Articles: personal-protective-equipment.
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COVID-19 has caused an unprecedented pandemic and medical emergency that has changed routine care pathways. This article discusses the extent of aerosolisation of severe acute respiratory syndrome coronavirus 2, the virus that causes COVID-19, as a result of oesophagogastroduodenoscopy and colonoscopy. ⋯ As it is a highly infectious disease, clinicians treating patients with COVID-19 require effective personal protective equipment. The main routes of infection are direct contact and droplets in the air and on surfaces. Aerosolisation carries a substantial risk of infection, so any aerosol-producing procedure, such as endoscopy, should be performed wearing personal protective equipment and with extra caution to protect the endoscopist, staff and patients from cross-infection via the respiratory system.
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Why do we need another PPE review?
This review contextualises the PPE issues with their (relatively low quality) evidence base, focusing particularly on anaesthesia given that this is a high-risk occupational group. Coming from both a UK expert and journal, the recommendations should be carefully considered in terms of the UK's severe COVID outbreak and PPE supply issues.
Important takeaways?
- The significance of airborne transmission, in particular the infectivity of airborne viral particles beyond 1 meter, is uncertain.
- PPE should be seen as an important and essential part of a larger safety system.
- Intubation is a high-risk procedure for aerosol generation. A ventilated negative pressure room and airborne-precaution PPE is recommended. Ventilation (frequency of air-exchange) is likely more important than negative pressure.1 Chinese evidence suggests COVID transmission at intubation is low with appropriate PPE, although there is wide variability in extremes of PPE used along with post-exposure disinfection (eg. showering).
- High-flow nasal oxygen and supraglottic airway (eg. LMA) placement may also be aerosol generating.
- Most risk of transmission from sneezing and coughing is probably droplet and contact, rather than airborne, although the science behind these questions are complex and uncertain. Evidence attempting to answer these questions is often from non-clinical settings.
- Fluid-resistant surgical masks when worn by staff may reduce transmission by at least 80%. Superiority of respirator masks (eg. P2,P3,N95) is not yet reliably supported by evidence.
- Cook highlights two main PPE problems: 1. PPE supply; 2. Inappropriate use of PPE (using higher level than required).
- PPE should be simple to remove (doff) after use, to reduce contamination risk. Cook notes that Canada's SARS experience highlighted increased risk of self contamination with more complex PPE.
On specific levels of PPE
- Contact precautions (gloves & gown) are recommended when in vicinity of COVID positive patient but not within 2 meters.
- Droplet precautions (+ mask & eye protecting) are recommended within 2 meters of patients.
- Airborne precautions (+ FFP3 respirator mask) are only recommended for aerosol generating procedures (AGP). However classification of procedures as AGP or not is only loosely evidence based.
"Public Health England recommends airborne precautions are used in ‘hot spots’ where aerosol generating procedure are regularly performed, if any suspected COVID-19 patients are present – these include intensive care unit, operating theatre, emergency department resuscitation bays and labour wards where mothers are in stage 2 or 3 of labour"
(Interesting that two recent meta-analyses found no evidence of benefit of N95 masks vs surgical masks for healthcare workers: Bartoszko 2020 & Long 2020.)
Hang on...
The elephant in the room is that the lack of PPE supply appears to be the main driver of the rapidly-changing PPE recommendations.
PPE choices need to be made in consideration of the spectrum of risk, hazard and cost, acknowledging different risk profiles depending on location, procedure and individual clinicians.
summary
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It's worth highlighting that negative pressure confers no protection on those in the room, it's purpose is to prevent escape of contagion to areas outside the room. ↩
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Dermatologic therapy · Jul 2020
ReviewCoronavirus disease (COVID-19): An updated review based on current knowledge and existing literature for dermatologists.
The world entered the year 2020 with reports of the emergence of a new viral illness in Wuhan city, Hubei province, China. In January 2020, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified to be the causative novel coronavirus for the cluster of patients suffering from pneumonia in China. The disease was later named as coronavirus disease (COVID-19) and was declared a pandemic by the World Health Organization on March 11, 2020. ⋯ The current management strategies focus on supportive care and prevention of complications. With no definite treatment, as of now, encouraging reports of some anti-viral and anti-malarial drugs in the management of COVID-19 generate some hope. This review intends to cover the current known aspects of COVID-19 and SARS-CoV-19, based on the available literature.
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The world is currently facing an unprecedented healthcare crisis caused by a pandemic novel beta coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The pathogen is spread by human-to-human transmission via droplets exposure and contact transfer, causing mild symptoms in the majority of cases, but critical illness, bilateral viral pneumonia, and acute respiratory distress syndrome (ARDS) in a minority. ⋯ This article presents a summary of learning points in epidemiological infection control from the SARS epidemic, alongside a review of evidence connecting current understanding of the virologic and environmental contamination properties of SARS-CoV-2. We present suggestions for how personal protective equipment policies relate to the viral pandemic context and how the risk of transmission by and to anaesthetists, intensivists, and other healthcare workers can be minimised.
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Otolaryngol Head Neck Surg · Jul 2020
ReviewHigh-Risk Aerosol-Generating Procedures in COVID-19: Respiratory Protective Equipment Considerations.
The correct selection and utilization of respiratory personal protective equipment is of the utmost importance in the current COVID-19 pandemic. This is especially true for health care workers exposed to high-risk aerosol-generating procedures, including otolaryngologists, ophthalmologists, neurosurgeons, maxillofacial surgeons, and laparoscopic surgeons. ⋯ However, high-risk aerosol-generating procedures may create aerosolization of high viral loads that represent increased risk to health care workers. In these situations, enhanced respiratory protection with filters certified as 99, 100, or HEPA (high-efficiency particulate air) may be appropriate.