Download Pandemic Flu and Anesthesia

Proper use of personal protection equipment during
intubation inside and outside the operating room
Overview
 History of Pandemic Influenza
 Modes of Transmission for Infectious Disease
 Personal Protection Equipment Review
 Donning/Doffing a PAPR
 Protocol for Intubation Outside the O.R.
 Intra-op Management of Pandemic Flu Patients
History—Pandemic Flu
 1918: worldwide
influenza A pandemic
 Spanish Flu (H1N1)
 675,000 U. S. deaths
 50 million deaths
worldwide
 Original source of the
virus: waterfowl or pigs
credit: Office of the Public Health Service
Historian
History—Pandemic Flu
 1957: Asian flu (H2N2)
 70,000 deaths in the U.S.
 1-2 million deaths worldwide
 1968: Hong Kong flu (H3N2)
 34,000 deaths in the U.S.
 700,000 deaths worldwide
History—Pandemic Flu
 1976: Swine Flu
outbreak at Fort Dix,
New Jersey
 13 soldiers infected; 1
dies
 Intensive epidemiologic
study and isolation limit
spread
 More Americans perish
from complications due
to the vaccine than from
swine flu
Courtesy: The Gerald R. Ford Library
History—Pandemic Flu
 1997: Avian Flu (H5N1)
 Discovered in Hong Kong
 18 infections; 6 deaths
 2004: Avian Flu moves to Thailand
 47 cases; 34 deaths
History--Avian Flu
 2006: spreads to Turkey,
China, Iraq, Azerbaijan,
Egypt
 2007: cases reported in
Nigeria

Image from Jan Conroy, UC Davis Graphics 8/2008 Courtesy of
UC Davis Newsletter
History: Avian Flu
 Currently, transmission requires contact with infected
birds or their secretions
 When the strain becomes transmissible via human-to-
human contact, how quickly would the pandemic
spread?
Avian Flu Model
Estimates of an Avian Flu
pandemic three months after the
arrival of 10 infected people to Los
Angeles.
Blue color: 1 or fewer cases per
1000 people
Red color: 100 or more cases per
1000 people
Courtesy: Los Alamos National Laboratory
News
April 4, 2006
History--SARS
 2003: Worldwide spread of Severe Acute Respiratory
Syndrome (SARS)
 Novel Coronavirus A
 29 countries affected
 8400 cases; 900 fatalities
 In Toronto, of 31 health care workers performing 36
intubations, 3 (all anesthesiologists) contract SARS
Modes of Transmission
 Influenza A
 Multiple routes of infection



Droplet transmission: 50-100 microns in diameter travel less
than one meter; aren’t suspended in air
Direct contact of contaminated hands one’s to nose, mouth
or eyes
 Auto-inoculation via fomites (objects contaminated with
virus)
?Potential for small droplets (less than 5 microns diameter) to
aerosolize (airborne), transmitting virus beyond 1-2 meters
Modes of Transmission
 Influenza and SARS may by transmitted through
aerosol generating procedures:
 Nebulizer treatments
 High flow oxygen
 Non-invasive ventilation (CPAP or BiPAP)
 Bronchoscopy
 High frequency oscillatory ventilation
 Bag-valve ventilation
 Intubation and suctioning
Personal Protection Equipment
(PPE)
Personal Protection Equipment
 Hand washing
 Either soap and water or alcohol based cleansing
solutions are effective in controlling influenza or SARS
virus.
 Must be done prior to patient contact, after removing
masks, gloves and gowns
 Health Care Workers (HCW) who consistently washed
their hands during care for SARS patients had lower
infection rates*

*Shaw,K Public Health, (2006) 120,8-14.
Personal Protective Equipment
 Masks
 Facemasks (surgical masks)


Loose fitting disposable masks that stop droplets, skin or hair
particles falling onto the patient from the HCW
Prevent splashes from contacting the HCW’s face
 Respirators


Air filtering devices that protect against inhalation of both
large and small particles
OSHA requires their use as part of a hospital respiratory
protection program:
Personal Protection Equipment
 OSHA Respiratory Protection Plan requirements:
 Qualified program administrator
 A written protocol including:





Appropriate respirator selection
Medical certification for the PPE wearer
Fit testing
Maintenance and cleaning of equipment
Program review
Pandemic Influenza Preparedness and Response Guidelines for Healthcare Workers and
Healthcare Employers www.osha.gov/Publications/OSHA_pandemic_health.pdf accessed
8/18/08
Personal Protection Equipment
 Respirators1
--Air-purifying respirators


Remove contaminants by filtration or absorption
May be passive or powered
 N-95 (filtering face mask)
 Powered Air Purifying Respirator (PAPR)
 Atmosphere-supplying respirators

