Perioperative Care During Covid-19 Pandemic Janice Chisholm, Andre - PowerPoint PPT Presentation

Perioperative Care During Covid-19 Pandemic Janice Chisholm, Andre Bernard, Bill Oxner, Greg Hirsch, Marcy Saxe- Braithwaite On behalf of The Departments of Surgery and Anesthesia (NSHA/Dal) and NSHA Perioperative (Surgical) Services Program

Goals of this webinar • Review best practices concerning: • Triage of Surgical/Interventional Radiology Patients during pandemic • Screening for COVID in patients considered for surgery/IR procedures • Conduct of an operation in a COVID positive or presumed positive patient • Provide a standard driven approach that can be adapted to local hospital/zone environments

Approaches Taken • Triage Document • Recognition of a need to triage urgent cancer patients while restricting surgery on non-urgent cases-draft 1 triage developed by Ryan Kelly (Surgical Director WZ). • Further developed in CZ by Geoff Porter with all cancer service lines represented and use of ACS triage band (1-4 highest to lowest urgency) approach (https://www.facs.org/about-acs/covid-19/information-for-surgeons/triage). • Broad input sought and addition of non-cancer and IR cases. • Screening and Conduct of Operation • Developed by Andre Bernard and Janice Chisholm (CZ Dept Anesthesia) with input from Infectious Disease (Ian Davis, Lynn Johnstone, Shelly MacNeil). • Multiple revisions with perioperative working group.

Key Points • COVID test sensitivity is low in asymptomatic patients • False negatives may provide inappropriate reassurance • Community COVID burden and spread are crucial to assessing risk • Current burden is very low • Daily updates will be sought by peri- op from public health (Gary O’Toole) and communicated broadly. • Respiratory Tract Surgery (oropharyngeal, airway, lung) has high risk of generating aerosols with very high viral burden in positive patients

Triage Bands-Cancer Cases 1. Conditions with threat to life/limb/organ over next 24 hours. Surgical examples include: (Malignancy with obstruction, perforation, significant bleeding; ENT malignancy with ongoing airway/swallowing compromise; spinal cord tumor with compression). IR examples include: (SVC syndrome). These cases should be booked urgently and leveled appropriate to your site practices.

Triage Bands-Cancer Cases Band 2: Conditions with threat to life/organ within two weeks. These conditions are not yet true emergencies but may quickly progress to a true emergency. Surgical examples include: (malignant brain tumors; transfusion dependent bleeding in renal and GI malignancy, potential for obstructing airway in advanced head and neck cancer, mediastinal mass with potential airway compromise, ureteral obstruction with acute renal failure, malignant biliary obstruction; AND/OR require clear timing related to receipt of neoadjuvant therapy). Band 3: Conditions with threat to life over next 4 weeks – most solid organ malignancies; brain tumors with neurologic compromise.

Triage Bands-Cancer Cases • Band 4: Conditions where delay of 8 weeks unlikely to impact oncologic outcome • Examples include: well-differentiated non-advanced thyroid cancer, low-risk prostate cancer, most non-melanoma skin cancer, DCIS breast; benign brain tumors without neurologic compromise. • These cases are not to be performed during the COVID-19 outbreak.

Triage Bands-Non Cancer Cases Band 1: Conditions with threat to life/limb/organ over next 24 hours. These cases should be booked urgently the same day. Band 2: Condition with threat to life/organ within two weeks. These conditions are not true emergencies but can progress to an emergency in a short period of time. Band 3: Conditions with threat to progress to emergency within four to eight weeks. Band 4: Conditions where delay of 8 weeks is unlikely to adversely impact outcome. These cases should not be performed during COVID-19 epidemic.

