGI) as a practical method to decontaminate the N95 mask.

We recommend members conduct literature reviews, review resources on the CDC and NIOSH websites, contact the manufacturers and assess the risks and benefits associated with such actions.

3. What types of masks should we use if N95s are not available?

Please review the CDC website for appropriate masks to use. We recommend industrial masks that offer equal to or greater protection than N95 (e.g. N100). Some facilities have considered the use of a tight mask that can be constructed with available anesthesia supplies (disposable anesthesia mask, straps, and HEPA filter) or other full-face masks with straps and HEPA filter. We do not recommend hand sewn or other fabric masks that have not undergone careful testing because of concerns about fit and filtration capability.

4. For what procedures does APSF and ASA recommend the use of N95 masks?

APSF and ASA recommends as optimal practice that all anesthesia professionals should utilize PPE appropriate for aerosol-generating procedures for all patients, during all diagnostic, therapeutic, and surgical procedures, when working near the airway. More complete guidance can be found in the ASA-APSF-AAAA- AANA joint statement. Appropriate PPE for aerosol-generating procedures including airway protection with N95 masks or PAPRs.

5. What types of masks should we use if N95s are not available?

We support anesthesia professionals purchasing and wearing alternate approved respirators, if they choose to do so. The Joint Commission also supports “allowing staff to bring their own standard face masks or respirators to wear at work.” There are no regulatory prohibitions that forbid health care professionals from wearing PPE when not required to. It is inappropriate for facilities to prohibit their employees from purchasing and wearing approved PPE.

6. If operating room staff do not have N95s, what are people doing to protect them from aerosolization from RSI?

We are concerned about any facility that does not have proper PPE for the intubation or extubation of COVID-19 and suspected COVID-19 patients. There is no safe substitute for wearing full, appropriate PPE for these aerosol generating procedures. Lower levels of PPE increase the risk of infection. If limited quantities of PPE are available, please see the CDC recommendations on extended use and limited reuse of PPE including N95s. https://www.apsf.org/news-updates/potential-processes-to-eliminate-coronavirus-from-n95-masks/

Using barrier methods may aid in reducing viral particle exposure in general, although there are no data on actual effectiveness. Additionally, the use of videolaryngoscopes may enable the person intubating to remain further away from the airway. Limiting the number of staff members present for intubations/extubations to reduce the risk of unnecessary exposure is recommended.

7. Do APSF and ASA have any specific recommendations on hand hygiene for a patient with COVID-19 for the duration of a surgical case once the airway has been secured? Should providers continue to double glove and remove outer glove when soiled? Or should providers single glove and perform hand hygiene between glove changes?

Hand hygiene should be rigorously followed in all cases and to the best of your ability. Any patient contact should require thorough and extensive hand washing per standard protocols. If available, double glove and removing outer gloves after patient contact.

8. Regarding gowns vs coveralls, is there any additional need for neck protection during airway manipulation of patients with known or suspected COVID-19 infection? Do we need a hood with neck cover for potential splashes of droplets during intubation or extubation?

Please see ASA guidance. We recognize the risk that airway management has when a patient coughs during intubation or extubation, leading to contaminated mist and droplet formation. All authorities recommend that you do not touch your hands to your face. A face shield will protect your eyes and also the N95 mask from surface contamination. Some are using a surgical mask over the N95 mask.

9. We have received feedback that specifying protection Level 3 for isolation gowns for operating room cases and intubations would be helpful. “Gowns” alone seems vague since they have different levels of protection.

We recommend that you review guidance materials found on the CDC website. We encourage you to have conversations with infectious disease consultants, infection control staff and supply chain managers who can inform your judgment concerning the best of alternative choices to protect all your patients and staff.

10. I have tried to put on clean masks and gloves prior to interviewing my patients. However, I have heard that this practice is not allowed by CMS. I feel that clean gloves and masks in all patient contact areas should be allowed to help in curtailing spread of this highly infectious virus.

