Infection Prevention Precautions for Routine Anesthesia Care During the SARS-CoV-2 Pandemic

Andrew Bowdle, MD, PhD, FASE; Srdjan Jelacic, MD, FASE; Sonia Shishido, DO; L. Silvia Munoz-Price, MD, PhD


Anesth Analg. 2020;131(5):1342-1354. 

In This Article

Abstract and Introduction


Many health care systems around the world continue to struggle with large numbers of SARS-CoV-2–infected patients, while others have diminishing numbers of cases following an initial surge. There will most likely be significant oscillations in numbers of cases for the foreseeable future, based on the regional epidemiology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Less affected hospitals and facilities will attempt to progressively resume elective procedures and surgery. Ramping up elective care in hospitals that deliberately curtailed elective care to focus on SARS-CoV-2–infected patients will present unique and serious challenges. Among the challenges will be protecting patients and providers from recurrent outbreaks of disease while increasing procedure throughput. Anesthesia providers will inevitably be exposed to SARS-CoV-2 by patients who have not been diagnosed with infection. This is particularly concerning in consideration that aerosols produced during airway management may be infective. In this article, we recommend an approach to routine anesthesia care in the setting of persistent but variable prevalence of SARS-CoV-2 infection. We make specific recommendations for personal protective equipment and for the conduct of anesthesia procedures and workflow based on evidence and expert opinion. We propose practical, relatively inexpensive precautions that can be applied to all patients undergoing anesthesia. Because the SARS-CoV-2 virus is spread primarily by respiratory droplets and aerosols, effective masking of anesthesia providers is of paramount importance. Hospitals should follow the recommendations of the Centers for Disease Control and Prevention for universal masking of all providers and patients within their facilities. Anesthesia providers should perform anesthetic care in respirator masks (such as N-95 and FFP-2) whenever possible, even when the SARS-CoV-2 test status of patients is negative. Attempting to screen patients for infection with SARS-CoV-2, while valuable, is not a substitute for respiratory protection of providers, as false-negative tests are possible and infected persons can be asymptomatic or presymptomatic. Provision of adequate supplies of respirator masks and other respiratory protection equipment such as powered air purifying respirators (PAPRs) should be a high priority for health care facilities and for government agencies. Eye protection is also necessary because of the possibility of infection from virus coming into contact with the conjunctiva. Because SARS-CoV-2 persists on surfaces and may cause infection by contact with fomites, hand hygiene and surface cleaning are also of paramount importance.


Some health care systems continue to struggle with large numbers of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)–infected patients, but epidemiologic models[1] have predicted that many others will be faced with a lower but variable prevalence of disease. The time course of the pandemic is unpredictable, and there is the possibility that the SARS-CoV-2 virus could become endemic, as with some other coronaviruses.[2,3] The virus will produce significant recurrent outbreaks of infection until there is "herd immunity"a [4] from broad application of a vaccine or until a sufficient proportion of people have been infected naturally, assuming that there is a long-lasting and protective immune response. Despite the lack of herd immunity, less affected facilities are progressively resuming elective procedures. In some instances, procedural volumes and anesthesia workload may be even larger than before the SARS-CoV-2 pandemic due to a worldwide backlog of approximately 28 million procedures that were delayed in preparation for the surge of patients infected with SARS-CoV-2.[5] Delays in performing nonurgent surgery have resulted in both hardship for patients and lost revenue for health care facilities and providers.

