COVID-19: Common Critical and Practical Questions.

To the Editor

We read with great interest the important editorial by Thomas Vetter and Jean-Francois Pittet[1] reiterating the journal’s commendable response in improving accessibility of clinician knowledge needed to address the constantly changing novel coronavirus disease 2019 (COVID-19) pandemic. We agreed that the COVID-19 has caused a worldwide pandemic crisis which has generated an unprecedented amount of substantial medical knowledge in a compressed amount of time. Thus, the journal’s call for COVID-19–related papers and the act of removing the paid barrier to open access of this information are important steps in informing the medical community. At the time of writing this article in late April 2020, there are already over 38 related articles published in Anesthesia & Analgesia in the journal’s COVID-19 collection. This demonstrates the rapid pace with which new information is being developed by physicians internationally, and the great interest taken by the anesthesiology community.

In fact, this is not surprising as the COVID-19 virus impacts anesthesiologists in clinical situations encompassing both perioperative management and critical care settings.[2-5] When faced with rapidly evolving information, many practicing anesthesiologists have expressed uncertainty and posed novel questions. In the midst of the pandemic, even those within the medical community have found it challenging to sort out the literature to answer the questions necessary for their practice, the safety of their patients, and that of themselves. More than ever, acquisition and proper dissemination of such knowledge in a quickly digestible form areurgent for all medical staff to properly and safely treat COVID-19 patients.

Following the sentiments of the editorial by Thomas Vetter and Jean-Francois Pittet,[1] this letter attempts to make updated information more accessible to health care workers. To combat the pandemic and remove the burden on anesthesiology providers from the waterfall of information over the past few months, a COVID-19 anesthesiology taskforce was established at our institution. Commonly occurring questions and issues (Table) were directed to the taskforce from the anesthesiology departments and perioperative staff. Many of these questions have no definitive guidelines or evidence. The answers provided here were primarily based on the current institutional practices and may not apply to other institutions. This information is not intended to replace medical literature or published guidelines, but rather is focused on sharing common questions from anesthesiologists in an academic center to alleviate some of the cognitive, emotional, and physical burden from the COVID-19 pandemic.

By asking and addressing common questions, this correspondence intends to remind health care workers and administrators on the importance of simplifying the vast amounts of available data, making it more easily accessible to physicians and thereby streamlining clinical anesthesia practice at their prospective institution. Nevertheless, as Confucius once said, “The man who asks a question is a fool for a minute, the man who does not ask is a fool for life.”

ACKNOWLEDGMENTS

The authors acknowledge all the staff and health care workers from Stanford Hospital and Lucile Packard Children’s Hospital at Stanford, Stanford, CA, for their contribution in preparing, commenting, and answering the questions.

Table.

