Guidelines for Surgery of Confirmed or Suspected COVID-19 Patients

• 1) A negative pressured OR or an OR with a portable negative pressure machine is established.

• 2) The OR is marked ‘Corona-OR’, and access by medical personnel is restricted.

• 3) After the patient has entered the room, the automatic doors are set to manual mode and closed.

• 4) If items are required from outside, a request is made to a person waiting outside the OR, and the items are handed over after opening the door from the outside (items are transferred via a pass box or the anteroom) [4].

• 5) The placement, exchange, and extubation of endotracheal tube are dangerous moments that can transmit infection as virus leaks from the patient's lungs into the air. Hence, it is essential that these procedures are performed with the utmost care in places under negative pressure [5, 6].

• 6) Depending on the clinical situation, one may consider performing intubation and extubation in a negative pressure ward or negative pressure intensive care unit (ICU), rather than the OR [5, 6]. However, it is important to be aware of the risk of droplet release into the air when moving an intubated patient to the OR.

• 7) When performing electrocautery, the use of an evacuator is considered [7].

• 8) If possible, it is preferable to avoid performing laparoscopy [7].

• 9) If the negative pressure environment is judged to be insufficient, the use of a portable high efficiency particulate air (HEPA) filter can be considered.

• 1) PPE is put on in the anteroom.

• 2) PPE and medical personnel requiring PPE [4, 5, 7]

  - Operating surgeon, assistants, OR nurses, anesthetist, nurse anesthetist, circulating nurse

  - Full-body protective suit (including shoe covers) + gloves + powered air-purifying respirator (PAPR) as standard (if unavoidable, a waterproof full-body gown, KF94 or N95 or higher mask, goggles or a face shield, and gloves can be used).

  - Medical personnel in the anesthesiology department and the anesthesia recovery room who are involved in patient intubation or extubation are also included.

  - After disinfection of the surgical site, the gloves and gown are changed before starting surgery.

• 3) Removing personal protective equipment after surgery

  - The surgical gown, gloves, and shoe covers are removed in the OR and placed in medical waste boxes.

  - If necessary, the outer surface of PPE can be wiped with a towel soaked in environmental disinfectant before removing.

  - Hands are washed before leaving the OR, disinfected in the anteroom before removing goggles, N95 mask, and hood and then disinfected again before putting on a new mask and hood.

• 1) Leaving the room: The patient is taken out of the room once they are completely recovered [8] (Depending on circumstances, the patient may be moved directly to an intensive care unit (ICU) negative pressure isolation room while still intubated [5]. If the patient is moved to the ICU in an intubated state, the risk of droplet release into the air while moving the patient should be considered).

• 2) The patient is moved in a manner that minimizes droplet exposure and contact. e.g.) using a negative pressure kit.

• 3) If the surgical team will participate in moving the patient after surgery, they should change their PPE before accompanying the patient [7].

• 4) Patient transport protocol is followed.

• 5) After surgery, PPE is removed in the anteroom.

1) Sample management

2) Waste and laundry management

3) Management of operating instruments [5, 8]

4) Environmental management [2, 8]

5) Reuse of the surgical suite after surgery

• 1) Endotracheal intubation is performed by a highly experienced consultant in anesthesia and pain medicine.

• 2) An assistant with ample anesthesia experience is used. The assistant should be sufficiently capable in techniques such as cricoid pressure during rapid sequence induction (RSI).

• 3) When wearing a level D protective suit it is recommended for the anesthesia team to work in shifts to prevent contamination and minimize fatigue of medical personnel.

• 1) Anesthetists participating in endotracheal intubation and extubation must wear appropriate PPE as stated above.

• 2) Awake fiberoptic intubation is not performed unless indicated as essential.

• 3) Spraying local anesthetic should be avoided, since this can cause the release of virus into the air.

• 4) To improve the success rate of intubation, the use of videolaryngoscopy should be actively considered.

• 5) The use of disposable instruments should be actively considered.

• 1) Use of high-efficiency hydrophobic filters

  - Between the face mask and the breathing circuit, or between the face mask and the reservoir bag

  - Between the endotracheal tube and the circuit tube

  - The connection between the circuit tube and the ventilator – the inspiratory and expiratory ports

• 2) Preoxygenation is performed for 5 mins using 100% oxygen.

• 3) After performing RSI, during manual ventilation, care is taken to minimize the release of virus from the patient's lungs to the air.

• 4) The method of RSI can be changed to suit the clinical circumstances. When manual ventilation is required, using a small tidal volume or insertion of a supraglottic airway instead of a face mask can be considered.

• 5) Using high-flow oxygen, such as a high-flow nasal cannula, should be avoided, since this can release virus into the air.

• 6) After endotracheal intubation, the door is not opened until at least 99% of the contaminated air has been removed (30 mins, given a ventilation rate of 12 air changes/h).

• 1) All types of instruments related to airway management are placed in a sealable plastic bag with a double-zipper, and sealed before disposal or disinfection.

• 2) After intubation, the laryngoscope is immediately sealed in a plastic bag that has been prepared in advance, to prevent further contamination of the environment by a contaminated laryngoscope.

• 3) The end-tidal carbon dioxide sampling line and trap are changed.

• 4) Care is taken to avoid the contamination of stethoscopes and other instruments or tools.

• 1) A patient transport team is formed.

• 2) The patient is moved in a manner that minimizes droplet exposure and contact. e.g.) using a negative pressure stretcher.

• 3) The transport team must perform actual simulation training.

• ※ Transport team composition and simulation training.

• ① Medical personnel responsible for the patient (physician and nurse).

• ② Infection control team (PAPR, protective suits, disinfection control, transport plan, and training).

• ③ Facilities/disaster prevention team (negative pressure, elevator operations).

• ④ Transport agent (practice for wearing and removing PPE).

• ⑤ OR medical personnel and OR supervisor (surgical suite preparation, contact, disease control, postoperative measures).

• 1) Staff are placed in the OR, waiting room, elevator, and corridors to secure paths for movement and minimize contact.

• 2) Movement paths are planned to avoid passing through waiting rooms and the anesthesia recovery room.

• 3) Movement after surgery is planned and executed using the same methods.

• 1) The patient is handed over for movement at the entrance of the patient waiting room (anteroom).

• 2) Staff are positioned to manage corridors.

• 3) An exclusive elevator is used.

• 4) Preparation and contact are made for the patient transport.

• 5) Negative pressure OR transport is performed.