UMMC Perioperative Guidance for Urgent Operations on Patients with Proven or Suspected COVID-19

Last update: June 17, 2020

This is meant to be a guidance document for UMMC. There are also best practice documents available from national surgical and anesthesia societies. The most important part of this document is the planning and preparation phase. 

• Patients with proven COVID-19 infection: Surgical team to discuss the risks/benefits of proceeding with urgent/emergent (level O, A or B) operation or delaying the operation.
• Patient Under Investigation (PUI): Surgical team to discuss the risks/benefits of proceeding urgently with the operation vs delay for results of testing. Delay to allow for a testing is preferable when possible in order to preserve PPE and other resources in cases where COVID-19 can be ruled out and to allow planning and preparation in cases which are proven positive.

The “rapid” test is now available in limited quantities at UMMC. The run time on this test is 51 minutes and the turnaround from collection to result is about 1.5 to 2 hours. The perioperative areas have been allocated 10 of these tests per week. At this point, the best use for these tests is for instances of urgent or emergent procedures, posted as Level O, A or B,  in which the patient can’t undergo reliable symptom screening (i.e. AMS/ICU) or when the patient has a positive screen.

1. In these instances, this test may allow the procedure to proceed without isolation/PUI precautions;
2. If the procedure needs to proceed as a PUI immediately, rapid testing allows for disposition from the procedure area to proceed with appropriate isolation precautions and expedites proper cleaning and turn-over procedures.

Given the small supply of these tests, we will be very selective of the situations in which we use them.  For the perioperative areas, Dr. Chris Anderson will need to approve their use.  Please contact Dr. Anderson if you have a situation similar to those outlined above where the rapid test may be useful.

Please familiarize yourself with guidelines for:

1. O, A & B Case level classification
   UMMC Case Classification O, A, B Policy Guidelines
2. Preoperative Testing Algorithm
   COVID Preop Testing Algorithm
3. Isolation precautions for suspected or confirmed COVID-19 patients.

Please also see the guidelines below for the use of PPE during transportation of COVID-19 suspected or confirmed patients, including those more detailed by the Critical Care Transport Team.

• COVID-19 Clinical Transportation of Suspected or PUI Outside of an Isolation Room
• COVID-19 Critical Care Transport Process

Planning

The surgical team should review the logistics and plan specifically where intubation and extubation will occur. Consideration should be given to intubation in a negative pressure room if it is safe for the patient. The same consideration should be given for extubation. The plan for the post-operative recovery should be reviewed.

• For patients who are not intubated:
  • Adults: They will be transported to the negative pressure room noted for that procedural area where intubation will occur. After securing and controlling the airway, the patient will be moved to the room where the procedure will be performed. Post operatively, they will be taken back to the designated negative pressure room where they will be extubated in a controlled fashion and recovered. If the patient is going to the ICU post op, they will be transported there remaining intubated.
  • Please familiarize yourself with the procedural areas negative pressure rooms COVID patient flows below:
    • COVID Periop Negative Pressure Rooms
    • COVID Periop & Procedural Patient Flows
• For patients who are in the ICU (intubated or not-intubated):
  • Required intubations will occur in the negative pressure ICU. Transport to the procedural area and then transport back to the ICU intubated.
    
    
• Discussion with the OR board and staff should be had well in advance when possible.
  • The OR staff will need to coordinate the teams for the operations and the runner to support the team.

Pre-operative phase

• Assemble all needed supplies in the OR.
• Prepare an area adjacent to the OR for donning and removal of PPE. Pre-assemble the needed PPE following institutional PPE guidelines. If intubation is carried out in the OR, only the needed personnel should enter the room during this procedure. During the intubation and extubation procedures, N95 masks should be worn.
• Remove all un-needed supplies from OR (remove all supplies from under tables). Remove all clear open bins with anesthesia supplies from these OR's.
• Cabinets/drawers closed.
• A dedicated OR runner will need to be assigned to deliver needs materials to the room.

Intra-operative phase

• NO in/out traffic. Starting team does complete case.
• Runner delivers needed materials via sub sterile corridor.
• Recommend circulators double glove to perform necessary tasks (picking up laps, etc.) to be able to remove top gloves and foam bottom gloves without exposing hands.

Post-operative phase

• Discard all unused supplies and trash into red trash bag.
• OR team to completely discard PPE in conjunction with current PPE policy.
• Gowns, gloves, and face shield should be removed in OR. Perform hand hygiene. Remove mask outside of the OR (ensure hands are clean prior to removing mask).
• Change scrubs immediately following the case.
• Send the instruments directly to SPD in their own case cart. Wipe down the cart before transport. Do not mix with other instrument sets. Label the cart with a green laminated dot to identify it as a COVID case cart. SPD will isolate and immediately process the instrument.
• Isolate OR while HEPA is running to allow for appropriate air exchanges (AC/H) as directed by Infection prevention decontamination guidelines below before terminal cleaning.
• Terminally clean using best practices for COVID 19 cleaning and room decontamination.
  • COVID Periop Turnover and Decontamination Infection Prevention Guidelines

Special considerations for laparoscopic/robotic operations

We recommend avoiding laparoscopy in known COVID patients if possible. If this is best for the patient, use the smoke evacuation systems throughout the case. Desufflate the abdomen through the in-line filter. Do not evacuate or desufflate the abdomen by opening the trocar valve.

• Stryker Pneumoclear Smoke Evacuation High Flow Tube sets: This is our standard tubing for our current insufflators and each set of tubing has an in-line HEPA filter that filters particles as small as 0.08 microns.
• Airseal delivery system: This is our standard insufflator for robotic cases but they can be used for routine laparoscopy as well. It has its own type of tubing and a specialized trocar but this will filter particles down to 0.1 microns.

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