CMS guidelines or accreditation organizations do not prohibit the use of masks or gloves outside an operating suite. However, this question highlights the need to be sensitive to resource utilization when critical shortages of supplies may occur. Current CDC recommendations do not include the use of PPE when in the presence of asymptomatic or presymptomatic patient. For all patients, hand hygiene remains a cornerstone of good medical practice to prevent the spread of any infectious disease.

11. We need active communication from the APSF and ASA regarding our safety, precautions, N95 fitting and increasing the production of this equipment. I’m doubting the CDC that surgical masks are adequate.

Please see “For what procedures does APSF and ASA recommend the use of N95 masks?” FAQ. The ASA, APSF, AAAA and AANA have released a joint statement on the use of Personal Protective Equipment. The document also references CDC guidance.

12. Do APSF and ASA have a position or recommendation on intubation/aerosols boxes? What is the evidence for using plexiglass cages/homemade tents attached to weak OR suction for intubations if no negative pressure rooms available?

APSF and ASA recommend that hospitals make available the highest level of protective equipment (PPE) for anesthesia team members for care of patient with COVID-19 disease. Other techniques may be useful to reduce transit of viral load into the room environment but they do not replace or lessen the need for the most effective PPE.

The APSF and ASA has no position on the use of mechanical barriers around the patient’s head during intubation and extubation. We recommend that you work closely with infection prevention experts and others on any new or untested devices. For example, at one facility, tests of a locally-constructed “intubation box” revealed that the device actually dispersed droplets toward the physician intubating the patients. When a fix was applied, further study of that particular device indicated that box trapped the particles and suction could not fully rid the box of contaminates. Because local experience and different construction of such products exists, we recommend an independent literature review on this subject, noting the risks and benefits of all novel and often untested devices.

Any device or shield that deflects or contains droplets (e.g. viral particles) might reduce exposure. There is no guidance on whether they are actually effective or if any technique is superior. Some alternatives are using the plastic intubation cubes/boxes, placing a sheet of clear plastic over the patient while intubating, or using clear plastic drape over a Mayo stand covering the patients head during intubation. Some people have added placing suction under the drape to reduce droplet exposure further. While these might aid in the reduction of airborne particles, some clinicians believe that they slow down intubation times.

13. I have COVID-19. When can I return to work?

Please review the CDC website for considerations on returning to work after a positive COVID-19 diagnosis.

14. What PPE should I use for patients who have tested negative for COVID-19?

Please review the APSF/ASA joint statement on PPE during the COVID-19 pandemic.

15. Should asymptomatic patients be considered COVID-19+?

Asymptomatic carriers are less likely to be present in areas with low COVID-19 prevalence. On the other hand, certain regions of the United States are significantly impacted by active COVID-19 disease and one can expect more asymptomatic carriers.

The prevalence of SARS-CoV-2 is available via your state’s health department. We recommend close coordination with your facility, Infectious Disease and Infectious Prevention specialists, and review of available data regarding COVID-19 prevalence.

16. What PPE should we use LMA and MAC in COVID-19 negative patients?

APSF and ASA recommends using PPE in accordance with CDC guidance. Aerosolizing procedures should continue to use aerosolizing precautions (N95 respirator or equivalent, face shield, gown, and gloves). Further guidance on PPE is available on the APSF COVID-19 website. When choosing to use LMA, MAC or ETT, we recommend you consider ASA Clinical Care FAQs #11, 12 and 17 here: https://www.asahq.org/about-asa/governance-and-committees/asa-committees/committee-on-occupational-health/coronavirus/clinical-faqs

17. We require one test three days before surgery and then have the patient self-isolate. In this scenario, is the recommendation with a negative test still N95 and full PPE for all cases?

A population risk assessment identifying the prevalence of SARS-CoV-2 should be reviewed.

When there is local or regional presence of SARS-CoV-2:

Because false-negatives may occur with testing, droplet precautions (surgical mask and eye covering) should be used by OR staff for operative cases. Before performing an aerosol -generating procedure, health care providers within the room should wear an N95 mask, eye protection, gloves and a gown.

