Okay not to scare everyone here are the latest guidelines from the American Society of Anesthesiology released yesterday! October 8, 2014 Ebola is an infectious disease caused by a filovirus (Ebola virus). It is usually transmitted by direct contact between contaminated blood and body fluids and broken skin or mucous membranes. An infection has been fatal in over 50 percent of patients in the affected areas of Western Africa. Ebola is now in the US with patients who contracted the disease while in the affected countries. To date there is no cure or vaccine and promising antiviral treatments are sparse or depleted. Some patients are receiving untested treatments. A health care worker in Spain has recently been diagnosed with Ebola after caring for a victim who died in a hospital there, despite reportedly having worn protective gear. An American cameraman for a network news program allegedly contracted the disease after assisting with cleaning of the interior of a car, which had carried an Ebola patient who subsequently died. Since anesthesiologists are at the forefront of care for the critically ill throughout the hospital, they must be aware of the risks and take adequate precautions to ensure they do not become infected or transmit the Ebola virus. There are several possible routes of transmission to health care workers. Body fluids that may contain the virus include blood, vomit, urine, stool, sweat, semen, and sputum. Percutaneous exposure via needles and other medical equipment is a particularly efficient route of transmission. The virus can live on surfaces for an unknown length of time but no known cases of transmission by the route has been confirmed at this time. The virus can potentially be “aerosolized” into droplets during intubation, by coughing and high velocity flow through an endotracheal tube, or during certain procedures. Proper protective equipment will be discussed below, along with identification and processing of potentially infected patients. Additional materials discuss the special situation of Ebola infected patients in the Operating Room. The identification of potential Ebola patients would include history of risk factors for exposure including travel to affected areas (Guinea, Liberia, Nigeria, Senegal, and Sierra Leone) and contact with infected individuals. The signs and symptoms of Ebola infection can appear anywhere from 2-21 days after exposure, with 8-10 days being most common. The patient will have a fever (greater than 38.6 C or 101.5 F), and in addition will have one of more symptoms such as severe headache, muscle pain, vomiting, diarrhea, stomach pain, joint and muscle aches or unexplained bleeding or bruising. A maculopapular rash will often develop by day 5-7. Patients with severe forms of the disease may develop multi-organ dysfunction, including hepatic damage, renal failure, central nervous system involvement and unexplained massive hemorrhage, leading to shock and death. The patient is infectious once symptoms and fever appear. A differential diagnosis of this condition will include malaria and Lassa Fever. There is a test for the Ebola virus done by the CDC, which takes days to process. A patient may test negative at early stages of the disease (less than 3 days after symptoms appear). The personal protection of health care workers is paramount. Standard Precautions plus Enhanced Contact and Low Level (modified droplet) Respiratory Isolation are effective in preventing transmission. All persons entering the patient room should wear: gloves, gown (fluid resistant or impermeable), eye protection, and a facemask. Additional Personal Protective Equipment (PPE) includes double gloving, shoe covers, leg coverings and use of a N95 respirator for situations where there are copious blood or body fluids, vomit or feces, or aerosolized fluids. The attached slides demonstrate the proper manner to don and remove PPE so as to not cause contamination. The following are considered aerosol generating procedures: Bilevel Positive Airway Pressure (BiPAP), bronchoscopy, sputum induction, intubation and extubation, and open suctioning of airways. Once in the ICU, some experts recommend placing the patient in a negative pressure room. Restrictions on the transit of personnel (and minimization of visitors) in and out of the room, and proper use of PPE should limit potential exposures. Once a patient has been identified, exam rooms and ambulances should be decontaminated, and contaminated clothing should be double red bagged. According to the CDC: if a health care worker is potentially exposed to Ebola virus via percutaneous or mucocutaneous exposures to blood, body fluids, secretions, or excretions from a patient with suspected disease, they should stop working and immediately wash the affected skin surfaces with soap and water. Mucous membranes (e.g., conjunctiva) should be irrigated with copious amounts of water or eyewash solution, and the worker should immediately contact occupational health/supervisor for assessment and access to post exposure management services for all appropriate pathogens (e.g., Human Immunodeficiency Virus, Hepatitis C, etc.). If an asymptomatic healthcare worker had an unprotected exposure (i.e. not wearing recommended PPE at the time of patient contact or through direct contact to blood or body fluids) to a patient with an Ebola diagnosis, they should receive medical evaluation and follow-up care including supervised fever monitoring twice daily for 21 days after the last known exposure. The CDC maintains that this exposed individual may continue to work while receiving twice daily fever checks, based upon (emphasis added) hospital policy and discussion with local, state, and federal public health authorities. If a healthcare worker with possible exposure develops any symptoms consistent with