Caroline Helwick

October 16, 2014

NEW ORLEANS — Anesthesiologists can be counted on to properly staff and safely care for patients with Ebola, and they should be key players in planning for this possible, though unlikely, scenario at their hospitals, according to one anesthesiologist with experience with these challenges.

With the latest transfer of an infected Dallas nurse, Emory University physicians and nurses have now cared for four patients infected with the Ebola virus.

"The Department of Anesthesiology prepared for our potential participation in their care by identifying services that might be needed, recruiting and training a core group of on-call anesthesiologists, using a defined operations plan, and collaborating closely with the patients' care team," said Matthew Klopman, MD, director of anesthesiology operations at Emory University Hospital in Atlanta.

"Overall, this resulted in minimal impact on the care of other patients in the facility," he reported.

Anesthesiologists were involved in airway management, vascular access services, and intraoperative or procedural anesthetic services.

Dr Klopman emphasized that participation in patient care was strictly voluntary. Although a few providers said, "absolutely not under any circumstances," more than half were very willing, he said.

Emory has one of four biocontainment units in the United States, and is equipped to isolate patients with dangerous infectious diseases.

Biocontainment Units

The other units are at the National Institutes of Health in Bethesda, Maryland; Nebraska Medical Center in Omaha; and St. Patrick Hospital in Missoula, Montana.

Dr Klopman described his team's involvement in planning for the arrival of the Ebola-infected patients here at Anesthesiology 2014. They focused on ensuring adequate voluntary staff, obtaining the appropriate supplies and equipment and using them safely, and dealing with decontamination challenges.

"When we received notification that we were getting the first two patients, as you can imagine, the hospital jumped into a very urgent and serious planning session," he said. Although an infectious disease committee had developed protocols years ago, they had never been activated.

"When questions arose as to who would intubate patients and provide vascular access, the planning broadened to include our department for these and other services that might be necessary," he said.

"To provide for emergent airway management, it was determined that training all on-call anesthesia providers to assist a patient would be problematic. Therefore, we recruited a core group of faculty member volunteers based on their presence in the hospital on a weekly basis," he explained.

Altogether, three providers each were on call for assistance with airway management, if required, and two back-up providers (Dr Klopman and the department chair) were available for additional 24/7 coverage. Although many providers volunteered for this mission, the department chose to minimize staff disruptions and train individuals most likely to be at the hospital anyway.

Training involved 2 hours of instruction in donning and removing personal protection equipment and in protocols for safely entering and exiting patient isolation rooms. The group "went a few steps beyond" recommendations from the Centers for Disease Control and Prevention, he said. They followed the highest level of protection and incorporated observers to monitor staff for safety breaches from the beginning.

Dr Klopman said one of the specific challenges in planning for invasive vascular access was how to safely incorporate an ultrasound machine. "We wanted ultrasound, not only to ensure rapid cannulation of the vessel, but also to allow one's nonoperative hand to be as far away from the sharp end of the needle as possible," he said. "If this meant sacrificing an ultrasound machine, we were going to do that."

Changing Protocols

"We thought a C-arm tray would be a novel way to drape the ultrasound machine, but in collaboration with our biosafety expert, the fear arose that, should the ultrasound system or the drape over it become contaminated, the process of removing that drape could spread contaminants and increase the danger to the providers in the room," he explained.

The decision was made to use the ultrasound system conventionally, on the rolling cart, with a sterile probe cover. The device remained in the patient's room until the patient was discharged. At that point, the entire unit was decontaminated with vaporized hydrogen peroxide, an electronics-compatible disinfecting method.

In addition, a cart containing all equipment and supplies necessary for vascular access was prepared and readily available. If a patient required surgery, all necessary equipment would be brought to the patient's room. Anesthesia would be provided using total intravenous anesthetic techniques and an intensive care unit ventilator, he said.

The anesthesia providers wore thick gloves and avoided the use of glass ampules, which might shatter and puncture the gloves. They took particular care when handling sharp objects, he said.

All anesthesiology departments should be prepared to treat Ebola patients, as they are for other infections, said ASA President John Abenstein, MD, who is associate professor of anesthesiology at the Mayo Clinic in Rochester, Minnesota.

These hospitals are experienced and particularly well equipped; however, transferring patients has associated risks.

"There are many infectious diseases that we are potentially faced with every day — such as tuberculosis and hepatitis B and C — that can cause serious disease in our patients and staff," he told Medscape Medical News. "All departments and all staff must be prepared to care for patients with serious infectious diseases, including Ebola."

"It will always be difficult, if not impossible, to predict when and where such patients will arrive for treatment," he explained. "At the Mayo Clinic, we are preparing our staff to treat these patients. Careful attention to detail is required to safely care for them."

When asked whether all Ebola-infected people should be transferred to one of the four designated biocontainment units, at least at this point, Dr Abenstein noted that such facilities are particularly well positioned to care for these patients, but transfer carries risks.

"These hospitals are experienced and particularly well equipped; however, transferring patients has associated risks to the patient and staff, and the decision to transfer a patient is best left to the physicians at the receiving facility and their colleagues at the disaster-prepared hospital," he said.

The American Society of Anesthesiologists' Committee on Occupational Health issued a statement on Ebola information and recommendations on October 8.

In the statement, guidance on surgical safety is provided by Sherry Wren, MD, from Stanford University in California, and Adam Kushner MD, MPH, from the Society of International Humanitarian Surgeons and Surgeons OverSeas. They indicate that elective surgical procedures should not be performed in cases of suspected or confirmed Ebola infection, and they provide a protocol to be followed in emergencies.

"Although protocols for personal protective equipment are in place to protect healthcare 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."

Dr Klopman, Dr Abenstein, Dr Wren, and Dr Kushner have disclosed no relevant financial relationships.

Anesthesiology 2014 from the American Society of Anesthesiologists (ASA): Abstract LBC02. Presented October 13, 2014.


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