Contamination prevention in C19 intubation

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KENY1

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KENY1 said:
Manikin study suggests all skin to b covered:
jamanetwork.com

Simulated Coronavirus Contamination of Health Care Workers After Endotracheal Intubation of Manikins

This study uses an atomizer and fluorescent markers to simulate contamination of uncovered skin and hair of health care workers wearing personal protective equipment after intubating patient manikins under emergency conditions.
jamanetwork.com jamanetwork.com

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Shower after every covid airway, if possible?
At a minimum shower before u go home
 
He found that intubation was highly contagious for what reason? The study examines risk rather than mode of transmission.

What is more likely for intubation:
Contact
Aerosol exposure from preexisting aerosols prior to induction
droplets from coughing prior to induction
 
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Spontaneous breathing before paralysis is also part of intubation. After paralysis the air in the trachea doesn't stand still when u intubate, it gets pushed out by lung recoil and by us pushing in the ETT. And we're very close to that. You may b right but as there is no other literature its hard to argue with it.

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eikenhein said:
Shower after every covid airway, if possible?
At a minimum shower before u go home
Click to expand...

i disagree...i haven’t showered since the pandemic started, and the biofilm i’ve developed has shielded me from any and all viral droplets...it also optimizes social distancing.
 
Guillemot said:
He found that intubation was highly contagious for what reason? The study examines risk rather than mode of transmission.

What is more likely for intubation:
Contact
Aerosol exposure from preexisting aerosols prior to induction
droplets from coughing prior to induction
Click to expand...
Yes, it's all of it:

1. Airborne - inhaled
a. viruses - 0.1 micron
b. aerosolized larger water drops

2. Contact contamination - of you dress or body a. splutter or splash
b. from your gloves directly or indirectly (repeat touch of a touch) onto a mucosa in the eye, nose or mouth.

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The distinction of what is actually causing the risk in intubation is important to clinical practice. Take for example of what in my opinion is the asinine practice of intubating someone inside a plastic box. I guess it might make sense if you were actually being sprayed with a bunch of disease, but in reality I doubt it does much to protect. It also has the potential to make the process of intubation significantly more difficult and slower.
 
Ronin786 said:
Your patients never cough with pre-oxygenation? With fentanyl administration? Or do you just push roc as an anxiolytic?
Click to expand...

If so, they cough into my anesthesia mask and circuit, or the surgical mask they are wearing when they come in the room.
 

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The fact that nurses, surgeons, and support staff make up the majority of HCW deaths has damning implications for PPE recommendations that we've all recieved. Coronavirus: Remembering 100 NHS and healthcare workers who have died

How can you argue that the disease does not have meaningful airborne transmission at baseline when airborne protection has prevented deaths amongst anesthesiologists and intensivitsts? These are the people who should be most at risk! Meanwhile the proceduralists and bedside nurses with droplet protection only are dying in much greater numbers.
 
teacher2md said:
The fact that nurses, surgeons, and support staff make up the majority of HCW deaths has damning implications for PPE recommendations that we've all recieved. Coronavirus: Remembering 100 NHS and healthcare workers who have died

How can you argue that the disease does not have meaningful airborne transmission at baseline when airborne protection has prevented deaths amongst anesthesiologists and intensivitsts? These are the people who should be most at risk! Meanwhile the proceduralists and bedside nurses with droplet protection only are dying in much greater numbers.
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Are there people who are actually taking care of patients who are not dressing up in airborne precautions? Not wearing the N95 and face shields and gowns?
I find it hard to believe. Maybe it was a lack of equipment situation.
 
chocomorsel said:
Are there people who are actually taking care of patients who are not dressing up in airborne precautions? Not wearing the N95 and face shields and gowns?
I find it hard to believe. Maybe it was a lack of equipment situation.
Click to expand...


There are many places that are still advising that N95's are only necessary during "aerosol-generating procedures". Remember that the initial guidance from the CDC is that for routine care of a Covid patient, even in the ICU, is that the patient and the nurse should both wear surgical masks. Now they've quietly changed the recommendation to state that N95s are preferable, but the surgical mask is an "acceptable alternative". (https://www.cdc.gov/coronavirus/2019-ncov/downloads/COVID-19_PPE_illustrations-p.pdf)
 
Is the consensus that if there is no mask ventilation, adequate paralysis and smooth insertion of the ETT, there is unlikely to be an aerosoliztion event? Or, is the mere act of intubating causing aerosols?

What about on extubation? If the extubation is smooth, without any coughing or mask ventilation?

What about smooth LMA placement and removal with spontaneous ventilation during surgery?

I ask because as we resume elective surgery with screening of patients for Covid prior to surgery (as imperfect as the tests are and accounting for the gap between testing and surgery), coupled with smooth intubations and extubations (obviously not all, but the majority), the actual risk of OR staff being exposed to aerosols containing Covid19 virus is going to be rather low. The risk is even lower in regions with low prevalence of Covid19.
 
