key: cord-0728913-3bar96k8 authors: Tian, Yi; Gong, Yahong; Liu, Peiyu; Wang, Sheng; Xu, Xiaohan; Wang, Xiaoyue; Huang, Yuguang title: Infection Prevention Strategy in Operating Room during Coronavirus Disease 2019 (COVID-19) Outbreak date: 2020-06-30 journal: Chinese Medical Sciences Journal DOI: 10.24920/003739 sha: bc7aee2fa92bc7b211788a33887953c3fe0241a9 doc_id: 728913 cord_uid: 3bar96k8 Abstract A novel coronavirus that emerged in late 2019 rapidly spread around the world. Most severe cases need endotracheal intubation and mechanical ventilation, and some mild cases may need emergent surgery under general anesthesia. The novel coronavirus was reported to transmit via droplets, contact and natural aerosols from human to human. Therefore, aerosol-producing procedures such as endotracheal intubation and airway suction may put the healthcare providers at high risk of nosocomial infection. Based on recently published articles, this review provides detailed feasible recommendations for primary anesthesiologists on infection prevention in operating room during COVID-19 outbreak. coaqulopathy.I" SARS-CoV-2 can be transmitted from person to person through respiratory droplets, direct or indirect contact and viral-containing aerosols.!" Incorrect infection prevention may warrant a super spreader who can introduce SARS-CoV-2 infections into a high-volume healthcare facility and cause serious nosocomial outbreak. Several recommendations on perioperative protection for health care workers (HCWs) have been issued, but detailed references for infection control strategy of environment and devices are very limited. Based on the existing experience from major designated hospital for COVID-19 and previous experiences from treating SARS, we provide recommendations on the perioperative infection precaution during SARS-CoV-2 pandemic. These recommendations include the appropriate use of personal protective equipment (PPE), preparation of the operating room, intraoperative management, cleaning and disinfection of anesthesia devices and envlronment.l? Common infection control practices include the use of PPE, hand hygiene, and respiratory hygiene/ cough etiquette, etc. Since transmission of SARS-CoV-2 almost certainly occurs through multiple routes, including large droplets, direct and indirect contact and even viral-containing aerosols, advanced infection control practices should be applied in operating room for COVID-19 related patients. [5l Recommended measures include: 1) hand hygiene, 2) use of PPE to avoid direct contact with the patient's blood, body flutds, secretions and incomplete skin, 3) avoid incidental needle stab or cutting injury, 4) proper disposal of medical waste, 5) equipment cleaning and disinfection, 6) environment disinfection. Recommended PPE for HCWs at different control levels'" was shown in Table 1 . PPE should be donned and doffed in a strict order according to one's specific institutional guidelines and under careful supervision of an infection control officer. During the SARS-CoV-2 outbreak, all elective surgeries for COVID-19-related patients should be postponed when possible. Patients with the exposure history of SARS-CoV-2 but without clinical symptoms need to receive a 14-day isolation and surveillance. The surgery can be carried out if COVID-19 could be excluded after the quarantine. When the suspected or confirmed COVID-19 patients are scheduled for emergency surgeries, they should be transferred to the designated should also know how to implement strict three-level protection standard during the perioperative period. [7, 8] During the epidemic period, detailed administration rules and regulations on infection precaution should be established. Contaminated zones, buffer zones and clean zones should be clearly demarcated. Contaminated PPE must be removed at the designated area and deposed properly. Face shield, goggle, fluid-resistant gown, outer gloves, and outer shoe covers should be removed and left at the contaminated area. Protective coverall, inner gloves, and inner shoe covers should be removed and left in the buffer area. Hair cover and N9S respirator should be removed at the clean zone and sealed in a double-layer bag in a designated area. These pollutants should not be worn or taken into the clean public area. Otherwise, contamination of the public area could result in a major clustering outbreak, since anesthesia department is a relatively enclosed area with high staff volume. Hand hygiene should be emphasized and alcohol-based hand disinfectant should be easily accessed in different areas. The public areas, including the doctors' offices, restaurants and toilets should be disinfected at least twice daily. The door handles, switches, telephones, and other frequently touched surfaces should also be disinfected regularly. Surfaces should be cleaned immediately when known to be contaminated with secretions, excretions or body fluids. The disinfection requirements and frequency for each area are presented in Table 2 . Negative-pressure operating room for COVID-19 patients Anesthesia and surgery for confirmed/suspected COVID-19 patients should be performed in a negative-pressure operating room with an adjacent anteroom where HCWs could apply and remove PPE. If no permanent negative-pressure operating room is available, an operating room with a separate air-conditioning and humidification system should be chosen. If the operating room also has separate atmospheric air in-lets and exhaust systems, it can be changed into a negative-pressure operating room temporarily. [9] For a positive-pressure operating room, the air-conditioning and humidification system should be shut down during the surgery. After the surgery, strict terminal disinfection should be implemented throughout the used operating room and the adjacent