COVID ‐19 safety: aerosol‐generating procedures and cardiothoracic surgery and anaesthesia — Australian and New Zealand consensus statement

Abstract

Introduction Coronavirus disease 2019 ( COVID ‐19) is a contagious disease that is caused by the severe acute respiratory syndrome coronavirus 2 ( SARS ‐CoV‐2). Health care workers are at risk of infection from aerosolisation of respiratory secretions, droplet and contact spread. There are a number of procedures that represent a high risk of aerosol generation during cardiothoracic surgery. It is important that adequate training, equipment and procedures are in place to reduce that risk. Recommendations We provide a number of key recommendations, which reduce the risk of aerosol generation during cardiothoracic surgery and help protect patients and staff. These include general measures such as patient risk stratification, appropriate use of personal protective equipment, consideration to delay surgery in positive patients, and careful attention to theatre planning and preparation. There are also recommended procedural interventions during airway management, transoesophageal echocardiography, cardiopulmonary bypass, chest drain management and specific cardiothoracic surgical procedures. Controversies exist regarding the management of low risk patients undergoing procedures at high risk of aerosol generation, and recommendations for these patients will change depending on the regional prevalence, risk of community transmission and the potential for asymptomatic patients attending for these procedures. Changes in management as a result of this statement This statement reflects changes in management based on expert opinion, national guidelines and available evidence. Our knowledge with regard to COVID ‐19 continues to evolve and with this, guidance may change and develop. Our colleagues are urged to follow national guidelines and institutional recommendations regarding best practices to protect their patients and themselves. Endorsed by Australian and New Zealand Society of Cardiac and Thoracic Surgeons and the Anaesthetic Continuing Education Cardiac Thoracic Vascular and Perfusion Special Interest Group.

Providing safe perioperative care in cardiac surgery during the COVID-19 pandemic

“…Stringent cleaning measures should be performed at regular intervals in all diagnostic rooms. [ 7 , 45 , 46 , 47 , 48 ] Some suggest nasal swab screening of asymptomatic medical personnel at regular intervals to minimize the risk of a possible nosocomial transmission of COVID-19 by asymptomatic hospital personnel. [ 41 ].…”

“…All efforts should be made to postpone the surgery during an active COVID-19 infection, for as long as is tolerated by the patient. [ 7 , 19 , 22 , 24 , 48 , 51 , 52 ] When to operate should be a decision shared by the surgeon, the cardiologist, the intensivist and the anesthesiologist, and the treatment of COVID-19 patients should be interdisciplinary. [ 53 ] While it remains unclear why COVID-19 patients undergoing cardiac surgery have significantly elevated mortality, one explanation could be the additive effect of cytokine release during surgery and cardiopulmonary bypass, possibly resulting in an overwhelming cytokine storm, as well as the pulmonary involvement with resulting acute hypoxemic respiratory failure.…”

“…These filters should be changed daily. [ 48 ] In the ICU, strict hygiene measures should be continued and respective critically ill patients should be carefully investigated for complications such as hypoxic respiratory failure and thrombembolic complications.…”

Anesthetic Management for Thoracic Surgery During the COVID-19 Pandemic

“…There is conflicting advice among societies regarding the use of bronchoscopy in this context. Regarding DLT placement, some societies advocate clinical confirmation of DLT position suggesting that bronchoscopy should be reserved for encountering difficulty or troubleshooting tube misplacement [ 27 , 28 ], whereas the majority still advocates the use of bronchoscopy in all patients [ 25 •, 26 •, 29 , 31 , 36 ], as it is the most reliable method of device placement. Guidelines concur that it should only be performed; during gas flow cessation, patient apnoea, without positive pressure in the circuit, and the adjustable pressure-limiting (APL) valve set at zero cmH 2 O.…”

Health and medicine in a pandemic year: moving from the “winter of despair” to the “spring of hope”

“…The MJA has engaged in the debate about how to protect health care workers from infection, 10 a devastating outcome of the pandemic that was largely preventable. MJA authors have jumped into the often heated debates about schools and virus transmission, 11 the value of face masks, 12 the positive and negative effects of various public health measures, 10,13 lessons learned in an early nursing home outbreak, 14 the urgency of ensuring sufficient numbers of intensive care beds, 15 professional guidelines, 16,17 and protecting Indigenous Australians, 18 to name a few of the areas touched upon in our Journal. As, despite evidence and expert agreement, aberrant beliefs continued to circulate widely on social media, often causing alarm, the MJA has provided a source of reputable peer‐reviewed evidence, with expert syntheses of what is known and what has changed, published as rapidly as is responsible 19…”