Please see the APSF/ASA statement on Perioperative Testing for the COVID-19 Virus for additional information.

18. Under what circumstances would APSF and ASA feel comfortable recommending de-escalation of PPE requirements?

At this time, no regulatory body or national organization has recommended de-escalation of PPE requirements. PPE exists for the protection of staff caring for patients. The Occupational Safety and Health Administration (OSHA) states that employers “must provide a workplace free of known health and safety hazards.” APSF and ASA recommendations are based on review of the guidance provided by CDC, major medical organizations and current medical literature. These recommendations are dynamic, and ASA is closely monitoring new guidelines as they are developed.

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CLINICAL CARE

1. Why are anesthesiologists and other anesthesia professionals being asked to perform more intubations in my facility when there are other physicians who are trained to do so?

In each location where intubations take place, the most experienced professional for that location should perform the intubation. In the operating room, this should be the most experienced anesthesia professional available. In non-operating room locations, including the Emergency Room and ICU, this should be an emergency medicine, critical care medicine or anesthesia professional, depending on availability and staffing for the facility. Every facility should develop a protocol for which medical service responds to the need for non-OR intubations.” This is not a training opportunity for students. Anesthesiologists would expect to be consulted when there are difficult intubations or to assist with a surge of patients. (See: https://www.asahq.org/about-asa/governance-and-committees/asa-committees/committee-on-occupational-health/coronavirus). Anesthesiology departments should work with hospital administrators and other personnel who are trained in intubation (e.g. critical care and emergency departments) on clear guidance that protects healthcare worker and patient safety. Stakeholders should conduct debriefings to discuss how to improve the process.

2. What should we do about “MAC” cases, with an open airway?

If dispersion of potentially contaminated exhaled gases from an open airway (e.g. “MAC”) is a risk, consider alternate anesthesia plans. Potential contamination of your workspace and the room should be considered. The safety of you and your colleagues is paramount.

3. Are there specific recommendations for EGD procedures and other procedures with a high risk of aerosolization?

Decisions need to be based on an understanding of your local COVID-19 risk profile for community spread in your area in consultation with your local infectious disease and infection control experts. This information will help inform your own risk assessment development considering the patient, skill sets of the endoscopists and local resources. ETTs provide the most secure airway. Patient face masks with apertures for gastroscopes such as a POM (Procedural Oxygen Mask by Curaplex) or similar devices may limit dispersion throughout the room but are not a safe alternative for appropriate PPE . ASA has also released guidance for procedures where there is a high probability of aerosolization.

Best practices may be in flux because of shortages of N95 masks, personal protective equipment and regional differences in known patients with COVID-19. As COVID-19 testing becomes more common, the regional risk profiles and supply chain limitations will help guide what is possible in a specific location.

4. With regard to COVID-19, do APSF and ASA have any recommendations for obstetric care overall and specifically related to epidurals and spinals?

We encourage you to review the recent statement published by the Society for Obstetric Anesthesia and Perinatology (SOAP) regarding obstetric care. In general, we are unaware of coronavirus is a contraindication to a neuraxial block. Spinals and epidurals should take into consideration appropriate precautions, especially regarding COVID-19 patients or those suspected of having COVID-19. Such precautions may include isolating the infected or suspected patient and placing them in rooms identified for that purpose as well as having a dedicated operating room. Ideally, these operating rooms would be negative pressure rooms. We also recommend the use of N95 masks, double gloves, gowns and protective eyewear as appropriate.

5. Given the concern for immunosuppressive during this time of COVID-19, I question whether or not to administer dexamethasone for PONV. According to one article, it doesn’t look like in the doses we provide for PONV prophylaxis- that it would cause clinically significant suppression but was wondering if you might be able to comment.

In general, low doses/single dose dexamethasone would not be regarded as clinically significant or sustained immunosuppression. Each patient is unique and we cannot comment on individual patient treatment options or anesthesia plans. To our knowledge, there is no clinical data on deciding whether to use or not use a single dose of dexamethasone in COVID-19 patients.

