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

Roadmap to Evidence-based Perioperative Infection Control

Note: Recommendations for positioning of equipment are evidence-based and should be utilized.[1]

Step 1: Hand Hygiene

  1. Leverage proximity to the provider: Place alcohol-based hand rubs on the intravenous (IV) pole to the left of the provider.[20] If alcohol-based hand gel or foam is not available, use chlorhexidine wipes and/or a dilute ethanol solution. There are over 350 hand decontamination opportunities during routine, intraoperative patient care.[18] Perioperative care has a high task-density that threatens hand hygiene compliance, especially during induction and emergence of anesthesia.[18] These are critical periods for viral and bacterial transmission to the surrounding patient environment. Using this approach will increase hand decontamination events 20-fold.[20]

  2. Double glove during induction: Intubation is associated with transmission of particles in a simulated environment.[21] Double gloving can reduce transmission in a simulated environment.[21] Place dirty equipment in the zip lock bag in the wire basket (see below) and seal.

Step 2: Environmental cleaning: Improve organization and increase frequency and quality of cleaning.[22] This approach will substantially reduce the overall contamination of the work area.

Organization: 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 (ie, laryngoscope blades and handles) and close. Designate and maintain clean and dirty areas.

Frequency: After induction of anesthesia, wipe down all equipment and surfaces with disinfection wipes that contain a quaternary ammonium compound and alcohol. Confirm your hospital's selected wipes have antiviral activity.

Quality: For improved routine and terminal cleaning, using a top-down approach, spray all surfaces and the anesthesia and circulating nurse work space—including but not limited to keyboards and mice—with a quaternary ammonium compound and wait the required time per agent utilized (typically 1–3 minutes). Then wipe with a dry microfiber cloth. This cloth should then be laundered. Wipe all surfaces and equipment again with the designated quaternary ammonium and alcohol surface disinfection wipes used above. This cleaning sequence is critical for achieving adequate bioburden reduction.

UV-C: Treat at-risk rooms defined by your hospital's surveillance. These treatments are typically 20–30 minutes and can be focused on the high-risk anesthesia work area and should also include the circulating nurse desk area that is likely to be contaminated and often excluded from cleaning procedures. If UV-C is not available, use the above cleaning process for a more extensive cleaning approach to at-risk environments (enhanced terminal cleaning). If your hospital does not have a surveillance process in place, use surveillance described below to guide strategic targeting.

Step 3: Patient decolonization: Patients are a proven reservoir of transmission, an obvious concern in the setting of COVID-19.[13–16] Respiratory secretions and droplets, resulting in direct (aerosolization during intubation) or indirect (contamination of surfaces followed by contact and transmission to eyes, nose, and/or mouth) modes of transmission, can lead to infection.[2–4] Microbes, viruses and bacteria, colonize our skin.[2–4] Apply standard PPE during procedures (N95 mask, gown, gloves, eye protection) for known cases. For known patients and/or patients with risk of exposure (presumptive positive, see surveillance below), use preprocedural chlorhexidine wipes, 2 doses of nasal povidone-iodine within 1 hour of incision, and chlorhexidine mouth rinse. Both agents have broad activity against bacteria and viruses that will serve to protect patients and providers from subsequent transmission. This approach (chlorhexidine wipes, nasal povidone-iodine, and chlorhexidine oral rinse) can be applied after patient induction/stabilization for emergent procedures.

Step 4: Vascular care: Intravascular catheters are in direct contact with the patient's intravascular space with contamination repeatedly associated with increased mortality and directly linked to infection.[7,8] Create a closed lumen IV system.[23,24] Open lumens should be outfitted with needleless, disinfectable devices, as open lumens are associated with increased risk of transmission compared to properly disinfected ports.[23] Improved hub disinfection reduces transmission to the patient and reduces infections.[24] Leverage proximity to the provider: place evidence-based disinfection caps for syringe and hub disinfection on the IV pole to the left of the provider.[24] Keep syringes free of the contaminated environment, disinfected, and ready for use. Scrub all ports before injection and keep covered with disinfecting caps during and after the procedure.

  • Steps 1–4 above are for hospitals in this moment to improve perioperative infection control. The additional step below is for ongoing support of perioperative transmission control.

Step 5: Surveillance: All the above interventions are behavioral with variable compliance, prone to failure, and therefore require data feedback for maintenance of fidelity. This requires the use of evidence-based surveillance for system optimization and sustainability.[14–17] We currently use Enterococcus, S. aureus, Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter spp. (ESKAPE) transmission as a fidelity marker for basic measures. This could be rapidly extended to COVID-19 with government and industrial participation.

Summary. Every anesthesia provider can start with steps 1–4. These are simple, evidence-based interventions designed and proven to protect patients and providers. This is especially critical given PPE deficits, community-associated spread of current pathogens, and likely ongoing transmission events. We should target these steps (1–4) and then proceed to a robust program of ongoing diligence and surveillance (step 5).