Routine Practice • Gloves • Surgical mask

Contact/Droplet Precautions • Long sleeved gown • Surgical mask • Face/Eye Protection • Gloves

Contact/Droplet/Airborne Precautions • Gloves • N95 Mask • Long gown • Face shield/goggles • Suggested in OR: • Neck cover • Foot/leg covering • Waterproof gown

POSITIVE NEGATIVE PRESSURE PRESSURE VS OR OR

DRAFT 8 Management of COVID-19 Surgical Cases in Halifax Infirmary OR Mar 20, 2020 1 2 3 4 5 6 Patient Arrives inside Surgery Covid-19 OR Case OR Setup Transport Induction Covid-19 OR Proceeds Activation Charge Nurse Nurses Nurses Nurses Anesthesia • Minimize  Receive booking  Assign roles: scrub,  Confirm readiness to  Standard preop nursing  Anesthesia entry/exit to form and phone circulating, RN runner receive patient check/assessment induction and OR I call from surgical  Don required PPE with  If non-ICU, arrange intubation as per including confirmation of service to confirm CoVART protocol spotter transfer of patient from patient ID N • Minimize P by Covid-19 status  Stock PPE trolley outside ED/Covid unit to OR Patient Attendant where T  Assign 3 nurses anesthesiologist/  Notify surgeon that patient R of OR (outer core) possible R  Assist in transferring CART, Tech 1 (scrub, circulating,  Order case cart and initiate is en route E supply and  Tech 2 in inner patient to OR table RN runner) for A setup; ensure appropriate instrument P core anteroom case setup materials in OR Anesthesia O needs from  Notify Nurses A  Ensure signs indicating Everyone out of OR; P  If ICU or unstable, anesthesiologist, airborne and contact R pass in by  Scrub nurse anesthesiologist and tech 1  Perform Surgical Safety E 2 anesthesia precautions are on all RN Runner scrubbed in distant A don airborne PPE & retrieve Checklist as per routine (all techs of booking doors R or Tech 2 corner of OR patient with all equipment,  Notify Covid19 T phases proceed as routine) Anesthesia as needed during airway A monitors & supplies Anesthesia Airway I management  Don required PPE with T Team (CoVART) Surgery  Circulating nurse O Surgery  Notify security to spotter I in room, away Patient N  Assist in transferring of  Prepare anesthesia secure elevator  Surgeon to don required from AGMP V Attendant and route supplies: airway, fluids, patient to OR table  RN runner in inner PPE and be stationed in  Notify patient E drugs (including core anteroom OR to for time out, receive  Exit and attendants opioids/controlled Anesthesia and position patient Surgery doff with substances) in OR on  Transfer/apply CAS spotter stainless steel tables Surgery  Scrubbed and on  Disinfect Patient Attendants monitors, finalize plan for  Prepare for all expected standby, away and clean  Confirm all special airway management if procedures, warming, etc.  Patient attendants to don from AGMP patient applicable, confirm blood equipment and  Confirm all necessary required PPE and be bed/ transfusion needs instruments with equipment is prepared in stationed in OR stretcher nurses room wearing *Spotter is a trained observer tasked with helping appropriate donning and doffing of PPE appropriate PPE 7 8A 8B P Emergence Transfer to ICU intubated Remain in OR for Extubation and Recovery O S Anesthesia Nurses Anesthesia Nurses Anesthesia T A  Circulating nurse  Anesthesiologist, Tech  Circulating nurse remains in OR for  Anesthesiologist/CoV  Anesthesiologist advises all non-essential O notifies ICU of extubation and recovery ART team decides on 1, Surgery transfer personnel to exit room before extubation P or impending  Scrub nurse prepares specimens (double  Anesthesiologist, Tech 1, circulating nurse extubation plan patient monitored and E transfer/clear route remain; anesthesiologist extubates bags) and prepares for pickup outside of versus transfer to ICU sedated to ICU; doff B  Place surgical mask on extubated patient  If extubation, direct all Surgery OR and remains or exits depending on R after transfer Patient Attendant (with oxygen as necessary) patient needs non-essential A  Surgeon or surgical  Anesthesiologist monitors patient until personnel to prepare  Assist in transfer to bed T assist transfers pt to criteria met for discharge to ward (PACU Surgery to exit, doff PPE as ICU bypass criteria) or IMCU I per protocol  When criteria met, anesthesiologist and 9  Surgical team exits for extubation and Room/Equipment Cleaning/Disinfection V RN to sequentially doff and don remains on call to OR Surgery  To be completed E appropriate PPE for transport  Surgeon and/or assist to doff PPE as per Doffing must be done under observation/coaching of a spotter. protocol

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