6. I have been hearing concerns of immunosuppression when performing steroid injections in the elderly population as it relates to COVID-19.

We do not have specific guidance on epidural steroid injections and COVID-19 with regard to individual patient medical histories. We recommend that you assess each patient and also consider decreasing the dose of steroid administered, keeping in mind that the effect of the long acting steroids will last for a while in your patient.

7. What is the APSF and ASA’s stance on safety of regional anesthesia in appropriate patients (especially those many that haven’t been tested) vs general anesthesia?

We are unaware of coronavirus as a contraindication to a neuraxial block. Spinals and epidurals should take into consideration appropriate precautions, especially regarding COVID-19 patients or those suspected of having COVID-19. For treating obstetric patients, please see guidance from the Society for Obstetric Anesthesia and Perinatology (SOAP).

8. Are APSF and ASA advocating use of a video laryngoscope as first line for intubation? We have a very limited supply of sleeves at my institution.

The recommendation is that providers perform intubations with the greatest chances of success on the first attempt. This must be balanced with the supply chain availability. Recommend close collaboration with your healthcare system to closely monitor the supply chain and determine how best to utilize limited resources. Please see for recommendations on intubating COVID and suspected (persons under investigation) COVID patients.

9. Should the plastic draping on any video laryngoscope you bring into a suspected or confirmed COVID-19 intubation patient be removed like doffing your gown each time or can the draping if plastic be wiped down?

Dependent on your supplies, the plastic draping should be removed and discarded after use. However, if your supplies are constrained then consider wiping down your draping using appropriate cleaning procedures designated by the manufacturer.

10. How should I deliver supplemental O₂ to a patient who is wearing a mask and who has or may have COVID-19?

If a patient has or is likely to have COVID-19, the first consideration is for your safety and the safety of everyone in the room. It is important that you wear appropriate PPE. Being at the COVID-positive patient’s head there is always risk of coughing and of needing to physically support the airway with jaw thrusts or intermittent positive pressure ventilation by face mask. Therefore, PPE for aerosol-generating procedures should be worn. There will be insufficient time to garb if there is an urgent clinical development. For the patient, nasal prongs under surgical mask with low-flow oxygen or simple face mask over surgical mask might suffice. However, if patient oxygenation is not maintained on low-flow oxygen, higher oxygen flows may be unexpectedly needed that might increase aerosolization of COVID-containing respiratory secretions. Each patient will need to be evaluated on a case-by-case basis to consider the balance of aerosolization at the oxygen flow needed to maintain a satisfactory oxygen saturation, and whether to convert to a more closed airway system (LMA or ETT).

11. What is the recommendation for LMA usage or MAC anesthesia? Or are we presuming ALL patients are carriers and LMA usage and MAC anesthesia be minimized? This would result in intubating all patients for general anesthesia and eliminating MAC anesthesia for most of our cases.

Since March 2020, anesthesiologist experiences in treating COVID-19, PUI and asymptomatic patients have matured and risk assessments have most likely been reevaluated at local facilities. When considering LMA use, we recommend a risk assessment be performed based on the COVID community-wide transmission. We also recommend that anesthesiologists, when determining airway techniques and anesthetic choices, take into consideration the results of a patient’s COVID-19 test, including the sensitivity and specificity of tests being used, and balance testing and community spread with choosing the appropriate PPE to use. Anesthesiologists may wish to discuss policies with local infection prevention experts.

At this time, no studies exist that assess risk of various airway techniques and anesthetic choices. While LMA usually seals the airway at low pressures, there is concern that higher positive pressure, if used, might create a leak with aerosol production. LMA may be an acceptable option with selected patients because of the lower risk of coughing.

Non-airway MAC cases with spontaneous ventilation may be acceptable if fresh gas flows are low, but consider the anesthesia provider’s proximity for jaw lifts or potential intermittent positive pressure ventilation if brief apnea occurs. Therefore, PPE for aerosol-generating procedures should be worn. However, airway cases, upper endoscopy, bronchoscopy, and situations that induce cough or sneeze should be considered high risk for aerosol production. There is potential risk for other providers present near the oropharyngeal airway as well, and gastroenterologist society recommendations warn of risk with upper and lower GI endoscopy.