Frequently Asked Critical and Practical Questions in Managing COVID-19 Patients

Questions	Answers (Represented LocalPracticesand for InformationOnly)a
General points
How much supplemental oxygen without protective airway for COVID/PUI?	Consider O2 by nasal prongs <6 L/min or nonrebreather mask 15L/min.Avoid HFNC, NIPPV to maintain Spo2 > 92%
What PPE should provider have?	Depending on the patient’s infectious riskCOVID-19/PUIGloves; gown; full-face shield + N95 or advanced PAPRAsymptomatic/low risk/negative COVID testGlove; gown; atminimum, use surgical mask; however, should consider using face shield + N95 (+/− reuse) for all AGP
What are recommendations for provider protection should adequate PPE not be available?	Crisis strategies must be considered in advance during severe PPE shortages and should be utilized with the contingency options to help stretch available supplies for the most critical needs. To ensure the safety of providers, hospital stakeholders must review frequently the recommendations posted by CDC and implement appropriate strategies to optimize the supply of PPE and equipment.
When should we intubate the patient?	Intubation should consider performing preemptively and electivelyPo2<65mmHgor RR>35–40 or Pco2>50 with Ph<7.3 in non-COPD patient
What PPE should the patient have?	Place surgical mask whenever possible over the nasal prongs or oxygen mask during perioperative period and transport
How can we organize the donning/doffing equipment and procedural setup to keep us all safe?	In the room: • Portable hand sanitizer that can be near door for the person who is doffing one at a time to hand hygiene but not be turning around in the room to the sanitizer mounted on the wall • Glove box at the doorway • Designated trash bag/bin to collect discarded gowns/gloves • Experienced staff only in PPE (eg, anesthesiologist, RN, and respiratory technician)
	Outside room: • 2 designated trash bins • Nearby wash station and hand sanitizer • If there is a little anteroom, one option is to have the PAPR helmet outside the mini-hallway so we could keep people sequentially exiting. In positive pressure room, this would also just be outside the OR. • Stand/shelf/table with chucks on it and Sani wipe container. • After person doffs shroud into the red trash bin, they do hand hygiene, reglove. • Then step down the “assembly line” to the table with chux, each user then takes off their helmet and wipes it down with Sani wipes and let sit on table for 2 min to dry. • After drying, to keep the PAPR unit together, package each PAPR helmet/belt/battery and bring it to the respective location for reprocessing. • Safety monitor to assist with PPE donn and doff checklist. • Ideally, another “watcher” to help watch/instruct the process of wiping down the PAPR helmet with Sani wipe as we want to make sure the units are appropriately processed and sent back, so we have them to use again the next time. • If this is done in a regular, positive pressure OR, the “watcher” who is helping the wipe down might need to help direct hallway traffic round this process during the critical time of exiting the room to avoid extra foot traffic at this time. • One additional experienced staff member with PPE and 1runner without PPE
Preoperative
My patient is in the ED or ICU. Can I intubate the patient in the ED, then transport to OR?	Yes, physicians can intubate OR-bound patient in the ED. Ideally, a specialized airway team should be in-house 24/7 and can help with intubation. If they are unavailable/busy, the next option is to call in an Anesthesia attending back up. Using a COVID protocol for intubation, one should include a HME filter in circuit for transport to OR. Please note HME filter is not the same as HEPA filter. HEPA captures dust, microbes, and particulates down to 0.3 μm.
What are some recommendations onhow to intubate COVID+/PUI without a specialized team?	If a specialized airway team is not available, the on-call attending and team is responsible for intubations and will intubate in full PAPR and PPE. There should be an additional safety helper (either a resident or anesthesia technician depending on the location) who can help with equipment and donning/doffing.
I have an inpatient/ED/ICU patient who is not COVID+/PUI, but I think the patient history is clinically suspicious for COVID and no COVID test has been done. How do I proceed?	Discuss your concerns with the primary team, explore the possibility of delaying surgery, and testing. If it is an urgent/emergent case and your concerns are not addressed, please contact your supervisors. Our current practice is for intubating/primary attending to use N95, face shield, gloves, and gown for asymptomatic patients.
I am doing an asymptomatic-for-COVID case. Can I use PAPR even if I am fit-tested and able to use N95?	The recommendation is to wear N95 for asymptomatic cases and reserve advanced PAPR for COVID/PUI intubations.
If my patient is coming to the OR from the ward/floor/ED, not intubated, where can I start my anesthesia care/where can I intubate?	If patient is already in a negative pressure room on floor/ward, intubation can be done in that room, then transport to OR intubated. The Airway COVID team can help if available, if your institution lacks a team, consider calling a backup anesthesia attending or spotter for PPE. Remember to use an HME filter next to ETT, clamp ETT if disconnecting circuit.
Where can I intubate if no negative pressure room or OR is available?	If a negative pressure room is not available, intubation will occur in a room with the fewest number of necessary health care personnel, all of whom will be donned in complete PPE and PAPR.