Provide clean breathing air from an uncontaminated source
 Self-contained breathing apparatus (SCBA)
 Allow entry into an oxygen depleted environment
1Szeinuk J et al Am Jour Indust Med (2000) 37:142-157
N-95 Respirators
PPE: N-95 Respirators
 Passive air filtration
 Industrial uses also require identification of resistance
of filter degradation to oil



N means not oil resistant
R means somewhat oil resistant
P means strongly oil resistant
 Respirators are also classified by the percent of small
particles are filtered (95, 99, or 99.97%)
 Thus N-95 respirators are not oil resistant and filter
about 95% of small particles.
PPE: N-95 Respirators
 Advantages
 Readily available
 No interference to using a stethoscope
 Not powered, noiseless
 Disadvantages
 Requires fit testing—only works with a tight seal
 Leaves some of the face and neck exposed to droplets
 Increases the work of breathing, uncomfortable
 Not generally reusable
 Can’t be used for men with beards
PPE: Powered Air Purifying
Respirators--PAPRs
PPE: Powered Air Purifying
Respirators (PAPR)
 Advantages
 Doesn’t require fit testing
 Completely covers the face; some also cover the neck
 Doesn’t increase the work of breathing
 Most components reusable
PPE: PAPR
 Disadvantages
 Requires ongoing training to put on (Don), use safely,
and take off (Doff)
 Fan noise impedes conversation
 Can’t use a stethoscope
 May cause claustrophobia
 Limited availability, some models can’t be used in an OR
 More challenging to use during a difficult intubation
PPE: Comparing N-95 vs. PAPR
 Most of the HCW’s in Toronto who contracted SARS
did so before N-95 masks/droplet precautions were
utilized1
 One intensivist contracted SARS during a difficult
intubation in spite of wearing a N-95/goggles/gown
and gloves
 PPE only work when used appropriately
 1Nicolle L, Can J Anesth (2003) 50:983-988.
PPE: Comparing N-95 vs. PAPR
 Prospective, randomized, controlled crossover study of
50 subjects comparing contamination following use of
PAPR vs. N-95 respirator
 Subjects using the N-95 had more frequent and larger
areas of skin contamination
 Subjects using the PAPR had increased risk of self-
contamination while doffing their PPE

Zamora J et al. CMAJ (2006) 175:249-254.
PPE: Comparing N-95 vs. PAPR
 Unanswered Questions:
 Minimal infective dose of viruses
 Safe distance away from patients to prevent HCW
infection
 Issues of PAPR use:




Claustrophobic reactions to HCW wearing a PAPR
Difficulty in communication due to Blower noise
Scary appearance of PAPR wearer to pediatric patients
Increased complexity of PPE increasing confusion and thus
self-contamination of HCW
PPE: Comparing N-95 vs. PAPR
 Recommendations
 The CDC and OSHA mandate using a N-95 respirator as
the minimum respiratory protection when in close
contact with SARS/pandemic flu patients
 The CDC and OSHA note that further respiratory
precautions are warranted (but not mandated)
 California and some hospitals have required using a
PAPR during aerosol-generating procedures

Rush’s policy also states that a PAPR will be used in aerosolgenerating procedures
What’s a PAPR?
Breathing Tube and airflow
indicator
Air-Mate Blower
What’s a PAPR?
Tyvek Head Cover--Rascal
Tyvek Hood
PAPR Head Covers in Use
Rascal Headgear
PAPR Hood
Donning/Doffing a PAPR
 Prior to entering the patient’s room
 Put on shoe covers
 Put on hair cover (if Rascal is being used)
 Prepare the Air-Mate blower:
Preparing the Air-Mate Blower
 Remove the back cover
 Check the filter is clean
 Ensure the filter arrows
point into the unit
 Replace the back cover
Preparing a PAPR
 Attach the air hose to the
Air-Mate Blower by
inserting the male end of
the hose and turning it
clockwise until a click is
felt.
Preparing the Air-Mate Blower
 Turn on the power
 Check the airflow with
the airflow indicator
 The indicator should
float on the air coming
out; the lower band of
the indicator should be
visible
 If this test fails do not
attempt to use the unit
Donning a PAPR
 Attach the breathing
tube into the headgear
 If present, remove the
tissue covering the
faceplate
 Place the Air-Mate on
mid-back; attach and
secure belt around waist
Donning a PAPR
 Pull the face piece over
your head
 Adjust the headpiece for
comfort
 Verify adequate airflow

Remove PAPR if:





Breathing becomes difficult
You feel dizzy or anxious
You smell or taste
contaminants
Your eyes, nose, or mouth
become irritated
Remove a PAPR only
outside a contaminated
room
Donning a PAPR
 Put on gown and gloves
 If using a hood, the
inner shroud tucks
inside the gown; the
outer shroud hangs
outside the protective
clothing.
 You may now enter the
patient’s room
Doffing a PAPR
 Before leaving the room:
 Remove shoe covers
 Remove gown by
grasping the shoulders
pull forward, rolling the
outside of the gown
inward and keeping the
contaminated surface
away from your body;
remove gloves
 Discard gown and gloves
in the red biohazard bag
Doffing a PAPR
Wash your
hands!
 Put on new gloves
 Exit the room, close the
door
Doffing a PAPR
 Assistant (wearing
gloves) supports the
PAPR power source while
the wearer takes off the
belt
 Take off the hood from
the inside, disconnect
the breathing tube (from
the inside of the hood)
 Place hood in
reprocessing bag or
waste
Doffing a PAPR
 The assistant places the breathing tube and Air Mate
in a biohazard bag for reprocessing
 Both remove their gloves
 Wash your hands!!
Donning a PAPR
Doffing a PAPR
1. Put on shoe covers and hair cover
1. Inside the room take
off shoe covers, gown
and gloves. Wash hands
and put on new gloves
2. Check the HEPA filter on the
Airmate blower unit
3. Check air flow out of the
blower hose using the bullet
4. Snap the blower hose into
the PAPR hood; attach the
Airmate belt securely on your
waist
5. Put on PAPR headpiece or
hood; verify adequate air
flow
6. Put on gown and
gloves; remember the
gown goes over the inner
shroud of a PAPR hood
2. Outside the room,
your assistant holds the
Airmate
3. Disconnect
the while you
unsnap
hose from the
insidethe belt
of the PAPR headpiece
4. Place PAPR
headpiece, hose and
Airmate in Red Bag for
cleaning
5. Waste gloves; WASH
HANDS!
Rush Protocols for Intubation of
SARS/Flu patients
Intubation Outside an O.R.
 Primary service or nursing staff notify Anesthesia On-
Call that a patient requires intubation using SARS/Flu
protocol
 Anesthesia PAPR’s from the local room brought with
anesthesia personnel to the patient’s room
 2 on-call anesthesia providers don PAPR’s for intubation;
assist with doffing PAPR’s
Intubation Outside an O.R.
 Determine if the intubation is elective or
emergent(i.e.. respiratory arrest)
 Perform focused H & P1:



AMPLE: Allergies, Medications, PMH, Last meal, Events
Airway exam
 Difficult airway? Ensure a fiberoptic cart is immediately
available
1Cooper A et al. CMAJ.ca Sept. 17, 2003
Intubation Outside an O.R.
 Anesthetic technique—minimize coughing
 Normal airway



Pre-oxygenate for 5 minutes—avoid bag-mask ventilation if
possible
Use a muscle relaxant prior to intubation
Consider giving glycopyrrolate IVP prior to intubation
Intubation Outside an O.R.
 Difficult Airway
 Experienced Anesthesia Provider to intubate the patient
 Have a difficult airway cart immediately available
 Avoid nebulized/topical/transtracheal lidocaine
 Consider deep sedation: midazolam 0.05 mg/kg IVP
and/or fentanyl 1 mcg/kg IVP every 3 to 5 minutes until
the patient is unresponsive to deep painful stimuli, low
spontaneous minute ventilation1

Consider ketamine as an alternative sedative
 Lidocaine 1.5 mg/kg IVP one minute before intubation
 After intubation is confirmed, administer a muscle
relaxant
1Cooper A et al.
Intubation Outside an O.R.
 For all cases
 Emergency drugs immediately available
 Disposable Capnometer
 Disposable stethoscope
 Container in the room to place laryngoscope (blade and
handle) immediately after intubation; second set
available
 Suction ETT with closed system only
Operating Room Policy
 Defer elective procedures on all Pandemic Flu/SARS
patients
 Schedule Pandemic Flu/SARS patients as last case of
the day
 Remove any unnecessary equipment from the OR prior
to patient arrival
 Minimize staff present for the operation
Intra-operative Management
 Patient Transfer1
 Transfer directly to the OR
 Infection Control determines route to transport the
patient from a negative pressure room to the OR
 Patient wears N-95/ Transporters use full
Droplet/Contact precautions

1www.apsf.org/resource_center/clinical_safety/sars.mspx accessed 6/2/08
Intra-operative Management
 On entry to the OR
 PAPR or N-95/full face shield and goggles; full
contact/droplet precautions

Two anesthesia providers—one stays “clean” managing the
anesthesia cart and keeping the anesthesia record1
 Disposable BP cuff, stethoscope
 Keep anesthesia cart “clean”, have a small table available
to place used/dirty laryngoscopes
 HEPA filter on inspiratory and expiratory limbs of the
anesthesia circuit
1Cooper et al.
Intra-operative Management
 End of case
 Recover patient in a negative pressure room or the OR

Transfer patient with a HEPA filter on the Ambu bag if
assisted/controlled ventilation is required
 Waste all disposables in red bags: circuit, CO2 sampling
line, BP cuff, tape, etc.
 Remove PPE using Rush Protocol, don new PPE prior to
transporting patient to negative pressure room
 Clinical Engineering and Housekeeping responsible for
disinfecting the OR and OR equipment