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

SLIDE 1

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

SLIDE 2

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

SLIDE 3

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.

SLIDE 4

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
• f generating aerosols with very high viral burden in positive patients

SLIDE 5

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.

SLIDE 6

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

• rgan malignancies; brain tumors with neurologic compromise.

SLIDE 7

Triage Bands-Cancer Cases

• Band 4: Conditions where delay of 8 weeks unlikely to impact
• ncologic 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.

SLIDE 8

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

• utcome. These cases should not be performed during COVID-19 epidemic.

SLIDE 9

SLIDE 10

SLIDE 11

Routine Practice

• Gloves
• Surgical mask

SLIDE 12

Contact/Droplet Precautions

• Long sleeved gown
• Surgical mask
• Face/Eye Protection
• Gloves

SLIDE 13

Contact/Droplet/Airborne Precautions

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

SLIDE 14

SLIDE 15

SLIDE 16

SLIDE 17

SLIDE 18

POSITIVE PRESSURE OR NEGATIVE PRESSURE OR VS

SLIDE 19

Management of COVID-19 Surgical Cases in Halifax Infirmary OR

P R E P A R A T I O N

DRAFT 8 Mar 20, 2020

 Receive booking form and phone call from surgical service to confirm Covid-19 status  Assign 3 nurses (scrub, circulating, RN runner) for case setup  Notify anesthesiologist, 2 anesthesia techs of booking  Notify Covid19 Anesthesia Airway Team (CoVART)  Notify security to secure elevator and route  Notify patient attendants

Charge Nurse

Covid-19 OR Case Activation OR Setup

Nurses

 Assign roles: scrub, circulating, RN runner  Don required PPE with spotter  Stock PPE trolley outside

• f OR (outer core)

 Order case cart and initiate setup; ensure appropriate materials in OR  Ensure signs indicating airborne and contact precautions are on all doors

Anesthesia

 Don required PPE with spotter  Prepare anesthesia supplies: airway, fluids, drugs (including

• pioids/controlled

substances) in OR on stainless steel tables  Prepare for all expected procedures, warming, etc.  Confirm all necessary equipment is prepared in room

Surgery

 Confirm all special equipment and instruments with nurses

Transport

Nurses

 Confirm readiness to receive patient  If non-ICU, arrange transfer of patient from ED/Covid unit to OR  Notify surgeon that patient is en route

Anesthesia

 If ICU or unstable, anesthesiologist and tech 1 don airborne PPE & retrieve patient with all equipment, monitors & supplies

Surgery

 Surgeon to don required PPE and be stationed in OR to for time out, receive and position patient

I N T R A O P E R A T I V E

Patient Arrives inside Covid-19 OR

Patient Attendant

 Assist in transferring patient to OR table

Nurses

 Standard preop nursing check/assessment including confirmation of patient ID

Everyone

 Perform Surgical Safety Checklist as per routine (all phases proceed as routine)

Surgery

 Assist in transferring of patient to OR table

Anesthesia

 Transfer/apply CAS monitors, finalize plan for airway management if applicable, confirm blood transfusion needs

Induction

Anesthesia

 Anesthesia induction and intubation as per CoVART protocol by anesthesiologist/ CART, Tech 1  Tech 2 in inner core anteroom

Nurses

 Scrub nurse scrubbed in distant corner of OR during airway management  Circulating nurse in room, away from AGMP  RN runner in inner core anteroom

Surgery

 Scrubbed and on standby, away from AGMP

Surgery Proceeds

• Minimize

entry/exit to OR

• Minimize

where possible supply and instrument needs from

• ut of OR;

pass in by RN Runner

• r Tech 2

as needed

P O S T O P E R A T I V E Anesthesia

 Anesthesiologist/CoV ART team decides on extubation plan versus transfer to ICU  If extubation, direct all non-essential personnel to prepare to exit, doff PPE as per protocol

Emergence

Nurses

 Circulating nurse notifies ICU of impending transfer/clear route

Transfer to ICU intubated

Anesthesia

 Anesthesiologist, Tech 1, Surgery transfer patient monitored and sedated to ICU; doff after transfer

Surgery

 Surgeon or surgical assist transfers pt to ICU

Remain in OR for Extubation and Recovery

Anesthesia

 Anesthesiologist advises all non-essential personnel to exit room before extubation  Anesthesiologist, Tech 1, circulating nurse remain; anesthesiologist extubates  Place surgical mask on extubated patient (with oxygen as necessary)  Anesthesiologist monitors patient until criteria met for discharge to ward (PACU bypass criteria) or IMCU  When criteria met, anesthesiologist and RN to sequentially doff and don appropriate PPE for transport

Nurses

 Circulating nurse remains in OR for extubation and recovery  Scrub nurse prepares specimens (double bags) and prepares for pickup outside of OR and remains or exits depending on patient needs

Surgery

 Surgical team exits for extubation and remains on call to OR

Patient Attendant

 Assist in transfer to bed

A B

• r

1 2 3 4 5 6 7

8A 8B

Patient Attendant

 Exit and doff with spotter  Disinfect and clean patient bed/ stretcher wearing appropriate PPE

Doffing must be done under observation/coaching of a spotter. *Spotter is a trained observer tasked with helping appropriate donning and doffing of PPE

Room/Equipment Cleaning/Disinfection

9

 To be completed

Patient Attendants

 Patient attendants to don required PPE and be stationed in OR

Surgery

 Surgeon and/or assist to doff PPE as per protocol

SLIDE 20

Questions