Can I take the anesthesiamachine still attached to the patient to the OR for surgery, after having intubated the patient in a negative pressure room/bay? Can the anesthesiamachine still function if it is disconnected from the wall outlet?	Yes, most anesthesia machine can run even when not plugged into wall outlet, provided it was kept plugged in and the battery is charged beforehand and oxygen tank is full and connected. The Apollo machines can run for up to 30 min without battery and the Perseus machines for up to 60 min.
Where should I extubate my COVID+/PUI patient?	Extubation should preferably happen in a negative pressure room. If patient is ICU-bound, consider taking the patient intubated to ICU and extubating there.
Should I stay in PPE for transport?	Yes, for COVID+/PUI patients, all patient contact including transport must be in PPE. It might be necessary to change outer gloves frequently if contaminated, with hand hygiene performed while keeping on inner gloves.
Who will be my “runner” to get me items when I am in PPE/intubating?	Anesthesia technicians can be the runner for PPE and anesthesia-specific items during this time.
What about a donning/doffing buddy?	For intubation, if the COVID airway team member is available, that person and the anesthesia attending can be donning buddy. Otherwise, properly trained anesthesia technicians and nurses can be doffing buddies.
I will bring an intubated ICU patient to the OR, using an ICU transport ventilator. Is it possible to connect the ICU transport ventilator also (in addition to the already connected OR anesthesia machine) to the wall gas outlets in the OR?	While we typically switch to the anesthesia machine in the OR from the ICU ventilator, the wall gas outlet could be set up with a Y-connector to run the transport ventilator. This can be done at some institutions but needs to be communicated with the technicians during their morning huddle.
Intraoperative
Where would I obtain plastic sheets to drape the anesthesiamachine, drug dispenser machine (eg, Omnicell, etc)? Who does the draping?	Ideally, anesthesia technicians can provide drapes and will drape the machine and drug dispenser machine.
Do we have dedicated anesthesiamachines for COVID+/PUI?	Ideally, a dedicated COVID +/PUI machine should be used. As well, the anesthesia technicians should prepare anesthesiamachines for such cases. Otherwise, the anesthesia machine used for COVID patients must undergo thorough decontamination according to their institutional protocol before reuse for other patients.
Do we have dedicated ORs for COVID+/PUI cases?	Dedicated ORs such as negative pressure OR are preferred if available. Those rooms should be avoided for clean surgeries and be reserved for intubation and extubation of COVID +/PUI patient.
Where do I obtain PAPRs?	PAPR should be readily accessible but kept in a secure location (eg, OR charge nurse). For Code Blues, it would prove useful to have an RN come to the Code with a backpack containing PAPRs, and other PPE).
Where do I don PPE for OR cases?	Donning can be done in OR or just outside. Have a designated trash bag and hand sanitizer available nearby.
Where do I doff PPE for OR cases?	Doff everything except PAPR/N95/faceshield, just inside the OR door, into a designated plastic biohazard bag. Perform hand hygiene. Then step just outside and doff face PAPR hood, helmet, N95, and face shield, just outside the OR door into a red plastic biohazard bag. Have hand sanitizer placed just outside the door.
Donning/doffing buddy?	Anesthesia techs should have some basic training in CAPR assembly, donning, doffing, but many may never have done it before and may not be experienced. Ideally, an RN/MD would be the donning and doffing buddy, but anesthesia technicians may also be appropriate depending on institution and availability
What if I need to go to the restroom during a COVID+ case?	Ask for relief. Relieving anesthesiologist dons PPE, enters OR, and takes over. Exiting anesthesiologist doffs PPE as detailed above. Entire process repeats on return of the anesthesiologist responsible for the case.
Can the PAPR shroud be reused if the primary anesthesiologist returns to OR after a break?	The PAPR shroud is designed for 1-time use. It is difficult to take off the shroud without ripping it and difficult to prevent self-contamination if you were to try to re-don the same shroud.
Postoperative
Where should COVID+/PUI be extubated?	Our current hospital recommendation is that extubation may only occur in a negative pressure room or negative pressure PACU bay. If this is not possible or one is not available, then the patient should be extubated in the same OR room with minimal staff presented. The same precautions and procedure, including PPE, followed for intubation should be observed for extubation.
How should I transport my intubated postoperative patient back to ICU?	Transport intubated patient back to the ICU with an ICU ventilator. Extubate in ICU, if appropriate. Ensure that the HME filter is connected to the ETT.

Abbreviations: AGP, aerosol-generated procedure; CAPR, controlled air-purifying respirator; CDC, Centers for Disease Control and Prevention; COPD, chronic obstructive pulmonary disease; COVID-19, coronavirus disease 2019; ED, emergency department; ETT, endotracheal tube; HEPA, high-efficiency particulate air; HFNC, high-flow nasal; HME, heat moisture exchange; ICU, intensive care unit; NIPPV, noninvasive positive pressure ventilation; OR, operation room; PACU, postanesthesia care unit; PAPR, powered air-purifying respirator; Pco2, partial pressure of carbon dioxide; Po2, partial pressure of oxygen; PPE, personal protective equipment; PUI, patient under investigation; RN, registered nurse; RR, respiratory rate; Spo2, oxygen saturation.

aThe questions and answers were adapted and modified based on those collected by Stanford COVID-19 team and may not apply to your institutional practice. Further information may be found via the Stanford website: http://ether.stanford.edu/covid-19/index.html.