Marching Ahead through the Pandemic: Continuing Anesthesia Services in COVID Era—Our Experience from a Tertiary Care Cancer Centre

Preparation of Operation Theatres and Setting up of Infection Control Protocols

What the guidelines suggest – Summary of major guidelines for infection control13 suggests screening for symptoms of COVID patients and attendants on arrival in hospital, COVID testing (RT-PCR-based) before surgery, and extensive use of masks for the patient in the perioperative period. For OT, preparation of both Indian1012 and international guidelines1114 suggested that a separate operating room with its ventilation system and a designated high-efficiency particulate air (HEPA) filter system be used as an OT for COVID-positive patients, high frequency of air changes (25/h) to minimize viral load is suggested in other OTs dealing with non-COVID patients.14

Our practice –As COVID cases reduced, elective OTs were gradually resumed. Our basic steps to prepare OT services infrastructure with COVID care were as follows:

• Social distancing with a minimum distance of 6 feet between beds was done and only a single attendee found asymptomatic at the screening was allowed to be with the patient during the perioperative period.

• A separate isolation chamber with adequate distancing between beds was made functional, a patient admitted for surgery was given a bed here, RT-PCR for COVID was sent and the patient was kept in this area until an RT-PCR report was available. After the negative report, the patient was shifted to the preoperative ward and from there the patient was taken into the OT. Patients when called up for the admission were screened telephonically for symptoms of COVID or any recent contact with a positive case. We avoided outside testing before admission and all RT-PCR tests were sent after admission; this was done as an institutional policy to minimize the financial burden on patients.

• The patient was taken for surgery within 48 hours of the negative report, i.e., as per the surgical list, most patients were operated the very next day of the negative report, in case of pending cases, patients were included in the list for the next day and thus were operated within 48 hours of the negative report.

• In rare postponed cases beyond 48 hours of a negative report, repeat COVID testing was done.

• A separate ward was designated as a postoperative ward and patients were shifted from the OT to this ward. From hereafter the postoperative stay patient was discharged. Thus, the one-way movement of a patient from admission to discharge was ensured.

• Separate donning and doffing rooms were created in the OT complex and separate entry-exit routes were used to ensure one-way movement of health care staff.

Preoperative Patient Evaluation and Optimization

What literature suggests – The main guidelines11 for the conduct of anesthesia in the COVID setting suggest minimal contact with proper hand hygiene and barrier protections such as masks during preoperative patient evaluation.

Our practice – Social distancing was ensured in the pre anesthesia clinic (PAC). As the planned elective surgeries were restricted the footfall in the PAC dropped thus measures such as mandatory masks for patients and attendants, and an adequate distance between patient and doctor were easily implemented.

Routine preoperative assessment in the PAC clinic of a case with unknown COVID status (first visit, OPD patient) physical evaluation with auscultation, percussion, detailed airway examination, etc., was not done. Fitness was given on the basis of history, blood investigation, and radiology (chest X-ray reports). In the preoperative visit, a day before surgery of a patient with a COVID-negative report, detailed airway assessment, auscultation, and physical examination were done by the anesthetist as deemed necessary.

Routine preoperative tests such as pulmonary function tests and cardio-pulmonary exercise tests were stopped as these are potential aerosol-generation sources. In addition, we tried to introduce the concept of PAC follow-up over the phone via a dedicated department phone for PAC follow-ups after the initial visit to reduce repeated visits to the hospital.

Tweaks in Anaesthesia Practices and Equipment

Keeping in mind the guidelines suggesting the use of video laryngoscopes and minimizing aerosol generation procedures in the OT, we made the following changes to our practice:

• Rapid sequence induction was used as a preferred modality of induction in nondifficult airway situations.

• Video laryngoscope-guided intubation with a stylet tube and the most experienced anesthetist doing the procedure to ensure success in the first attempt in minimum time.

• Direct cuff inflation and connection to anesthesia circuit before starting positive pressure ventilation.

• Awake intubations were avoided, and an elective tracheostomy was planned in cases of an extremely difficult airway.

• Supraglottic devices were avoided in the initial stage of the pandemic over concerns about aerosol generation due to leaks around the device; however, as the literature cleared the directions for their use,1516 second-generation devices (I-gel) were brought back into use.

• Measures such as the proper fit of the SGD and insertion in a deep plane of anesthesia were taken to ensure minimal leaks. In cases where > 20% leak was detected the device was removed and the patient intubated.

• Barrier methods such as transparent boxes were initially adopted as the guidelines suggested but they were stopped from use as the literature progressed and their use showed no benefit.17

• HME filters were used in the inspiratory and expiratory limbs of the anesthesia circuit.

• Extubation practices were changed to ensure minimal coughing and generation of aerosols.

• For procedures under sedation or monitored anesthesia care, spontaneous respiration was allowed with oxygenation as required. However, high aerosol-generating methods of oxygenation such as high-flow nasal cannula, high-flow oxygen on non-rebreathing masks were not employed. Methods of oxygenation with minimum aerosolization such as low-flow oxygen via nasal prongs were used and barrier methods to prevent the spread of infection were employed at all times.

• For procedures planned under regional anesthesia alone, regional anesthesia was used as necessary and methods of oxygen supplementation with minimal aerosolization, e.g., low-flow oxygen via nasal prongs were used. However, preoperative evaluation and COVID testing protocols were the same for cases under general anesthesia, regional anesthesia, or sedation and monitored care.

Postoperative Anesthesia Care

What guidelines suggest – Adequate distancing in the recovery rooms, use of masks by patients in the postoperative area, avoiding extubation in the postoperative area.

Our practice – We minimized the use of recovery rooms, only one or two patients were kept in the recovery to ensure distancing, and procedures such as extubation, were avoided. As seen by our data, we planned and sent every major case to the ICU for recovery/ventilation and extubation. In the ICU, we had adequate resources and could ensure appropriate practices.

Disinfection Practices and Healthcare Worker Screening

What guidelines suggest –Both international and national guidelines insist on hand hygiene, wearing of masks, at least a long-sleeved water-resistant gown with eye protection, N95 or equivalent mask for aerosol generation procedures such as intubation.10

Our practice –All personnel involved in intubation and extubation wore an HIV kit with eye shied and N95 masks throughout the case. A full protection PPE kit as used in COVID areas was used for all positive cases/emergency cases with unknown COVID status.

• As seen the world over the use of plastics increased in the operation theatre, we tried to minimize this. No plastic covers were put over the workstations or monitors as our OT complex was regularly fumigated if a case came out positive.

• Anesthesia circuits, soda-lime canisters, and disposables were changed after every case.

• Disposables such as patient circuits, OT table sheets, syringes, etc., were changed after every case.

• Single-use devices such as I-gel for ventilation or video laryngoscope with disposable blade (McGrath) for ease of use were increasingly put into practice.

All health care workers were regularly screened for symptoms, a symptomatic healthcare worker was immediately isolated and tested. The backup ansethesia team was kept if the main team was isolated in contact tracing with a case.

High-risk contacts with a case (more than 15 minute exposure or exposure from less than 1 meter or exposure without N95 mask, gown, and gloves) were isolated for the incubation period of the virus, i.e., 5 days, and then tested. As seen by our data (Table 4), these practices yielded results in the form of 149 OT staff testing positive but no severe case or mortality was seen.