JAO-HNS Covid-19 surgical recommendations

April 27, 2020

 

RE: COVID-19 RESPONSE IN ENT PATIENTS

 

The novel Coronavirus 2019 (COVID-19) has been declared a pandemic with all the consequent implications. Reports suggest that Otolaryngologists are to be considered extremely high risk of contracting COVID-19 due to the manner in which we interact with patients in close proximity to the known portals of entry of the virus – nose/nasopharynx and oral cavity and the consequent risk of exposure to aerosolized secretions. As a result of this, it is prudent for us to take decisive actions to safeguard our own health and the health of our families while still playing our essential role as part of the global Health response to COVID-19.

Based on the most current compilation of information, the American Academy of Otolaryngology–Head and Neck Surgery, the British Laryngological Association and ENT UK have all issued recommendations for all Otolaryngologists to limit providing patient care activities to those individuals with time-sensitive, urgent, and emergent medical conditions.

In keeping with this, we are making and, in many instances, endorsing the following recommendations for our surgical practice.

The main risk lies in the fact that the corona virus enters the body and colonizers the nose, nasopharynx and oropharynx before spreading to other areas such as the lower airways (trachea and lungs). While in these sites, the virus may become aerosolized during the performance of any procedure involving these areas. These viral particles can then infect the health care workers and other patients without adequate preventative measures. The main surgical procedures that will be highlighted are –

1. Endonasal procedures (nasal endoscopy, functional endoscopic sinus surgery, endoscopic trans-sphenoidal hypophysectomy and other endoscopic skull base operations)
2. Tracheostomy
3. Oral and maxillofacial surgery

 

GENERAL GUIDELINES

1. Establishment of a COVID-19 response team, the size and composition of which will depend on staff cadre and patient workload but should include Consultant staff and different levels of Resident staff.
2. All Members of staff should be fit-tested for at least N95 respirator masks and adequate supplies of personal protective equipment (PPE) should be procured and made available for staff to use. Members of staff should also be shown how to don and doff the PPE without contaminating themselves and others.
3. PPE should comprise of waterproof cap, N95/FFP3 mask, face shield/goggles, impervious gowns, cover shoes and gloves.
4. Postpone all non-emergency/non-urgent surgical and endoscopic procedures.
5. It would be ideal to have all patients undergoing high risk procedures tested for Covid-19 and the results known prior to the procedure. However, it is the reality that this will not be possible in all cases. This reality should lead us to manage the Covid-19 unknown cases like Covid-19 positive patients with the same precautions taken

TRACHEOSTOMY GUIDELINES

EMERGENCY TRACHEOSTOMY

1. All patients who meet established criteria for emergency tracheostomy should be managed as suspected as having COVID-19 positive. With certain respiratory symptoms they may still fulfil criteria for suspected COVID-19 but there will not be time for testing in this situation.
2. For patients with reversible cause for airway obstruction
   1. Intubation rather than tracheostomy would be preferable, follow difficult airway guidance
   2. Avoid use of high flow oxygen
   3. Most skilled airway manager (anaesthetist) present should manage airway to maximise first pass success
   4. Most skilled airway manager (ENT) for tracheostomy if required
   5. Reduce unnecessary team members to essential staff
   6. See Standard Operative Procedure for tracheostomy below
3. For patients with irreversible cause for airway obstruction i.e. (Laryngeal mass)
   1. In this case, trans-laryngeal intubation is not appropriate so tracheostomy should be done as per standard operative procedure below
   2. At this time, it may not be advisable for laryngeal debulking in those whose COVID-19 status is unknown

 

ELECTIVE TRACHEOSTOMY

 