Ebola infection, they should not report to work or should immediately stop working, notify their supervisor, seek prompt medical evaluation and testing, notify local and state health departments and comply with work exclusion until they are deemed no longer infectious to others. While there is no direct association between Ebola infection and the need for the Operating Room, if an infected patient requires an operative procedure, please see the attached Surgical Protocol for Possible or Confirmed Ebola Cases by Sherry M. Wren M.D., F.A.C.S., F.C.S. (ECSA) and Adam L. Kushner M.D., M.P.H., F.A.C.S. Thank you to Robin Stackhouse M.D., longtime chair of the Advisory Group for Infectious Diseases and member of the Occupational Health committee for her substantial contributions. Attachments: 1.Proper Donning and Removal of PPE 2.Transmission Based Precautions from the 3rd Edition of the ASA Recommendations for Infection Control 3.Surgical Protocol for Possible or Confirmed Ebola Cases References: 1.CDC Ebola Page: cdc.gov/vhf/ebola/ 2.CDC Ebola virus disease Information for Clinicians in U.S. Healthcare Settings: cdc.gov/vhf/ebola/hcp/clinician-information-us-healthcare-settings.html 3.CDC Health Alert Network: emergency.cdc.gov/han/index.asp 4.CDC information for Health Care Workers: cdc.gov/vhf/ebola/hcp/index.html 5.San Francisco General Hospital Infection Prevention & Control: Ebola Virus Disease Guidance 6.Ebola Preparedness Plan from Mayo Clinic Division of Infectious Diseases 7.The 2014 Ebola Outbreak. JAMA. 2014;312(14):1388. Proper Donning and Removal of PPE (Attachment 1) Transmission-Based Precautions (From ASA Recommendations for Infection Control, 3rd Edition) (Attachment 2) Modes of Transmission 1.Direct contact transmission This is the transmission of an infectious agent directly from 1 person to another. This may occur via contact of blood or secretions with mucous membranes, open cuts, or mites. 2.Indirect contact transmission This occurs when an infectious agent is transmitted via an intermediate object (fomite) that has been previously contaminated. This may include, but is not limited to patient-care devices, environmental surfaces, and clothing. 3.Droplet transmission This is a specific type of contact transmission. Droplets are formed when a person coughs, sneezes, talks, sings, and during endotracheal intubation and suctioning. Droplets are defined as being 5 m. They remain suspended for short periods and tend to be deposited within 3 feet of where they are generated. The distance that a droplet travels may be affected by factors such as temperature, humidity, and air currents. It is recognized, however, that the particle size of emitted respiratory secretions is a continuum from aerosol size particles (5 m) to droplets (5 m). Droplets are preferentially deposited in the upper airways, whereas aerosols penetrate deeper into the lower respiratory tract. 4.Airborne transmission This occurs with organisms that can remain infectious when disseminated over distance and time as the droplet nuclei (5m particles) are dispersed on air currents. Transmission Based Precautions Standard precautions These precautions reduce the risk of transmission of infectious agents from patient to patient, patient to health care worker (HCW), or HCW to patient. •Apply to all patients, as anyone may be infected or colonized with a transmissible disease. •Wear gloves for all contact with blood, body fluids (except sweat), non-intact skin, and mucous membranes. Change gloves when they become soiled or when contact with a clean body part follows that with a contaminated part. Remove gloves after patient contact. Minimize environmental contamination. •Perform hand hygiene before patient contact and upon removal of gloves. See section on hand hygiene. •Gown, face, and eye protection should be worn if there is a risk of splash or spray. •Environmental cleaning after contamination by body substances. •Use a standard surgical mask when inserting a central line or performing neuraxial anesthesia. •Needle and sharp safety: Avoid recapping (when necessary, use 1-handed technique), bending or breaking used sharps. Dispose sharps in appropriate puncture-resistant container. See safe injection practices section. •Practice and encourage respiratory hygiene/cough etiquette. Contact precautions (in addition to standard precautions) •Private patient room or cohort patients. Spatial separation of 3 feet between patients recommended. •Signage outside room to indicate level of precautions. •Gown and glove upon entering room and with any patient or environmental contact. •Face and eye protection if there is a risk of splash or spray. •Remove gloves and gown before exiting room. Care must be used to avoid self-contamination when removing personal protective equipment (PPE). •Perform hand hygiene after removal of PPE. •Dedicated patient equipment whenever possible. Appropriately clean equipment prior to its use with other patients. See “Disinfection of Equipment.” •Appropriate cleaning of room when vacated. •Maintain contact precautions during transport and entire perioperative period. •Communicate precaution level to those who will receive patient postoperatively. Droplet precautions (in addition to standard precautions) •Single patient room optimal. May cohort or with existing roommate when necessary. •Spatial separation of patients 3 feet. If curtain present, keep drawn. •Signage outside room to indicate level of precautions. •HCWs should wear standard surgical mask, gloves, gown, and eye protection as required under standard precautions. •Patient should wear standard mask (if tolerated) when transport outside room required. •Respiratory hygiene/cough etiquette. •Maintain precautions throughout perioperative period. •Communicate precaution level to those who will receive patient