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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

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pandemic flu and anesthesia

Pandemic Flu and Anesthesia

Proper use of personal protection equipment during intubation inside and outside the operating room

  • 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
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 flu5
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 flu6
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 flu7
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
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 flu9
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
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 transmission13
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 transmission14
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
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
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 equipment18
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 8/18/08

personal protection equipment19
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

ppe 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 respirators22
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 papr
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
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 papr27
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 papr28
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 papr29
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 aerosol-generating procedures
what s a papr
What’s a PAPR?

Breathing Tube and airflow indicator

Air-Mate Blower

what s a papr32
What’s a PAPR?

Tyvek Head Cover--Rascal

Tyvek Hood

papr head covers in use
PAPR Head Covers in Use

Rascal Headgear


donning doffing a papr
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
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
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 blower37
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
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 papr39
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 papr40
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
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 papr42
Doffing a PAPR
  • Wash your hands!
  • Put on new gloves
  • Exit the room, close the door
doffing a papr43
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 papr44
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

2. Outside the room, your assistant holds the Airmate while you unsnap the belt

3. Disconnect the hose from the inside of the PAPR headpiece

4. Snap the blower hose into the PAPR hood; attach the Airmate belt securely on your waist

4. Place PAPR headpiece, hose and Airmate in Red Bag for cleaning

5. Put on PAPR headpiece or hood; verify adequate air flow

5. Waste gloves; WASH HANDS!

6. Put on gown and gloves; remember the gown goes over the inner shroud of a PAPR hood

intubation outside an o r
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 r48
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. Sept. 17, 2003
intubation outside an o r49
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 r50
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 r51
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
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
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
    • accessed 6/2/08
intra operative management54
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 management55
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