Intubation/extubation: yes it is an aerosolizing event - all guidelines and papers tell us that. If u do everything right it's just less aerosolizing.
LMA: in a good number of cases one has to change position or size or use positive pressure ventilation without a complete seal. I wouldn't suggest to use an LMA in a C19+ patient, most people would consider that an error or worse.
It's a big question whether we can use LMAs in negative/presumed negative patients. Many people want to do that and I think it will not be considered contraindicated. There will of course be false negative cases and spread from LMAs. It will depend on the approach of the anesthesiologist - the more careful ones will not do it and the less careful ones will.

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ETT as well as an LMA require general anesthesia so thw difference isn't huge.
A bigger question is whether it is safer to intubate and go through two big aerosolizing events - intubation and extubation - or do a spinal or a MAC with patient breathing spontaneously with low-flow O2 nasal cannula covered with a regular mask hooked up to a suction or the large anesthesia mask with a harness hooked up to the anesthesia machine via the anesthesia circuit.
It seems to me not intubating and extubating may be preferable but it is not clear what is preferable.
Some intubate for GI procedures nowadays. It might be safer for surgeons if we intubate and extubate because they may not be in the room when we do that.



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People cough much less (if at all) with an LMA. At least in the right hands.

In the context of Covid-19, my opinion is that MAC or GA with mask (connected to circuit and viral filter, no NC -> leak) and tight headstrap > LMA with SV (i.e. long oral airway) >>>> ETT (cough on extubation, ?need for mask ventilation) > LMA with PSV/CV (?leak).

For endo, I don't intubate, just keep them as deep as possible.

Disclaimer: when I say LMA, I mean 2nd generation (Supreme, I-gel etc.), not standard (Unique).
 
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I hate to post this but all CRNAs/MDs should assume there will be asymptomatic patients undergoing elective surgeries. My best guess is that 1/150 patients may test negative yet still be contangious for Covid 19. Maybe in your area the correct stat is 1/200 but the number isn't zero. The younger and healthier the patient the more likely he/she could be an asymptomatic carrier.

That said, if you wear an N95 mask, eye protection, gloves, gown, etc then your biggest risk is bad technique when taking off your PPE. Self contamination is something we all need to be aware of as we do case after case each day.

IMHO, smokers and recent ex-smokers are those most likely to cough after extubation or removal of an LMA. This is especially true of marijuana users (regular users.) So, be extra careful in that subgroup and inform the O.R. team of your suspicion of coughing post anesthetic.
 
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The sailors who tested positive have spent the past month isolated in various locations on U.S. Naval Base Guam, including schools and gymnasiums. The sailors who tested negative have been quarantined in hotel rooms and houses across the island. To return to the ship, each sailor must have completed a quarantine or isolation and test negative twice. However, some sailors have tested positive even after weeks of isolation and after testing negative previously.

www.politico.com

USS Theodore Roosevelt sailors still showing virus symptoms despite month of isolation

The news is the latest setback for the crew after an outbreak of Covid-19 forced it to halt its Pacific deployment.
www.politico.com www.politico.com
 
FFP said:
People cough much less (if at all) with an LMA. At least in the right hands.

In the context of Covid-19, my opinion is that MAC or GA with mask (connected to circuit and viral filter, no NC -> leak) and tight headstrap > LMA with SV (i.e. long oral airway) >>>> ETT (cough on extubation, ?need for mask ventilation) > LMA with PSV/CV (?leak).

For endo, I don't intubate, just keep them as deep as possible.

Disclaimer: when I say LMA, I mean 2nd generation (Supreme, I-gel etc.), not standard (Unique).
Click to expand...
I tend to agree with you and think a spont vent GA with a face mask and filter is a nice non aerosol generating technique -- but I wish I had evidence
 
BLADEMDA said:
The sailors who tested positive have spent the past month isolated in various locations on U.S. Naval Base Guam, including schools and gymnasiums. The sailors who tested negative have been quarantined in hotel rooms and houses across the island. To return to the ship, each sailor must have completed a quarantine or isolation and test negative twice. However, some sailors have tested positive even after weeks of isolation and after testing negative previously.

www.politico.com

USS Theodore Roosevelt sailors still showing virus symptoms despite month of isolation

The news is the latest setback for the crew after an outbreak of Covid-19 forced it to halt its Pacific deployment.
www.politico.com www.politico.com
Click to expand...

Another data point are prisoners. 96% who test positive were asymptomatic. Downside is that there is clearly asymptomatic spread within that population. The upside is that 96% are asymptomatic.
 
Is normal spontaneous ventilation (without coughing) an aerosolizing event? Is talking an aerosolizing event? There is evidence from the choir outbreak near Seattle that singing is an aerosolizing event.
 
nimbus said:
Is normal spontaneous ventilation (without coughing) an aerosolizing event? Is talking an aerosolizing event? There is evidence from the choir outbreak near Seattle that singing is an aerosolizing event.
Click to expand...
Even spontaneous breathing is an aerosolizing event, though nothing like sneezing, coughing or talking loudly.

We won't be able to avoid exposure 100%, especially as months pass. All we can do is minimize the dose. One could argue that the highest exposure is after extubation, so strap on the mask and the viral filter you were using during the case.
 