1. Planning should take place several days before the actual procedure.
2. COVID-19 testing to be performed in all patients prior to elective tracheostomy.
3. Tracheostomy is a high-risk procedure because of aerosol-generation (ENT UK), it may be prudent to delay tracheostomy until the patient has recovered from active COVID-19 disease.
4. ENT and ICU consultant to discuss appropriateness of tracheostomy in COVID-19 positive patient.
5. Consider waiting a minimum of 14 days of endotracheal intubation prior to considering tracheostomy.
6. Make every attempt to extubate the patient prior to resorting to tracheostomy
7. The patient should be requiring PEEP ≤10cmH2O and FiO2 ≤0.4 (to promote tolerance to periods of apnoea and potential de-recruitment).
8. The patient should be haemodynamically stable with minimal pressor requirement.
9. Review CXR to ascertain starting distance of ETT tip above carina
10. If COVID negative following testing, proceed as per standard operating procedure (fluid resistant surgical mask, surgical gown, gloves and eye protection).

 

Standard operative procedure for tracheostomy in COVID 19 positive patient/Unknown status

1. These recommendations would typically apply to the Covid-19 positive patient who has been intubated for a prolonged period.
2. Most skilled anaesthetic and ENT clinician performing anaesthetic and procedure, to ensure that the procedure is safe and swift.
3. Reduce unnecessary team members and limit attendance to essential staff who should all be in PPE
4. Should be done in a negative pressure operating room or isolation room or at least in a regular operating room with doors closed.
5. Preparation and Gowning:
   1. Use FFP3/N95 mask.
   2. Eye/face protection should be worn for performing tracheostomy or changing a tracheostomy tube due to the risk of respiratory secretions or body fluids. One of the following options are suitable: 1. surgical mask with integrated visor 2. full face shield/visor
   3. Fluid resistant disposable gown should be worn. If non-fluid resistant gown is used a disposable plastic apron must be worn underneath. A sterile disposable gown must be used for surgical tracheostomy.
   4. Gloves must be appropriate to allow palpation, use of stitches and surgical instruments. Consider using Eclipse system or “double-gloving”.
   5. All instruments should be prepared and laid out prior to bringing the patient into the operating room. This includes the testing of the cuff of the tracheostomy tube and an air-filled syringe attached.
   6. The tip of the endotracheal tube (if present), should be advanced to the carina.
   7. Cuffed non-fenestrated tracheostomy should be used to avoid aerosolizing the virus. If possible, use a double lumen tube to prevent the need for changing of the tracheostomy tube (local recommendation).
   8. Patient should be completely paralyzed to avoid coughing and subsequent aerosolization.
   9. Avoid use of electrocautery for example by using surgical ties to achieve haemostasis, especially once the trachea has been opened.
   10. Prior to entry, ventilation should cease.
   11. During entry into the trachea, every effort should be made not to pierce the cuff of the endotracheal tube.
   12. Initial advancement of the endotracheal tube should be performed prior to tracheostomy window being made.
   13. If possible, cease ventilation whilst window in the trachea is being performed and check the cuff is still inflated before recommencing ventilation
   14. Ventilation to cease prior to tracheostomy tube insertion and ensure swift and accurate placement of tracheostomy tube with prompt inflation of the cuff
   15. Confirm placement with end tidal CO2.
   16. Ensure there is no leak from the cuff and the tube is secured in position in usual manner.
   17. Endotracheal tube should be clamped prior to removal in order to reduce the risk of aerosolization.
   18. Tracheostomy tube should preferably be connected to in-line suction system to avoid disconnection for suctioning.
   19. HME (Heat and moisture exchanger) should be placed on the tracheostomy to reduce shedding of the virus should the anaesthetic tubing be disconnected
   20. Avoid disconnecting HME but if necessary, disconnect distal to HME.

Post tracheostomy care

1. The Royal College of Anaesthetists suggests avoiding humidified wet circuits as theoretically it will reduce the risks of contamination of the room if there is an unexpected circuit disconnection.
2. Avoid changing the tracheostomy tube until COVID-19 has passed, will have to review with infectious diseases.
3. Cuff to remain inflated and check for leaks.
4. Make every effort not to disconnect the circuit.
5. Only closed in-line suctioning should be used

Tracheostomy and Tracheostomy Tube Changes in confirmed negative or not suspected COVID 19

1. Equipment and Gowning:
   1. Use fluid resistant surgical mask.
   2. Eye/face protection should be worn for performing tracheostomy or changing a tracheostomy tube due to the risk of respiratory secretions or body fluids. One of the following options are suitable: 1. surgical mask with integrated visor 2. full face shield/visor
   3. Usual surgical gown for tracheostomy and single use disposable apron for tube change.
   4. Gloves must be appropriate to allow palpation, use of stitches and surgical instruments. Consider using Eclipse system or “double-gloving”.