operating rooms as well under the guidance of the Infection Control Office of hospital. If a negative-pressure operating room is applied, room pressure should be tested before surgery. The room pressure should be maintained below -SPa in the main operating room during the surgery. It is recommended to spray chlorine-containing disinfectant on the damper at the exhaust duct. During the operation, it is necessary to keep the operating room closed and restrict HCWs pass through the door. After the operation, cleaning and terminal disinfection should be implemented to the environment and object surfaces of the operating room. Then, the negative-pressure system should be run for another 30 minutes. After that, the exhaust duct and damper should be disinfected or replaced. It is suggested that the operating room should be re-used only after careful detection by the Infection Control Office of hospital. COVID-19 patients should be transferred directly to the negative-pressure operating room through an exclusive path and elevator by a physician wearing proper PPE. During the transportation, contact and respiratory precautions should be implemented. In addition, the transfer vehicle should be marked with a bold COVID-19 sign and parked in the designated isolation area, in case of being used by other patients without COVID-19 before proper disinfection. Patients undergoing general anesthesia should receive extubation and postoperative recovery within the negative pressure operating room, or be directly transferred to the isolation ward with tracheal intubation. Do not transfer the patients to the post-anesthesia care unit for tracheal extubation and postoperative recovery. For the patients who are not intubated during the operation and those who are extubated in the operating room, disposable surgical mask or medical protective mask should be applied. After the operation, the patient should be covered with a one-off waterproof operation sheet, and be transferred directly to the isolation ward through an exclusive path and elevator by a physician wearing proper PPE. Before transfer, it is recommend- Remove the unnecessary devices out of operating room before surgery as far as possible. All necessary devices, such as computer, keyboards, displayer and telephones, are protected with disposable plastic wrap. All the anaesthesia devices in the operating room should be strictly disinfected according to the procedure of "Operating room management of special infections" when used on patients with suspected or confirmed COVID-19, and the principle of final disinfection should be strictly followed. 2) The surfaces of monitor, computer, infusion pump and anaesthesia machine only need middle/ low-level disinfection. They should be protected with a disposable transparent cover before usedY2] All equipment surfaces should be in contact with disinfectant, such as 500-1000 mg/L active chlorine, 500 mg/L chlorine dioxide, or 2000 mg/L peroxyacetic acid, for at least 30 min. [13] When cleaning the place apparently contaminated with blood or body fluids, the surface should be wiped with higher concentration of disinfectant carefully. Electrothermomenters need to be covered with film as soon as possible during the surgery and wiped with 75% alcohol after surgery, since they can't tolerance the temperature more than 100°C. 3) It is recommended to choose disposable visual laryngoscope or single-use laryngoscope blades for endotracheal intubation when possible. The laryngoscope handle and screen should be protected by disposable sheaths before using and then disinfected by any of the following four methods (alcohol 75%, chlorine-containing disinfectant, hydrogen peroxide, or disinfectant machine). covered with a disposable transparent film before using, and wiped with 3% hydrogen peroxide after the power is turned off. The probe should be covered with disposable sterile protective sheath, and wiped with disinfectant (3% hydrogen peroxide, 2% glutaraldehyde, 0.55% ortho-phthalaldehyde, 0.55% Clorox) after examination. 5) The infusion support, guard bar, bed board and wheels could be wiped with 2000 mg/L active chlorine. One wiping cloth is exclusively used for one device, and the contact time with chemical should be up to 30 mtn.!"" After 30min, those disinfected surfaces should be wiped with water. All disinfecting clothes and disposable goods should be thrown into double-layer medical waste bags after disinfection. Members of the departmental infection control commission should evaluate and record the effectiveness of disinfection for backtracking. Suggestions on disinfection of anesthetic devices are presented in Table 3 . Medical apparatus and instruments should be infection", along with the department, date and category of the medical waste. All the bags with medical waste should be tighten and sealed before being taken out of the contaminated area. After that, the bag surface should be sprayed with 1000 mgjL chlorine-containing disinfectant, or covered into another bag from the outside, and then handed to professional staff. After closing the laminar air-flow handling system and independent fresh air system, the air disinfection in the OR should be performed with 3000 mgjL peroxyacetic acid and 30000 mgjL hydrogen peroxide water-soluble aerosol spray. The dosage of disinfectant should be satisfied 20-40 ml/rrr', sprayed evenly from inside to outside, top to bottom, left to right, and remain the aerosol full of a confined space for 60 min. [16 l Automated room disinfection also make effect, such as ultraviolet light for one hour. Ensure that nobody is exposed whether using the disinfectant spray or UV light. The smooth floor should be disinfected with 2000 mg/L peroxyacetic acid or 1000-2000 mg/L chlorine solutions. 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