Perioperative COVID-19 Defense: An Evidence-Based Approach for Optimization of Infection Control and Operating Room Management

Franklin Dexter, MD, PhD, FASA; Michelle C. Parra, MD; Jeremiah R. Brown, PhD; Randy W. Loftus, MD


Anesth Analg. 2020;131(1):37-42. 

In This Article

Abstract and Introduction


We describe an evidence-based approach for optimization of infection control and operating room management during the coronavirus disease 2019 (COVID-19) pandemic. Confirmed modes of viral transmission are primarily, but not exclusively, contact with contaminated environmental surfaces and aerosolization. Evidence-based improvement strategies for attenuation of residual environmental contamination involve a combination of deep cleaning with surface disinfectants and ultraviolet light (UV-C). (1) Place alcohol-based hand rubs on the intravenous (IV) pole to the left of the provider. Double glove during induction. (2) Place a wire basket lined with a zip closure plastic bag on the IV pole to the right of the provider. Place all contaminated instruments in the bag (eg, laryngoscope blades and handles) and close. Designate and maintain clean and dirty areas. After induction of anesthesia, wipe down all equipment and surfaces with disinfection wipes that contain a quaternary ammonium compound and alcohol. Use a top-down cleaning sequence adequate to reduce bioburden. Treat operating rooms using UV-C. (3) Decolonize patients using preprocedural chlorhexidine wipes, 2 doses of nasal povidone-iodine within 1 hour of incision, and chlorhexidine mouth rinse. (4) Create a closed lumen IV system and use hub disinfection. (5) Provide data feedback by surveillance of Enterococcus, Staphylococcus aureus, Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter spp. (ESKAPE) transmission. (6) To reduce the use of surgical masks and to reduce potential COVID-19 exposure, use relatively long (eg, 12 hours) staff shifts. If there are 8 essential cases to be done (each lasting 1–2 hours), the ideal solution is to have 2 teams complete the 8 cases, not 8 first case starts. (7) Do 1 case in each operating room daily, with terminal cleaning after each case including UV-C or equivalent. (8) Do not have patients go into a large, pooled phase I postanesthesia care unit because of the risk of contaminating facility at large along with many staff. Instead, have most patients recover in the room where they had surgery as is done routinely in Japan. These 8 programmatic recommendations stand on a substantial body of empirical evidence characterizing the epidemiology of perioperative transmission and infection development made possible by support from the Anesthesia Patient Safety Foundation (APSF).


Anesthesia professionals are poised to address the coronavirus disease 2019 (COVID-19) pandemic as they lead the global dissemination of an evidence-based, perioperative infection control program that can generate substantial reductions in perioperative pathogen transmission and associated infection development. Our programmatic recommendations stand on a substantial body of empirical evidence characterizing the epidemiology of perioperative transmission and infection development made possible by grant support from the Anesthesia Patient Safety Foundation (APSF) for studies conducted at Iowa, Dartmouth, and UMass Memorial Medical Center. Our specialty has acquired extensive expertise that yields preparedness for this pandemic. Prevention of pathogen transmission events is of paramount importance, especially considering limitations in availability of personal protective equipment (PPE) that we are currently facing.

Through ongoing collaboration with Dr Jeremiah Brown (Professor of Epidemiology at Dartmouth) and Randy Loftus (Associate Professor of Anesthesia at Iowa), we recommend and are prepared to assist with rapid adaption of a planned approach to attenuate perioperative transmission (section "Evidence-Based Perioperative Infection Control"). Through widespread adoption of these evidence-based approaches,[1] we can better protect our patients and our health care coworkers.

A simultaneous and related concern is operating room (OR) management considerations for patients without confirmation of COVID-19. In most US hospitals, routine COVID-19 testing is impractical, so that many if not all patients could be at high risk of viral carriage community spread. This could lead to environmental contamination and subsequent patient and provider workspace exposure. Dr Franklin Dexter outlines an evidence-based approach for perioperative management of such patients in section "OR Management Strategies in the COVID-19 Era."

In addition, in the near future, we will

  1. provide a video demonstrating this multifaceted perioperative infection control bundle and

  2. host a webinar for institutional implementation coaching. We, with the help of the Anesthesia Patient Safety Foundation (APSF) and American Society of Anesthesiologists (ASA), are committed to bringing all clinicians the tools to improve perioperative infection control.

Note: Our goal is to prepare the perioperative arena (preoperative, intraoperative, and postoperative) for optimized care of patients and provider protection (section "Evidence-Based Perioperative Infection Control") and for strategic OR management of patients who remain asymptomatic and are unaware of known exposures (section "OR Management Strategies in the COVID-19 Era"). While our recommendations can be applied to operative care of patients suspected or known to be infected with COVID-19, these patients represent only the tip of the iceberg. Testing every patient for COVID-19 has economic and logistic considerations that are likely to be unachievable in the short term and unsustainable for the long term. Even after establishing effective control of viral transmission over the next few months, we will need to be prepared for ongoing infections and resurgence as we resume normal operations involving the care of a wide variety of patients undergoing elective surgery.