key: cord-0830093-xp5q9f0r
authors: Lai, Yu Yung; Chang, Chia Ming
title: A Carton-Made Protective Shield for Suspicious/Confirmed COVID-19 Intubation and Extubation During Surgery
date: 2020-04-20
journal: Anesth Analg
DOI: 10.1213/ane.0000000000004869
sha: 993ad1358886d471388d2e0146d7d95598c00b6f
doc_id: 830093
cord_uid: xp5q9f0r

nan

To the Editor W ith the widespread Coronavirus Disease 2019 (COVID-19) pandemic, respiratory treatment and supportive care for the patients have become an important part of standard treatment. Endotracheal intubation is an essential step in airway management. During the intubation process, the patient's cough may produce secretions and become a source of transmission to infect the caregivers and surrounding working area. Many intubation precautions and devices have been proposed, 1 including medications, personal protective equipment (PPE), and barrier enclosure. A barrier enclosure has recently been proven to effectively minimize the spread of patients' droplets and aerosols during intubation. 2 However, in the scenario of suspicious/confirmed COVID-19 patients who need to undergo emergency surgery, extubation and emergence cough after general anesthesia are another potential source of transmission, and might contaminate the operating room. The importance of COVID-19 extubation should be emphasized to minimize the potential virus infection during a surgery. Both level-3 PPE and negative pressure operating rooms are suggested for such cases.

Here we proposed a simple, carton-made, protective shield that provides an effective reduction of transmission of droplets and aerosols during both intubation and extubation. First, we used a carton made of corrugated fiberboard as an alternative to the transparent plastic cube; the design diagrams of the protective shield are now available as an open source at the aerosol block website. 3 Then we used a transparent plastic wrap to cover the upper portion of the carton, which allows direct vision inside the shield (Figure 1 ). The advantage of corrugated fiberboard is the flexibility to tailor the size of the shield according to the patient's appearance and surgical need. It is also easy to obtain corrugated fiberboard cartons, and the shield is disposable after a single use.

Before using, to avoid patient anxiety, we recommended communication with the patient describing the protective shield and why it is necessary in the anesthetic evaluation. Second, all the intubation devices (video laryngoscope with disposal blade is recommended) should be set inside the shield before induction, including anesthetic circuit and suction tube through the side ports of the shield. After preoxygenation, the laryngoscopist should perform a rapid sequence induction and intubation following COVID-19 perioperative management recommendations for the local institution. Communicating with the surgeon is also important to ensure that the protective shield will not occupy the operation field. After the A Carton-Made Protective Shield for Suspicious/Confirmed COVID-19 Intubation and Extubation During Surgery shield interrupts operation, it should be discarded and a new one prepared for extubation. At the end of general anesthesia, to avoid droplet and aerosol transmission from emergence cough, extubation should be performed inside the shield (Figure 2) . Finally, the protective shield should be discarded in accordance with contaminated waste.

This pragmatic method is definitely not standard airway management of COVID-19. However, the protective shield has proven to be effective in minimizing the spread of aerosols during intubation. When extubation of suspicious/confirmed COVID-19 after general anesthesia is needed, the adjunct protective shield may help minimize droplet and aerosol transmission and reduce operating room contamination. 

Recommendations for endotracheal intubation of COVID-19 patients

Barrier enclosure during endotracheal intubation