FFP said:
Even spontaneous breathing is an aerosolizing event, though nothing like sneezing, coughing or talking loudly.

We won't be able to avoid exposure 100%, especially as months pass. All we can do is minimize the dose. One could argue that the highest exposure is after extubation, so strap on the mask and the viral filter you were using during the case.
Click to expand...

The placement of an LMA means you will be close to the airway. The removal of an LMA is also a potential hazard in being exposed to Covid 19. You must treat every airway as a potential Covid + patient but the younger the patient (male sex?) the higher the risk they tested negative but are still asymptomatic carriers.

Good hygiene and precautions are just as important as that N95 mask. The false assumption that every patient is Covid - may lead to sloppy technique and your own self contamination with Covid 19.

Besides the obvious of breathing in Covid 19 the virus can and does get on your hands or your hair or your face. I realize most providers won't be using a face shield for Covid- patients so good hygiene is essential.

As the months go on I have no doubt several anesthesia providers will become Covid + over time. That is why we must get tested regularly in my opinion.
 
Should we just not be shy and use PAPR all the time now ? That's really the only thing we need to do to be maximally protected. I will tell you I don't understand how one would say - were gonna get C19 and that's it without wearing the PAPR.

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KENY1 said:
Should we just not be shy and use PAPR all the time now ? That's really the only thing we need to do to be maximally protected. I will tell you I don't understand how one would say - were gonna get C19 and that's it without wearing the PAPR.

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Not everyone has access to PAPR. If you do, great.
Cross contamination is very easy especially when having to reuse PPE.
Have you seen the CDC video on YouTube on doffing PPE? Very easy to contaminate.
I know that we were all contaminating ourselves where I was taking care of patients. But we kept our masks on and we washed our hands and arms till they were raw.
 
Sure, but I'll tell you I see people wearing PAPRs for intubation and extubation then immediately ripping off the PAPR hood and draping it over their shoulder or tucking it under their arm, or carrying it around in their bare hands without cleaning it appropriately. May as well not wear it at that point IMO.
 
So, is anyone else encountering nonsensical demands from hospital admin to wear full airborne precautions PPE throughout cardiac cases (in negative patients), just because there is a TEE probe in place? They are citing recommendations from ASE and SCA that TEE is an aerosol-generating procedure, even with an ETT and general anesthesia, and are thus requiring full precautions, for everyone in the room, for the entirety of the case. I find it ridiculous, and counter to actual physics and common sense. In their recommendations, the authors at the ASE/SCA note that it is "generally accepted" that TEE warrants airborne precautions, regardless of whether or not a patient is intubated, but fail to provide any source to back up that assertion. A TEE probe in the esophagus of an intubated patient cannot generate airflow necessary to aerosolize particles and lead to an increased infectious risk. Virus on the probe itself can be infectious, but that's what gloves are for, not PAPR. Following this recommendation will lead to even faster depletion of already low resources in the hospital with no benefit to the OR staff.
 
ETT vs. LMA: which generates more aerosol ?

Paralysis makes a difference as LMA is inserted in a spontaneously breathing patient, whereas the patient is only breathing spontaneously during extubation.
LMA often requires manipulation to optimize it's position and the seal is not as good as with an ETT. Positive pressure is sometimes needed.

Likely Conclusion:

ETT intubation generates less aerosol (paralysis).

LMA generates more aerosol during surgery.

Extubation generates equivalent amount of aerosol.p



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KENY1 said:
Should we just not be shy and use PAPR all the time now ? That's really the only thing we need to do to be maximally protected. I will tell you I don't understand how one would say - were gonna get C19 and that's it without wearing the PAPR.

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Click to expand...
You can't use PAPR in the OR.
 
How so ?

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CopaceticOne said:
Says who?
Click to expand...
AORN. There are hospitals that don't allow using PAPRs in the OR, based on that.

Certain types of PAPRs have no filter on the exhaust, hence one is aerosolizing all the crap from the anesthesiologist's airways (think MRSA) in the room.

3 Interventions When Using a Powered Air-Purifying Respirator in the OR - Periop Today - AORN

Routine use of a PAPR is not recommended in the OR due to risk of sterile field contamination, but PAPRs may be necessary in specific circumstances—here’s what to know to use a PAPR safely.
www.aorn.org www.aorn.org
 
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Anesthesiologist should be tested and negative.


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FFP said:
AORN. There are hospitals that don't allow using PAPRs in the OR, based on that.

Certain types of PAPRs have no filter on the exhaust, hence one is aerosolizing all the crap from the anesthesiologist's airways (think MRSA) in the room.
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No. AORN does not say that. They said there is insufficient evidence.
 
CopaceticOne said:
No. AORN does not say that. They said there is insufficient evidence.
Click to expand...
This is not just about the AORN. This is about the low IQ and high Dunning-Kruger of the clipboard nurse who decides.

Look at the recommended "thought" process in my link above:
"Is the person that is unable to wear a surgical N95 respirator critical to the procedure or can that person can be safely replaced by an equally qualified individual who can wear a surgical N95 respirator?" What do you think the answer to that will be?
 
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