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

Evidence-based Perioperative Infection Control

Confirmed modes of viral transmission (eg, influenza A and severe acute respiratory syndrome [SARS]) are primarily but not exclusively contact with contaminated environmental surfaces (fomites) and aerosolization.[2–4] Viral pathogen survival on environmental surfaces extends for several days; COVID-19 can survive for at least 3 days on a variety of materials commonly encountered in ORs (eg, stainless steel, plastic).[5] Usual OR and recovery cleaning practices, especially for noncritical items such as near bedside equipment, are often inadequate.[6–8] This is a significant issue for both patients and providers because of current cleaning failures and/or lapses in practice that increase the risk of cross-contamination during patient care.[5–8]

Evidence-based improvement strategies for attenuation of residual environmental contamination involve a combination of deep cleaning with surface disinfectants and ultraviolet light (UV-C).[9–11] UV-C is proven to reduce bacterial and viral contamination across a variety of health care settings by addressing both surface and air column disinfection,[9,10] and this technology has been shown to reduce the incidence of both bacterial and viral health care–associated infections (HAIs).[10] Consensus however is that improved cleaning should include both surface disinfection and UV-C approaches because UV-C alone may be limited by shadowing (areas of the room that the UV-C light does not reach).[11] Similarly, surface disinfection procedures (ie, deep terminal cleaning) should also be supplemented with UV-C or equivalent technology because of human factors resulting in cleaning failure.[12]

While environmental cleaning is an important infection control consideration, our evidence-based approach for perioperative COVID-19 control should leverage a comprehensive understanding of the epidemiology of transmission for our health care arena. The epidemiology of intraoperative pathogen transmission is well characterized.[6–8] The incidence of Staphylococcus aureus transmission (a common cause of surgical site infections [SSIs]) is reported to be as high as 39% for the general perioperative arena.[13,16] Perioperative S. aureus transmission events are tightly associated with SSI development with 50% of S. aureus SSIs linked by whole-cell genome analysis to one of more intraoperative reservoirs.[14] Similarly, isolation of one or more Klebsiella, Acinetobacter, Pseudomonas, or Enterobacter (KAPE) pathogens from one more intraoperative reservoirs are associated with increased risk of a Gram-negative HAI development.[17] Intraoperative bacterial transmission relates to nadirs in hand hygiene compliance that occur during induction and emergence of anesthesia and correlate with peaks in environmental contamination.[18] As such, single modality improvement strategies (ie, hand hygiene alone) have been associated with a trend toward increased risk of infection.[19] Hand hygiene, while an important preventive measure, should not stand alone for control of perioperative spread of COVID-19. It is insufficient.

The solid foundation of published evidence generated during the past 12 years indicates that a multimodal approach is indicated to maximally attenuate high-risk intraoperative pathogen transmission events. Improved hand hygiene, environmental cleaning, vascular care, patient decolonization, and surveillance optimization should be used in parallel during the process of patient care as a multifaceted approach to improved perioperative infection control for both bacterial and viral pathogens.[7,8,13,17] The approach should involve improved provider hand hygiene leveraging proximity to the provider, improved frequency and quality of environmental cleaning, targeting of high-risk environments with UV-C, improved vascular care, improved patient decolonization, and surveillance optimization.