Articles: coronavirus.
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Lockhart et al. provide a considered exploration of COVID-19 infection-control issues specific to anaesthesiologists, proposing an additional third category of personal protective equipment (PPE).
Give it to me in point form!
They propose three PPE types:
- Droplet & contact precaution PPE: surgical mask, gown, gloves.
- General airborne, droplet & contact PPE: addition of N95 respirator mask and eye protection.
- PPE for high-risk aerosol-generating medical procedures: addition of gown neck protection and double gloves.
Why should I take notice?
The Canadian view on PPE is tempered by both their current significant COVID burden, and their experience of the 2003 SARS pandemic which infected 257 Canadians, 20% of whom were healthcare workers. Much of our PPE evidence is based upon SARS. This article emphasises the importance of PPE for anaesthesiologists and their airway assistants.
On airborne spread?
Unfortunately much of what we did not know about respiratory spread and SARS in 2005 persists today:
Although this observation [about lack of knowledge of SARS infectious droplets] was made 15 years ago, basic questions regarding nosocomial spread during the SARS epidemic, and now the COVID-19 pandemic, have yet to be answered.
Absence of evidence however, should not imply evidence of absent airborne spread.
The role of airborne particles in the spread of COVID-19 remains unclear, although Lockhart notes the infamous case of Hong Kong's Amoy Gardens housing complex in the 2003 SARS outbreak, resulting in 187 cases – likely via airborne spread.
Endotrachial intubation has been shown in several studies to be a high-risk procedure for healthcare worker infection. Considering this the authors reccomend a third level of PPE, adding:
- AAMI level-2 gown, incluidng neck protection, noting that the neck is a high-risk area for contamination in simulation studies.
- Double gloves that overlap the sleeve, noting that the gown-glove interface is a common PPE failure site, and that Verbeek's 2020 Cochrane review concluded that there was less contamination vs single gloving (RR 0.36).
Additionally:
- Only allow presence of essential staff in room during AGP.
- Provide access to shower resources for staff after high-risk AGP.
- Do not ‘‘MacGyver’’ homemade combinations of PPE.
- Doffing is a high-risk critical moment, that should not be rushed, distractions should be minimised, and use a doffing supervisor. Pay attention when donning to ease later doffing.
- Masks should be the last item removed.
Final word
Lockhart emphasises that there is no ideal PPE, but by focusing on consistent protection at known high-risk interactions (ie. intubation) safety improvements can be made.
summary -
As COVID-19 disease escalates globally, optimising patient outcome during this catastrophic healthcare crisis is the number one priority. The principles of patient blood management are fundamental strategies to improve patient outcomes and should be given high priority in this crisis situation. The aim of this expert review is to provide clinicians and healthcare authorities with information regarding how to apply established principles of patient blood management during the COVID-19 pandemic. ⋯ We discuss how preventative and control measures implemented during the COVID-19 crisis could affect the prevalence of anaemia, and highlight issues regarding the diagnosis and treatment of anaemia in patients requiring elective or emergency surgery. In addition, we review aspects related to patient blood management of critically ill patients with known or suspected COVID-19, and discuss important alterations of the coagulation system in patients hospitalised due to COVID-19. Finally, we address special considerations pertaining to supply-demand and cost-benefit issues of patient blood management during the COVID-19 pandemic.