For anesthesia professionals, an additional consideration is that a failed MAC case may need to be transitioned rapidly to tracheal intubation that likely bears higher risk for suboptimal conditions. Local experts report that natural-airway MAC anesthesia is not being used in areas of high COVID-19 community prevalence, but instead, planned controlled endotracheal anesthetics.

For discussions on air exchange rates, please refer to Hospital & Facility Administration FAQ #5.

12. I routinely perform ECTs. Are there any considerations I should have when developing my anesthesia plan?

We realize that ECT is likely a time-sensitive case, the risk of aerosolization is high, and that you’re trying to balance the benefit of the case with the risk of COVID-19 transmission. Our FAQs provide for considerations for an anesthesia plan, if applicable (See Clinical Care: https://www.asahq.org/about-asa/governance-and-committees/asa-committees/committee-on-occupational-health/coronavirus/clinical-faqs). Based upon community spread and other risk factors, we recommend the use of PPE for aerosol-generating procedures, including those for COVID-19 and suspected COVID-19 (please see the ASA, APSF, AAAA and AANA statement – it includes caveats for limited supplies as well). Viral filters should be used for known and suspected COVID patients. Please review the APSF FAQs for further information on filters, including how to extend filter use.

13. Does ASA have any recommendations on using negative pressure rooms when intubating or delivering surgical care to COVID-19 patients?

ASA recommendations state, “When possible, perform procedures in an airborne infection isolation room rather than in an operating room. An airborne isolation room has a negative-pressure relative to the surrounding area. In contrast, a typical operating room is designed to provide positive-pressure relative to the surrounding area and incoming air is often flow-directed, filtered, and temperature and humidity controlled. If a procedure cannot be postponed or done at the bedside, then schedule the patient when a minimum number of healthcare workers and other patients are present in the surgical suite.”

We recognize that limited resources and available rooms in a specific hospital may decrease the opportunity for this to occur. In those instances, considerations should include possibility of a difficult airway (benefit/risk OR vs ICU intubation), local resources and urgency of the situation.

We encourage anesthesiologists also contacting and collaborating with local infection control expertise on appropriate locations, planning and policy development.

14. Should we use negative pressure rooms for intubations and extubations in asymptomatic patients coming to an operating room?

As with other considerations of asymptomatic patients, a risk assessment should take place to determine feasibility and assess safety considerations, including risk of transporting an intubated patient and the provision of bridging sedation. Next, an assessment of disease prevalence should be made. In locations with low prevalence (<1%), the risk of intubating and extubating an asymptomatic patient is most likely low. Currently there is no requirement or guidance that intubation and extubation of non-COVID19 patients should take place in a negative pressure environment. Nevertheless, planning is needed to minimize aerosolization of secretions in all patients (e.g., avoid coughing, temporary use of a transparent plastic cover during extubation), and wear appropriate PPE.

15. Are there any COVID related risks with jet ventilation?

Jet ventilation will most likely disperse far more droplets/particles than standard ventilation techniques. This presents a risk of becoming infected through contact with oral, nasal or ocular surfaces. Jet ventilation of an open airway, either supraglottic or subglottic, should be considered an aerosol generating procedure (AGP). Jet ventilation within an endotracheal tube attached to a breathing circuit with filters is not an AGP.

16. For an asymptomatic patient in an area with widespread community transmission, are there recommendations regarding avoiding the use of an LMA with positive pressure ventilation versus an endotracheal tube, in a standard operating room (positive pressure room)?

We recommend that anesthesiologists and anesthesia professionals, when determining airway techniques and anesthetic choices, take into consideration results of a patient’s COVID-19 test, the sensitivity and specificity of testing being used and community spread. Based upon these criteria, anesthesiologists and other anesthesia professionals can determine whether a conservative or more liberal approach is necessary, especially if there is high community spread. In assessing risk of exposure, anesthesiologists should also consider whether individual LMA, MAC and regional cases would have a risk for general anesthesia conversion.

