Preventing Transmission of COVID-19 in Intensive Care

Tracheostomy –

Tracheotomy in ventilated patients with COVID-19: Guidelines from the COVID-19 Tracheotomy Task Force, a Working Group of the Airway Safety
Committee of the University of Pennsylvania Health System, published in Annals of Surgery

Indication – Tracheotomy may be considered in patients with prolonged periods of intubation, defined as greater than 21 days, who are otherwise without significant comorbidities and would be expected to have a good prognosis if recovery is achieved.

Pre-Procedure – Rule out whether the patient is still positive or negative by performing PCR and/or CT chest. Informed consent must be obtained from NOK.

Location
The procedure should be performed at bedside in a negative pressure room to minimize the risk of transmission during patient transport, if feasible.

Personnel
Minimise exposure- max 3 people in the room.

PPE-

Proper donning and doffing of PPE for each person in the room is essential.
o As a tracheotomy is considered an aerosol-generating procedure, airborne and droplet precautions should be followed.
o Each person should wear a head covering, a powered air-purifying respirator (PAPR), gown, and gloves. If a PAPR is not available, it is strongly recommended to delay the procedure.

Percutaneous dilational tracheostomy

• The patient should be fully paralyzed to minimize cough reflex during airway entry
• A disposable percutaneous dilational tracheotomy kit should be used, as well as a disposable flexible bronchoscope with monitor
• If the patient has very favourable anatomy, performing the procedure without the use of bronchoscopic guidance may be considered.
• For patients undergoing the bronchoscopic-assisted approach, ventilation should be held when the bronchoscope adaptor is added to the circuit.
• The hypopharynx should be packed and a Yankauer suction placed in the mouth to reduce aerosols when the ETT is high with the balloon at or above the glottic aperture.
• Ventilation should be held prior to adequate minimal cuff deflation to retract the ETT to the point of insertion site visualization, and the cuff re-inflated prior to resuming ventilation.
• If tolerated, ventilation should be held prior to the insertion of the dilator until the tracheostomy tube is in place, the cuff is inflated, and the tube is connected to a closed circuit.
• Tube placement should be confirmed with end-tidal CO2 and appropriately secured.

Post procedure –

• A viral filter should be used in line with the ventilator circuit.
• Closed in-line suctions should be used
• Disposable inner cannulas should be disposed of and replaced per the manufacturer’s guidelines. They should not be cleaned and replaced
• Even after ventilator weaning, a closed system, such as a heat-moisture exchange device with a viral filter, should be used to minimize aerosolized secretions. Trach collar should be avoided.
• Tracheotomy tube change should be deferred until the patient is no longer infectious after consultation with the Infectious Disease team.

CPR – Edelson et al.: Interim Guidance for Life Support for COVID-19

Reduce provider exposure
● Don PPE before entering the room/scene
● Limit personnel
● Consider using mechanical CPR devices for adults and adolescents who meet height and weight criteria
● Prioritize oxygenation and ventilation strategies with lower aerosolization risk
● Use a HEPA filter, if available, for all ventilation
● Intubate early with a cuffed tube, if possible, and connect to mechanical ventilator, when able
● Engage the intubator with highest chance of first-pass success
● Pause chest compressions to intubate
● Consider the use of video laryngoscopy, if available
● Before intubation, use a bag-mask device (or T-piece in neonates) with a HEPA filter and a tight seal
● For adults, consider passive oxygenation with a nonrebreathing face mask as an alternative to the bag-mask device for a short duration
● If intubation delayed, consider supraglottic airway
● Minimize closed-circuit disconnections
Consider resuscitation appropriateness
● Address goals of care
● Adopt policies to guide determination, taking into account patient risk factors for survival

Intubation –

1.         Intubation should be carried out in a well-planned manner. All essential equipment must be in full readiness before you start.

2.         Don adequate PPE including water-resistant gowns, gloves, fit-tested N95 masks or higher, goggle or face shields, and cap.

3.         Not more than three healthcare personnel should be by the bedside to carry out intubation. One staff member should administer medications while the other assists with intubation and monitors the patient during the procedure. The person who performs the intubation must be the most experienced with airway management in the team.

4.         A vasopressor infusion (e.g., noradrenaline, 4 mg/50 ml) must be set up and ready to infuse in case of hypotension after the administration of anesthetic agents.

5.         Use a bag-mask system to pre-oxygenate to ensure maximal oxygen saturation prior to the administration of anesthetic drugs.

6.         To reduce air leak, the mask must be held tightly across the face with both hands. Do not attempt positive pressure ventilation with bag and mask if possible; if considered absolutely necessary, the assistant carries out insufflations. 

7.         Once the patient is asleep, suxamethonium 1.5 mg/kg or rocuronium 1.2 mg/kg is administered for muscle relaxation. Ensure adequate muscle relaxation before attempts at laryngoscopy. 

8.         A video laryngoscope is preferred if the operator is skilled, as it reduces the proximity of the operator to the airway compared to direct laryngoscopy.

9.         It is important to get it right the first time; failed attempts are associated with increased risks of transmission of infection to staff. Intubate with a 7.0 or 7.5 mm ID endotracheal tube in female patients and 8.0 or 8.5 mm ID endotracheal tube in male patients.

10.       Do not apply positive pressure before cuff inflation; this may cause a significant leak around the cuff and contamination.

11.       Perform in-line suction to prevent the spread of aerosol; do not perform open suctioning. 

12.       If necessary, draw samples for virology during suctioning.

13.       Carry out careful doffing of personal protective equipment after the procedure.

USG & Echocardiography –

Use standard PPE in a suspected case, including N95 masks

Use a probe sleeve

Assume every patient has COVID-19, and clean and disinfect the equipment after use

Low level disinfection for procedures where skin is intact. High level disinfection where probe is incontact with body fluid e.g TOE

Low level disinfection include cleaning with wipes using viraclean.

High level disinfection includes cleaning with wipes, soaks, hydrogen peroxide mist and in extreme situations UV-C cleaning.

Further reading- Prevention of pathogen transmission during ultrasound use in the Intensive Care Unit: Recommendations from the College of Intensive Care Medicine Ultrasound Special Interest Group (USIG)