postoperatively. Airborne precautions (in addition to standard precautions) •Place patient in an airborne isolation room (AIIR). See “Glossary.” •Signage outside room to indicate level of precautions. •N95 respirator or greater protection should be used when in the patient’s room. •Patient should remain in AIIR with door closed at all times, except for medically necessary procedures. •Elective procedures should be postponed until patient no longer requires respiratory isolation. •Patients should wear a standard surgical mask when transported outside the AIIR. The purpose of the mask is to prevent respiratory droplets from being expelled into the environment where they can become droplet nuclei. •Operating rooms (ORs) are designed to be positive pressure in relation to the environment. Therefore, it is important to choose the most appropriate OR to minimize the risk of contaminating the OR suite. Options include the OR that is most remote from others, one with an antechamber, or one in which a portable negative pressure isolation chamber can be installed at the door. •The surgical procedure should be scheduled at a time when it will minimize exposure of other patients and medical staff to the airborne infectious disease. •Post-anesthesia recovery must take place with the same level of respiratory precautions •Communicate precaution level to receiving personnel. •Room should remain vacant after the patient leaves until adequate time has elapsed to result in a 99.9 percent air turnover (duration dependent on number of air exchanges per hour in room). Surgical Protocol for Possible or Confirmed Ebola Cases (Attachment 3) Sherry M. Wren MD, FACS, FCS (ECSA) and Adam L. Kushner MD, MPH, FACS Stanford University (Dr. Wren) Society of International Humanitarian Surgeons/Surgeons OverSeas (SOS) (Dr. Kushner) Ebola is an infectious disease caused by a filovirus (Ebola virus), whose normal host species is unknown. Infection can be potentially fatal and operating room personnel (nurses, surgeons, technicians, and anesthesia staff) all need to be aware of patients with possible or confirmed Ebola infection. Elective surgical procedures should not be performed in cases of suspected or confirmed Ebola. In cases where an emergency operation must be performed this protocol should be implemented to minimize risk to hospital personnel. The choice of operative approach (open or MIS) should take into consideration minimizing potential hazards to all members of the OR team. Although protocols for Personal Protective Equipment (PPE) are in place to protect health care workers, there is no guideline for operating room personnel and surgical providers who might need to perform an operation on a patient with confirmed or suspected Ebola infection, therefore we have adapted relevant Centers for Disease Control Recommendations and apply them specifically to the OR environment. PROTOCOL Patient Transport and Transfer to OR All healthcare providers should wear the following PPE to transport and transfer a patient to the OR with confirmed or suspected Ebola infection. •Gloves •Level 3 Association for the Advancement of Medical Instrumentation (AAMI) fluid resistant gown •Eye protection (goggles or face shield) •Facemask Surgical Checklist Suspected or confirmed Ebola status should be discussed in the pre and post operative briefing as an integral part of the Safe Surgery Checklist so all personnel are aware of potential risks of exposure. OR Staff Personal Protection Equipment Due to the significant risk of exposure to blood or bodily fluids all OR room personnel should wear: Personal Protective Gear •AAMI Level 4* Impervious Surgical Gowns •Leg coverings that have full plastic film coating over the fabric not just over the foot area. •Full face shield •Mask •Double gloves •Surgical Drapes AAMI Level 4* drapes should be used. *Level 4 AAMI rated gowns, drapes, and protective apparel demonstrate the ability to resist liquid and viral penetration in a laboratory test, ASTM F1671 (Standard test method for resistance of materials used in protective clothing to penetration by blood-borne pathogens using Phi-X174 bacteriophage penetration as a test system). Instrumentation and Sharps •Keep sharps to a minimum •Use instruments, rather than fingers, to grasp needles, retract tissue, and load/unload needles and scalpels •Give a verbal announcement when passing sharps •Avoid hand-to-hand passage of sharp instruments by using a basin or neutral zone that has been agreed upon at the case start •Use alternative cutting methods such as blunt electrocautery •Substitute endoscopic surgery for open surgery when possible •Use round-tipped scalpel blades instead of pointed sharp-tipped blades •Use elctrocautery preferentially to scalpel for incisions •No needles or sharps on the Mayo stand •No recapping of needles •Use blunt tip suture needles when possible •Continue “sharps safety” techniques during OR table clean up post procedure OR Staff Exposure (adapted from CDC guidelines) Persons with percutaneous or mucocutaneous exposures to blood, body fluids, secretions, or excretions from a patient with suspected or confirmed Ebola should: •Stop working and immediately wash the affected skin surfaces with soap and water. •Mucous membranes (e.g., conjunctiva) should be irrigated with copious amounts of water or eyewash solution •Immediately contact Infectious Disease consultant in your hospital for post exposure evaluation. Guideline Creation Version 1 October 6, 2014 References cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf cdc.gov/sharpssafety/resources.html cdc.gov/vhf/ebola/hcp/infection-prevention-and-controlrecommendations.html Reply, Reply All or Forward | More Click to reply all Send
Posted on: Fri, 10 Oct 2014 01:16:18 +0000
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