 

 

ENDOSCOPIES

1. All non-emergency endoscopies should be cancelled pending control of the pandemic. This should include nasal endoscopies, laryngoscopies (telescopic, flexible fibreoptic and direct), esophagoscopies and endoscopic sinus surgery.
2. For emergency endoscopic procedures (cancers, trauma & foreign bodies) extreme precautions should be taken. These measures include:
   1. The donning of personal protective equipment that includes – N95/FFP3 masks (preferably masks that have been fit tested), face shield/goggles, impervious gowns, cover shoes and gloves.
   2. All personnel should have been shown not only how to don (put on) the PPE, but also how to safely remove the equipment without contaminating yourselves and those around you.
   3. Consider nasal and nasopharyngeal irrigation with Povidone iodine to potentially reduce viral load. (HS Parhar et al., Head & Neck April 2020).

ORAL AND MAXILLOFACIAL SURGICAL PROCEDURES

1. These procedures which may involve the use of drills and surgical saws in the upper aerodigestive tract also risk aerosolization of viral particles
2. The decision to cancel elective lists (for non-airway cases) should be taken in line with the general hospital/MOH policy.
3. Cancer operations must continue to be done in a timely fashion in order to achieve good prognosis.
4. The number of persons that might be exposed should be kept to a minimum.
5. The duration of exposure should be restricted by abbreviating any surgical procedure
6. Consider conservative management of jaw fractures including intermaxillary fixation under local anasethesia, during which staff should wear full PPE

OUTPATIENT/AMBULATORY CARE

1. Ambulatory/Out-patient clinics should be curtailed to facilitate contact with only patients with urgent/time-sensitive and emergency conditions only (cancers, and genuine emergencies).
2. PPEs should be worn when dealing with patients with epistaxis.
3. Screening of all patients making appointments –
   1. Symptoms matching current case definition – fever, cough, shortness of breath/difficulty breathing and hyposmia/anosmia/dysgeusia
   2. Contact with Covid-19 positive patients or patients with symptoms matching the case definition
4. Similar screening of any “walk-in” patients although an appointment system will help to avoid overcrowding and facilitate social distancing. Temperature recording should also be a part of the screen.
5. Support the order to wear masks in public areas.
6. Ensuring patients wash or sanitize their hands upon entry into the clinic. A sanitizer with at least 70% alcohol is best.
7. “Physical distancing” measures should be adhered to as much as possible in waiting areas and in the examination rooms.
   1. Limit the number of persons in the office to the number that will allow for adherence to the physical distancing guidelines (depends on the size of the Clinic).
   2. Space seating 3 -6 feet apart (where possible).
   3. Limit the number of persons in the examination room to include only essential persons.
8. Frequent sanitization of surfaces that are touched frequently – door handles, faucets, plastic chairs, BP cuffs, computer keyboards, telephone. Disinfection of floors and walls using chlorine bleach.
9. Avoid touching of cellular phones. Consider using handsfree device and ensure phone is sanitized frequently if use is unavoidable.
10. If a patient enters the office and is coughing/sneezing, present the patient with a mask and make a decision whether to advise patient to leave, self-quarantine and call the MOH Helpline OR see the patient while wearing PPE (if available).
11. Remove magazines and other reading materials from waiting areas.
12. Staff should be shown how to properly don and remove masks and gloves without touching exterior of these items.
13. Proper arrangements should be made for disposal of biohazardous waste.
14. Personal protection
    1. Consider use of telemedicine.

Frequent hand sanitization and handwashing.

1. Avoid touching face and exterior of mask.

 

JAO-HNS