17. Do APSF and ASA have any guidance on the treatment of stroke patients during the COVID-19 pandemic?

The Society for Neuroscience in Anesthesiology and Critical Care has released several documents for consideration, including the “Anesthetic management of Endovascular Treatment of Acute Ischemic Stroke During COVID-19 Pandemic” and a decision tree for “Endovascular Therapy for Acute Ischemic Stroke.” (See: https://www.snacc.org/)

18. I have read that some hospitals are giving all COVID-19 patients a unilateral DNR, i.e. making them a DNR on admission regardless of physical status or prognosis. Is this ethical?

There was an article in the Washington Post recently that used the term “universal” in the headline, though it seemed to be actually referring to “unilateral” DNR orders, i.e. making someone a DNR based on one’s clinical judgment but without consent of the patient or surrogate.

It is not considered ethical to make a class of patients DNR with no regard to their individual prognosis. However, during a time of public health crisis there may be a shortage of resources, high risk to caregivers and/or logistical problems involving donning the proper PPE.

In such cases caregivers may have a lower threshold to unilaterally decide that certain treatments are inappropriate and/or futile for individual patients and will not be provided or may have to be withdrawn. Certainly, if time permits, the patient and/or surrogates will be informed of this process but won’t necessarily have to agree with the decision. While these decisions will be gut wrenching for all involved, they are clearly in line with ethical principles.

This statement only addresses the ethics of the dilemma. If you have concerns about the legality of any medical decisions please contact your own legal counsel who will be familiar with the laws in your state.

19. What are some considerations for the treatment of patients who are obese in the ICU?

The ASA Committee on Critical Care Medicine discussed the ramifications of the obese population and diabetic population in the US on the management of patients infected with Covid-19. Patients with obesity or type 1 or type 2 diabetes make up roughly 33% and 9% of the US population respectively^{1, 2}.

Diabetic patients do make up a substantial portion of patients hospitalized with Covid-19 (up to 19-58%)^{1, 3}. Diabetes has been demonstrated to be a risk factor for acute kidney injury in ARDS in the general population while acute kidney injury (AKI) appears to occur in about 15% of Covid-19 patients⁴. Diabetes itself is associated with increased ACE2 receptor expression which is the receptor that Covid-19 binds to in order to facilitate disease and impairs immunity⁵.

The clinical experience of our committee thus far further suggests that patients who are morbidly obesity are doing worse in that they are very difficult to ventilate and are requiring deeper sedation and more frequent paralysis. Additionally, they appear to have a higher rate of AKI. Lastly, critical care myopathy (weakness), which is classically associated with prolonged neuromuscular blockade) also effects the ability of morbidly obese patients to successful extubation. Please note that the overall clinical experience with extubation appears limited at this point.

There appears to be less clinical experience within the committee specifically pertaining to diabetes mellitus, but as it is extremely common, any significant patterns may not yet be obvious. There is not a clear treatment pattern in the literature for the diabetic population.

An executive summary of the consensus of the committee on critical care medicine is as follows:

Preventive measures before obese patients becomes critically ill is likely the most effective way to reduce the morbidity burden of these patients.
1. While on the floor, medical teams can remind patients to put themselves in prone position at regular intervals and/or walk a specified number of laps in the patient’s hospital room based on their condition.
  1. Forethought pertaining to teaching the patient to make themselves prone can prevent the nurse from having to enter the room as well, thus conserving PPE.
  2. Creative thinking/positioning with pillows but our hope is that patients can do this themselves without requiring nursing to come in.
  3. Consideration may be given to implementing prone positioning in the EMS setting if feasible and further clinical data supports it
2. Once mechanically ventilated, challenges in ventilation may be expected but not necessarily preventable at this stage. Prone positioning should be continued but may be more challenging for staff.
Patients with diabetes may be at higher risk for morbidity, but there does not yet appear to be a way to mitigate that risk

References:

Bhatraju PK, Ghassemieh BJ, Nichols M, Kim R, Jerome KR, Nalla AK, Greninger AL, Pipavath S, Wurfel MM, Evans L, Kritek PA, West TE, Luks A, Gerbino A, Dale CR, Goldman JD, O’Mahony S, Mikacenic C: Covid-19 in Critically Ill Patients in the Seattle Region – Case Series. N Engl J Med 2020.
De Jong A, Chanques G, Jaber S: Mechanical ventilation in obese ICU patients: from intubation to extubation. Crit Care 2017; 21: 63.
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, Xiang J, Wang Y, Song B, Gu X, Guan L, Wei Y, Li H, Wu X, Xu J, Tu S, Zhang Y, Chen H, Cao B: Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395: 1054-1062.
Panitchote A, Mehkri O, Hastings A, Hanane T, Demirjian S, Torbic H, Mireles-Cabodevila E, Krishnan S, Duggal A: Factors associated with acute kidney injury in acute respiratory distress syndrome. Ann Intensive Care 2019; 9: 74.
Muniyappa R, Gubbi S: COVID-19 Pandemic, Corona Viruses, and Diabetes Mellitus. Am J Physiol Endocrinol Metab 2020.

20. How long are you able to keep a patient continuously ventilated on an anesthesia machine without disconnecting to change circuit, run machine check, change the filters? Our ICU docs are very concerned about losing lung recruitment when we have to change these things out.

There are numerous makes and models of anesthesia machines. APSF and ASA recommends discussing these concerns with the manufacturer’s technical services. Anesthesiologists and other anesthesia professionals are well trained to balance the risks and benefits on an individual basis for patients under their care.

APSF and ASA haves written guidance on the use of anesthesia machines as ICU ventilators. These guidelines suggest disconnecting the patient at least every 72 hours to restart the anesthesia machine and perform a startup test. A step-by-step procedure for doing this is provided, Loss of lung volume is prevented by briefly clamping the endotracheal tube when it is disconnected. The breathing circuit and filters can be changed during this time. Additionally, filters may need to be changed more frequently when they become partially obstructed.

To support patients during the anesthesia machine power up test refer to this Startup-Test Checklist for step-by-step guidance.

21. Do APSF and ASA have any suggestions about performing tracheotomies on COVID-19 patients? What is the time frame, if any, on performing a tracheostomy on a COVID-19 patient? Should we wait for one or two negative COVID-19 tests prior to performing this procedure?

We cannot provide clinical recommendations regarding testing prior to this procedure. We instead recommend consulting with local infectious disease experts and infection control staff. Tracheostomy would be considered a high-risk procedure and risks and benefits should be considered based upon individual patient care and need (e.g. FiO_2,oxygenation and PEEP). We recommend physicians considering this procedure review guidance provided by the American Academy of Otolaryngology-Head and Neck Surgery.

Performing a tracheostomy is an aerosol generating procedure (AGP), and open tracheostomies generate respiratory droplets and aerosols at a high rate. Tracheostomies, when performed, should follow a protocol such as described in this 2003 study entitled “Safe tracheostomy for patients with severe acute respiratory syndrome.”

22. Do APSF and ASA have any recommendations regarding pediatric airway management?

we do not have specific recommendations but the Society for Pediatric Anesthesia’s Pediatric Difficult Intubation Collaborative and the Canadian Pediatric Anesthesia Society have published “Pediatric Airway Management in COVID-19 patients – Consensus Guidelines.

23. What guidelines do APSF and ASA have for anesthetizing patients that have a history of test-positive COVID-19, but are now completely asymptomatic? How long should we wait to anesthetize these patients and what kind of precautions (for both personnel and equipment) are necessary?

Some studies have noted that patients who have resolved their COVID-19 infections may continue to shed virus for several weeks. According to current guidelines for diagnosis and treatment for COVID-19, if one is tested by RT-PCR negative twice, he/she is considered cured. Recent studies and observations have noted that some patients who were “cured” and discharged have later again tested positive by RT-PCR. Many factors could lead to “false negative” in these cases. Therefore, even if two PCR tests show a negative result, the patient should still be treated with caution with the use of full droplet precautions.