Among the challenges will be protecting patients and providers from recurrent outbreaks of disease while increasing procedure throughput. We present here an approach to routine anesthesia care in the setting of variable prevalence of SARS-CoV-2 infection. We should emphasize that the approach we describe applies to patients who are not known or suspected to be infected with SARS-CoV-2. Patients known or suspected of being infected require a more elaborate approach, as previously described.[6–9]

In response to the human immunodeficiency virus (HIV) epidemic during the early 1980s, the Centers for Disease Control and Prevention (CDC) encouraged a policy of "Standard Precautions," which were outlined in a guidance document. As reported by the CDC, "The 1987 document recommended that blood and body fluid precautions be consistently used for all patients regardless of their bloodborne infection status. This extension of blood and body fluid precautions to all patients is referred to as 'Universal Blood and Body Fluid Precautions' or 'Universal Precautions.' Under universal precautions, blood and certain body fluids of all patients are considered potentially infectious for HIV, hepatitis B virus (HBV), and other bloodborne pathogens."[10] A key feature of these recommendations is that all patients are considered to be potentially infected. The universal precautions approach, now more commonly known as standard precautions, recognizes the imperfections of testing for disease, including limitations in the availability of testing and falsely negative test results, which may occur for a variety of reasons. Today, most health care providers routinely practice standard precautions against bloodborne infection, such as the wearing of nonsterile examination gloves to prevent contact with blood and other fluids and prevention of needle stick injuries.

Before the SARS-CoV-2 pandemic, most anesthesia providers infrequently experienced the need for precautions against transmissible respiratory infectious organisms, the most common examples being tuberculosis and seasonal influenza. However, the SARS-CoV-2 pandemic is only the most recent of a series of novel respiratory virus epidemics that have occurred in the 21st century (SARS-CoV, 2003; H1N1 influenza, 2009; Middle East respiratory syndrome coronavirus [MERS-CoV], 2012). We are now faced for the foreseeable future with the need for an approach not only to bloodborne threats such as HIV and hepatitis viruses but also to respiratory disease threats, especially SARS-CoV-2. Should we practice respiratory precautions for anesthesia care, that are analogous to "standard bloodborne precautions"? Should we implement certain respiratory precautions for the duration of the SARS-CoV-2 pandemic or even beyond the pandemic?

We would argue that the answer to these questions is "Yes, we should practice certain respiratory precautions for the duration of the SARS-CoV-2 pandemic." Our knowledge of SARS-CoV-2 virology and epidemiology is evolving rapidly, and a comprehensive review is beyond the scope of this article. However, there are several key aspects of SARS-CoV-2 infection to consider. First, SARS-CoV-2 is spread by respiratory droplets (≥5 μm), by contact with fomites, and by airborne transmission (<5 μm; ie, droplet nuclei).[11–13] In all likelihood, there is a continuum of droplet and airborne spread of many respiratory pathogens.[14–16] While the relative importance of airborne spread for SARS-CoV-2 is unknown, aerosolizing procedures, such as airway management, are thought to increase the risk of airborne spread of respiratory viruses.[17–19] Second, there is evidence that SARS-CoV-2 can be spread by asymptomatic and presymptomatic patients.[20–23] A substantial portion, if not the majority, of infected persons are asymptomatic.[22,24,25] Third, testing for SARS-CoV-2 infection is problematic because of the limited availability of testing in many places and false-negative results.[26,27] While the rate of false-negative tests is uncertain and may vary greatly depending on the particular circumstances, available evidence suggests that this frequency could be substantial.[26–34] Given the possibility of airborne spread and the practical difficulty of determining who is infected, we propose a strategy similar to standard bloodborne precautions. For the time being, we should assume that any patient may be infected with SARS-CoV-2.

We should evolve precautions that are practical, affordable, and efficient in the anesthesia setting while considering the limited availability of personal protective equipment (PPE). At the same time, we should strive to improve the supply of PPE. In Table 1, we have proposed options for respiratory precautions that can be applied to all patients during anesthesia care, along with examples of evidence in support of the effectiveness of the proposed precautions, where evidence is available. In addition, explanations for our proposal are given below.

aThe term herd immunity has been used in a variety of ways but generally implies the proportion of a population that must be immune for person-to-person transmission of an infectious disease to be prevented. Such immunity could occur either from vaccination or prior exposure to the disease or both.