Anaesthetic management of patients with COVID-19: infection prevention and control measures in the operating theatre. Comment on Br J Anaesth 2020; 125: e239-e241.

Editor—We read with great interest the case report by Wong and colleagues on coronavirus disease 2019 (COVID-19) infection prevention and control measures. There was an exponential increase in the number of COVID-19 cases in the current pandemic with ∼15% of infected patients requiring intensive care. As many hospitals would be dealing with patients that are either severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive, suspected, or under surveillance, a comprehensive protocol is imperative if they require surgical intervention.

We agree with the authors' stepwise recommendations about operating theatre preparation for anaesthesia, infection prevention, and control in patients with COVID-19 undergoing tracheostomy, effective workflow processes, staff training, and resource management. We appreciate that the authors have dealt with several patients requiring tracheostomy and reported one case as an example. However, we believe the report lacks some important information that will surely strengthen and improve processes and effective management of COVID-19 patients undergoing tracheostomy.

It would be interesting to know if the decision to perform tracheostomy was made when the patient was seronegative or seropositive for COVID-19. Also, it would be helpful to know if a repeat polymerase chain reaction (PCR) test, chest radiograph, or chest CT scan was performed to assess the progress of the disease. The British and Canadian guidelines recommend that elective procedures should be avoided in patients who are PCR positive for SARS-CoV-2 or have an active infection because of chances of spreading the infection. , During the course of treatment, if the patient has become PCR negative, is there still a need for taking lengthy and elaborate precautions? However, if the patient was COVID-19 positive, what were the reasons to delay open tracheostomy until the 39th day? A recent study showed that mortality was 80% in COVID-19-positive patients who had survived beyond 28 days on mechanical ventilation with tracheal intubation. Tracheostomy is considered a high-risk procedure, and chances of transmission of SARS-CoV-2 to providers are high.3, 4, 5 An early tracheostomy is considered beneficial for pulmonary secretion clearance, reduced risk of subglottic stenosis, reduced sedation, and early weaning from mechanical ventilation.

Although the authors mention that a huddle was performed, there was no mention of whether they followed the recommendations and had a dedicated responsible individual to liaise with other team members. Did the authors use or recommend using a depth of anaesthesia monitor as mandated by the Royal College of Anaesthetists?

Open tracheostomy is generally performed in a controlled environment, such as the operating theatre, where the air should be purified through high-efficiency particulate air filters and ultraviolet light, but whether was it in accordance with Food and Drug Administration recommendations? Perhaps under the circumstances, it is worth considering performance of tracheostomy at the bedside as COVID-19-positive patients are nursed in a negative-pressure room, where the required equipment and surgeons and their assistants would perform the procedure by the bedside. This would minimise logistical and other problems related to the transfer of critically ill patients.

We hope our suggestions will compliment strengthening the workflow and preparation for anaesthesia, infection prevention, and control in COVID-19-positive patients undergoing tracheostomy.

Declarations of interest

The authors declare that they have no conflicts of interest.