key: cord-313503-wvgwf9n3
authors: D’Amico, Randy S.; Khatri, Deepak; Kwan, Kevin; Baum, Griffin; Serulle, Yafell; Silva, Danilo; Smith, Michael L.; Ellis, Jason A.; Levine, Mitchell; Ortiz, Rafael; Langer, David J.; Boockvar, John A.
title: Neurosurgical/Head and Neck drape to Prevent Aerosolization of COVID-19 - The Lenox Hill Hospital/Northwell Health solution.
date: 2020-07-23
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.07.133
sha: 
doc_id: 313503
cord_uid: wvgwf9n3

nan

The "Coronavirus disease 2019" or COVID-19 pandemic has resulted in dramatic changes in the way we practice medicine and neurosurgery. Given its long incubation period, high transmission rate, and estimated 3% mortality, this virus will likely affect the way we live and work for the foreseeable future. 1,2 This has been particularly true in New York City which quickly became the global epicenter of the infection. While many departments have curtailed elective surgery, neurosurgical procedures that are deemed emergent, urgent, or semi-urgent will warrant intervention during these restrictive times. Although COVID-19 screening and testing guidelines have been proposed and adopted by many hospitals, these may not adequately protect the operating room personnel who are in proximity to the patient for prolonged periods. There are concerning reports of especially high transmission rates of COVID-19 in trans-mucosal head and neck procedures conducted by otolaryngologists and neurosurgeons, despite attempts at wearing what constitutes appropriate PPE. 3 Here we describe the simple intraoperative technique we utilize at Lenox Hill Hospital/Northwell Health for all cranial, endonasal, spinal, and neuro-interventional cases to limit the intraoperative transmission COVID-19 to essential staff in the operating rooms and the endovascular suite who are at a substantially higher risk of exposure to the disease. 4, 5 We expect that these COVID-19 pandemic intraoperative precautions will extend into the COVID-19 recovery period as well as hospitals attempt to prevent a return to widespread infection.

Formal screening and testing guidelines are currently being devised. We recommend that all patients should undergo testing within 24 hrs of emergent/planned surgical procedures. These services may be provided by the hospital pre-op department or via at-home companies capable of performing the testing (i.e. Labfly; https://www.northwell.edu/northwell-health-labs/labfly).

Aerosolization of the virus prior and during intubation and extubation deposits the virus into the air and on fomites in the operating room. 4, 5 This is particularly important as transconjunctival spread has been reported. Enhanced PPE precautions should be utilized by all personnel in the negative pressure operating room and endovascular suites. Furthermore, all non-essential staff should leave the room during intubation and extubation.

We are currently utilizing a large fluoroscope drape to cover the eyes, nose and mouth following intubation to limit potential dispersal of aerosolized virus (Premiere Guard Fluoroscope Drape, 91 x 112 cm; http://www.premierguard.com; Houston, Tx; Figure 1A) . With the help of the selfadhesive edges, the clear drape is secured low on the brow and hangs down over the eyes, nose and mouth allowing visualization of the face and endotracheal tube ( Figure 1B) . The application of this drape can be modified to accommodate necessary cranial incisions or secured at the neck for cases where the patient is positioned prone or lateral. After the drape application, the surgical site can be prepped and draped sterilely in the usual fashion ( Figure 1C) . Since the drape only covers the face and is not applied over the cranium, it leaves the whole cranium accessible for usual prepping which is performed after the application of this drape. Any cranial incision can be easily marked and draped around using the sterile blue towels in the conventional manner. The drape does not restrict any surgical activity including the usage of a drill. The drape is carefully discarded at the end of the surgery prior to, or after extubation according to anesthesia's desired protocol. Strong consideration should be giving to leaving the drape over the mouth and nose during extubation as preliminary reports support its utility in limiting aerosolization. 6 This is particularly important in cranial cases where the surgeon and his assistant stand at the head of the bed, although we feel it should be used for all interventions using general anesthesia (cranial, spine, endovascular). Notably, the mechanism of protection of this drape is proposed to limit aersolization from the oropharynx during intubation, extubation, and endonasal sinus cases. This is not proposed to protect the surgeon during drilling of aerosolized sinuses such as the mastoid bone. In all settings, and in particular these cases, we recommend maintanence of recommended PPE practices.

Infected patients have a high viral load in the upper airways and the risk of aerosolization of COVID-19 may be extremely high during sino-nasal and upper airways procedures. 7 This is particularly true when high-speed operative drills are employed. Recently, the American Association of Otolaryngology-Head and Neck Surgery (AAO-HNS) has recommended deferring endoscopic endonasal procedures unless emergent. 8 In these scenarios, enhanced PPE should be utilized regardless of COVID-19 testing status. In such cases, the prevention drape should be modified with a small aperture (horizontal slit) to allow instruments to pass into and out of the nares (Figure 2) . If an approach surgeon is utilized, we recommend all non-essential personnel remain outside of the OR until adequate exposure has been achieved.

Recently, a Negative-Pressure Otolaryngology Viral Isolation Drape (NOVID) was utilized at another center for endoscopic skull base and transoral surgical procedures in four patients. 9

Compared to the NOVID, our technique offers a simple, commonly available alternative which avoids the use of additional retractor system. Moreover, this technique can be utilized in all neurosurgical procedures.

As we continue to work through the COVID-19 pandemic and focus on recovery, sustained efforts to limit transmission will be necessary to protect physicians, staff, and patients. The COVID-19 aerosolization prevention drape may limit intraoperative dispersal of COVID-19 particles and add an additional layer of protection against the spread of the virus. In addition, its availability and cost effectiveness make this technique especially attractive to practical utilization in centers with limited resources. 

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A Framework for Prioritizing Head and Neck Surgery during the COVID-19 Pandemic. Head Neck

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Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists

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