The Day of Surgery

Review the following suggestions with your anesthesiologist:

  1. Preoperative Patient Communication: Have the anesthesiologist or nurse anesthetist communicate with the patient the day before surgery:
    • a. Ensure the patient follows all preoperative instructions.
    • b. Screen patients for COVID-19 symptoms (see COVID-19 Screening).
  2. PPE recommendations are stratified, based on the risk category of the patient and procedure. Follow state and local guidelines as well as facility requirements. No-valve N95 respirators are preferred for use in a sterile field.
  3. Aerosol-generating: For all patients undergoing procedures that are aerosol-generating and/or the patient or procedure is considered moderate or high risk, PPE decisions must be appropriate for this high-risk status. N95 or N99 respirators, gowns, gloves, and eye shields are recommended for all OR personnel. Follow appropriate donning & doffing procedures. Do not operate without adequate PPE.
  4. General anesthesia: For all other patients undergoing any procedures under general anesthesia:
    • a. Intubation and extubation (and all assistance with such) requires use of N95 respirators, gloves, and eye protection.
    • b. The surgical team waits outside the OR for a required full turnover of air based on the specific ventilation system of the operating room, after which the surgical team may proceed using routine surgical masks and protection. If they enter the OR prior to the completion of the required air exchange period, then N95 respirators and eye protection are required. The surgical team should leave the room for extubation.
    • c. Local anesthesia or IV sedation, surgical site above clavicle: For all procedures that are above the clavicle (but not otherwise aerosol-generating): the surgeon and all OR staff should use, where available, N95 respirators and eye protection as part of their PPE.
  5. Local anesthesia or IV sedation, surgical site below clavicle: For all that are below the clavicle, but not otherwise aerosol generating, standard PPE can be used.
  6. Cases that are likely to require heavy IV sedation should be re-considered for performance under general anesthesia, to avoid the possibility of loss of airway and the need for sudden intubation without enough time for donning PPE’s.
  7. Anesthesia Machine Protection: Have anesthesia consider the following:
  8. Protecting the staff
    • a. All patients considered POSITIVE as a universal precaution.
    • b. Intubation/extubation precautions in aerosolizing procedure.
    • c. All personnel present for intubation/extubation should wear N95 mask (or equivalent) and face shield, WHERE AVAILABLE.
    • d. PPE recommendations as per STEP 8.2.
    • e. Staff who clean rooms/instruments use N95 mask/face shield, WHERE AVAILABLE.
    • f. Proper training in donning and doffing of PPE.
    • g. During intubation/extubation only the anesthesiologist/nurse anesthetist are present. All other staff required to be in the room during extubation should wear N95 masks (WHERE AVAILABLE), eye wear, and PPE.
    • h. All staff other than the cleaning crew should follow the OSHA & CDC recommendation of waiting for 99.9% removal of airborne contaminants before doors to room are re-opened and allowed to re-enter without N95 masks. Calculations of this process can be researched at: https://www.cdc.gov/infectioncontrol/guidelines/environmental/appendix/air.html#tableb1
    • i. Adjust schedules with expectations of delays.
  9. Post Anesthesia Care Unit (PACU)
    • a. N95 Mask Use: aerosolizing procedures in PACU which require use of N95s, WHERE AVAILABLE, include:
      • i.Use of BiPaP or CPAP
      • ii.Nebulizer administration
      • iii.Induction of sputum
      • iv.Bag valve mask ventilation
      • v.Chest compression / CPR
    • b. Surgical Mask Use: low-aerosol generating procedures in PACU, which require use of surgical masks, include:
      • i. High flow oxygen > 6L/min
      • ii. Chest physical therapy
      • iii. Oropharyngeal suctioning by Yankauer or respiratory suction
      • iv. High flow oxygen by face mask or nasal cannula > 6L/min
      • v. Intra-nasal medication use
    • c. No visitors in PACU. Perform necessary education at an earlier time.
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