|Ahead of print publication
Cohabitation with COVID
Mukul Chandra Kapoor
Department of Anesthesiology, Max Smart Super Speciality Hospital, New Delhi, India
|Date of Submission||26-Apr-2020|
|Date of Acceptance||30-Apr-2020|
|Date of Web Publication||24-Jul-2020|
Mukul Chandra Kapoor,
Department of Anesthesiology, Max Smart Super Speciality Hospital, New Delhi - 110 017
Source of Support: None, Conflict of Interest: None
Coronavirus disease (COVID-19) invaded our planet a few months back and left life in disarray. In no time the microorganism became a terror for all, including the people considered all-powerful. Nonbelievers were forced to realize the potency of COVID and had to seek shelter. All organizations in the world forgot their mission statements and changed their motto to “Stay Safe.” The panic and fear were unprecedented. The COVID invasion is quasi-permanent, at least for a few years. With the possibility of the pandemic ebbing soon, elective surgery has restarted. We need to formulate policies to prevent getting afflicted by the virus and learn to cohabit with COVID.
Anesthesiologists are at the forefront in this war against the dreaded, invisible enemy Corona. We face a higher risk than other health care personnel as we are exposed to patient-generated aerosol due to a more intimate exposure to the patient's oronasal cavity. Our colleagues in critical care, especially the junior ones, are at extreme risk of exposure to very high viral load. Restrictions of human resources, medical equipment, and personal protective equipment (PPE) further compromise our safety. Multiple guidelines and innovations have been proposed to help prevent the onslaught of the virus. Despite this education and practicing recommended precautions, many anesthesiologists across the globe have been afflicted by COVID-19. A large number of anesthesiologists have unfortunately even succumbed to its infection.
PPE is essential to protect the health care provider from inhalation and contact with aerosols/droplets that are potentially generated. Strict adherence to the N95 mask, eye protection with goggles/shields, impervious gown, waterproof leg covers, and double gloves, are highly effective in limiting droplet and contact transmission. Although some of us are fortunate to have access to proper PPE, most health care providers have been denied quality PPE.
Anesthesiologists need to continue taking aerosol prevention measures, as the threat of the virus will remain. Most of us have used improvised techniques, which may not offer the safest conditions. Many perilous improvizations of maverick anesthesiologists are viral on social media. On display are videos with transparent buckets for protection of the head/neck, use of polythene bags to cover the face, and use of garbage bags to protect the torso. Following a safe technique to don and doff PPE is perhaps the most critical element to protect health care providers. Multiple instructional videos, to don and doff PPE, have been uploaded on social media. Many of these have severe deficiencies in technique, making them potentially unsafe. Anesthesiology professional bodies should promote official videos and flowcharts to make fail-safe guidelines. The guidelines must be mandatory, with no deviation permitted, just like the cardiopulmonary resuscitation guidelines.
The safety of anesthesiologists should not be limited to PPE. We need to follow many other safe practices. General anesthesia, as a technique, must be avoided wherever possible. Many unconventional methods have been recently described in social media to reduce aerosol exposure while securing the airway. The methods described include the use of transparent plastic screens; intubation boxes; a plastic cover over the patient head-end, with the face mask and endotracheal tube kept under the sheet; preoxygenation and rapid sequence intubation; and use of video laryngoscope; stopping fresh gas flow during disconnect and laryngoscopy. At tracheal extubation, similar precautions are a must. Measures must be taken to prevent contamination by patient bucking after reversal of neuromuscular blockade and coughing after tracheal extubation. Many of us may not have access to some of these safety features. We need to coerce hospital management to procure such equipment as these precautions will have to continue. We should educate them that even after the epidemic recedes, the virus will not disappear into thin air but would rather inhabit the world for a long time.
The venting of exhaled gases and insufflated laparoscopic gases pollutes the operation room (OR) atmosphere. Collection and expulsion of vented gases are not possible; hence laparoscopy must be avoided. In closed-circuit breathing systems, 99.99% efficiency hydrophobic bacteria/viral filters (high-efficiency particulate air [HEPA] class 13) must be placed on the inspiratory and expiratory limbs to prevent machine contamination. In manual mechanical ventilation, using Bain's circuit or any other breathing system, we need to pass the waste anesthetic gases (WAG) through a 1% solution of sodium hypochlorite. Anesthesia gas scavenging systems (AGSS) may prevent OR pollution but WAG potentially contaminate the atmosphere in the area surrounding the hospital building. There is a need to pass the WAG through a sodium hypochlorite tank at the venting end of the AGSS or place HEPA filters in the AGSS line.
ORs and areas housing COVID patients should have negative pressure air-conditioning (AC). Considering all patients to be potentially positive for COVID, we need to ensure resetting of OR airflows from positive pressure AC to negative pressure AC. Minimal personnel should be present in the OR to limit exposure of personnel.
Many anesthesiologists are taking care of intensive care units (ICU). The use of PPE is inescapable during the entire duty shift. Taking off the mask or the other PPE elements are forbidden. One should consider wearing diapers before donning PPE. ICUs do not have AGSS, and the virus loaded expired gases are vented into the ICU room. Chances of aerosol and airborne transmission are very high. Several innovations are under trial to treat and safely vent the expired gases from ventilators. However, none of them are foolproof. ICU postings are very stressful as mortality rates are very high, and failure to successfully treat patients despairs clinicians.
The most stressed anesthesiologists are ones who freelance. They work in stand-alone facilities with limited resources. Most of them are working without adequate support and education about safely handling cases in the current environment. The small OR setup is generally devoid of safe, specialized equipment, lacks special OR features and specialized AC. The life of these anesthesiologists during the current environment can be very unsafe.
Job security cannot be guaranteed in the present condition. Most private hospitals are running at losses at present and will continue to remain in the red for a long time. Almost all private hospitals have informed their clinicians about a significant reduction in their minimum assured guarantee remuneration. Remuneration of those working as visiting consultants is falling like nine-pins. With limited work and high input costs, revenue generation has become difficult. With hospitals continuing to run at low capacity, the reduced surgical load will trigger retrenchment, something unimaginable in the field of anesthesiology till sometime back. Let us brace ourselves for these difficult times and prepare for significantly lower payouts.
The way forward in the current biosphere is to learn to cohabit with COVID. With no hope of a significant therapeutic breakthrough to overcome this pandemic on the horizon, we have no choice but to ensure our safety. There is a need to keep ourselves updated about developments in managing the cases to keep ourselves safe. The focus of all must be “Staying Alive” and keep reminding the general public to “Stay Home” for our safety.
| References|| |
Peng PWH, Ho PL, Hota SS. Outbreak of a new coronavirus: What anaesthetists should know. Br J Anaesth 2020;124:497-501.
Nicolle L. SARS safety and science. Can J Anesth 2003;50:983-8.