24. Many children have upper respiratory infections (URI) yet are not COVID-19 positive. How would one differentiate a URI from COVID-19? Should children also be tested for COVID-19?

Our statement on perioperative testing applies to all patients. For elective surgery, even for non-COVID positive patients, the risks and benefits of the procedure should be weighed with the increased risk of anesthetizing a child with an active infection.

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Wellness

1. What about health and wellness? I’m quite stressed right now along with my colleagues, and want to know what resources are available for me and my colleagues? What can I do?

Taking care of yourself and your emotions, especially during times of higher stress and anxiety, is a good first step to protecting yourself and those you love. Below we have highlighted common reactions and some practical pieces of advice for managing the fear of Coronavirus.

Common Reactions

Fear and anxiety about you or someone you know contracting the virus; thinking over and over about the virus spreading
Irritability or feeling “on edge”
Physical reactions like headaches, upset stomach, or muscle tension
Difficulty concentrating or being preoccupied with thoughts related to the virus
Insomnia
Information overload: perhaps you are repeatedly monitoring media and websites for the latest news on the virus

Self-Care/Coping with the Stress Caused by a Health Crisis

Maintain perspective and remind yourself of the facts – how real is this threat to me right now?
Try to follow as many routine activities as possible, as this enhances comfort and predictability.
Talk with friends, family, coworkers or a counselor about your feelings and concerns.
Engage in some form of exercise daily; this is very effective in reducing stress.
Limit your intake of news related to the virus.
Do things you enjoy. Part of taking care of yourself is making time to let go and engage in positive activities; this helps give your mind a break from worry and helps to maintain balance.
Relax; use deep breathing, meditation, prayer or other relaxation techniques that work for you.

Our professional organizations have established simple-to-use resources for us to manage the daily stress associated with our profession:

There are many meditation apps available, here is just one that provides free mediation sessions if you are feeling anxious about the uncertainty of COVID-19.

Moreover, please consider discussing your concerns with your primary care physician and/or calling your Health Care Organization’s Employee Assistance Program for confidential assistance with many problems, including coping with health fears. This is particularly important to do in the event your feelings of worry or anxiety that have become prolonged or too intense.

2. Do I need to isolate myself from my family when I return after treating COVID-19 patients?

Returning to and being connected with our family is more important now than ever. It is normal to worry that we are causing risk for the ones we love. The precautions that we take at work, that help minimize the risk of our contracting the virus (effective hand-washing, not touching our faces and hair, proper donning and doffing of personal protective equipment) in turn decrease the risk of our transmitting the virus to others, including those at home. We should make sure scrubs are kept at work; and decrease the chance of contamination via footwear by either using shoe covers at work or wearing dedicated footwear at work that do not travel home. In this way, the risk of our transmitting COVID-19 should not be any greater than community-acquired spread.

Frequent hand washing and cleaning of home surfaces should be adequate in homes where there are no symptomatic family members. Separately, there are recommendations if you or someone at home develops signs of viral infection: most institutions offer recommendations about self-monitoring and criteria for testing and for working. The CDC recommendations for minimizing transmission of virus at home:

▶ CDC Recommendations

3. How Can I Practice Social Distancing in the OR?

We are getting better at implementing social distancing into our personal and professional lives. However, we can do better with social distancing in our OR and ICU practices. Here are several recommendations:

Minimize talking in OR and ICU rooms because phonation may generate aerosolization of respiratory and oral-nasal secretions. This may underlie community spread. Only those conversations necessary for patient care should occur.
Only people with active duties should remain in OR and ICU rooms. Staff violating this practice should be politely asked to leave.
Do not congregate in work areas. Patient care discussions should be done between the minimum number of providers necessary or over the telephone.
Within OR rooms, breaks are an important part of patient safety for anesthesia professionals. Staff should continue to work collaboratively to facilitate breaks, especially those involved in prolonged surgical procedures.

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