UAB COVID-19 Cesarean Section OR Management Step-By-Step · 2020-03-29 · COVID-19 Cesarean Section OR Management ... • Prepare all equipment outside room-take your time-be purposeful

UABCOVID-19CESAREANSECTIONORMANAGEMENT

©2020,TheBoardofTrusteesoftheUniversityofAlabamafortheUniversityofAlabamaatBirmingham

COVID-19CesareanSectionORManagement

• Documentwillbeupdatedasneeded.

• RefertoORsimulationvideoforreference.

Non-intubatedL&DpatientsforC-section

EncourageOBtocommunicatepotentialforCSearly

ApositiveorsuspectedinfectionwithCovid-19isnotacontraindicationtoneuraxialanalgesia/anesthesia

Anesthesiapersonnel(max2)towaitinORforpatientregardlessofurgencyofCS

STATCS=decision-to-incisiontimeof<30minutes

Limitroutineuseofoxygenvianasalcannulaorfacemaskunlessmedicallynecessaryformotherorfetus

Ifnecessary,attempttouselowflows(ptshouldwearaproceduralmaskovertheNCorfacemask)

Ventilatedtransportpatients-HMEfilteronventisinproximalendofcircuit.Specialprecautionsneedtobemadeifanesthesiamachinehastobeused.1stchoice-utilizeICUvent.

o Clamptubeafterexpirationo Allowcircuittodecompresso DisconnectandimmediatelyplaceFilteredcircuitonETT

o Unclampcircuit

Inductionsite:WICOR3ifpossible

• Patientshouldbewearingsurgicalmask-transportedfromfloorutilizingrecommendedHighRiskPPE-Refertoreferencedtransportguidelinesatendofdocumentifbaggingptordirectcontactanticipated

o Bouffanthato Isolationgowno N95masko Doublegloveo Faceshield

• Suppliesneeded:Appliestoallairwaycalls

o InWICOR

§ Airwaytray-respiratorycodetraycontents

• DisposableHandle-Mil3,MAC3&4-placeinairwaybagoutside.Lowlikelihoodtoneed.

• ETT-7-8.5

• 1in.tape

• 10ccsyringeforcuff



• Bougi(tubeexchanger)

• Stylette

• EtC02detector

• Med(yellow)oralairway

§ Anesthesiamedications-AnesthesiaCareTeam(ACT)andcasedetermined,recommendations:

• Lidocaine1%

• Inductionmed-Propvs.Etomidatevs.Ketamine

• Succvs.RSIdoseRoc.

• Epinephrine-10mcg/mlsyringe-highriskcardiaccollapse

• Phenylephrinesyringe

• Ephedrinesyringe

• Outsidereadilyavailable

o Albuterolinhalero Intubationmedkito Considerdrugtray1&2

§ HMEviralfilterfromanesthesiacircuit§ CMACwith#3#4blade§ Bag-valvemaskpreparedwithHMEthenEtC02indicator§ Suction§ Several(4recommended)disposableimperviouschucks§ Clearplasticdrape-4x4plastic§ Nostethoscope-Potentialriskofself-contamination§ EtC02gasmonitor§ Hovermattobeplacedunderneathpatientpriortoinductionforpatientsover300lbs.

Needtominimizeairflowofcontaminatedpt.§ Inlinesuctioncatheterfromrespiratory§ EyecareandTheratears§ ConsiderETTtubeclamp(paddedlargeclamps)§ BiohazardZiplockbags§ Nervestimulator-verifynotwitchafterinduction§ Minimalanesthesiacartutilized-seerecommendeditemsaddendum§ FullystockedcartoutsideOR

o LaborEpiduralconversion § Either3%chloroprocainevs2%lidocainewithepinephrineandbicarb

o SAB/CSE§ spinal/CSE kit§ Medications

o Outsideroom



§ Isolationdoorsignagewillincludedonning/doffingPPE§ IsolationcartwithappropriatePPE§ Additionalairwayequipmentinairwaybag

• AirQLMA3.5,4.5,5.5

• PusherstyletforAirQ

• Disposablelaryngoscopesfromresp.tray

• Abovementionedmedications

• Fullystockedanesthesiacart

• GeneralAnesthesiaCaseallORstaffpresentdonHighRiskPPEappropriately-Alldonninganddoffingshouldbeobserved

o RNwillobservetoensurecorrectPPEhasbeendonnedo PPEincludesdonningHighRiskPPEforbothanesthesiaprovidersaslistedbelow

§ ImperviousGownforairwayteam(yellowisolationgownorhigher)§ Longcuffedgloves§ Secondsetdisposablegloves§ N95mask§ Bouffanthat§ Eyeshield§ Bouffanthat

• LaborEpiduralconversion/CSE

o OnlyanesthesiacareteaminIsolationroomdonHighRiskPPEo ORteamdonstandardPUI/COVID-19PPE

o Willverifypatientarmband,Pre-inductionBriefingORCirculator

LaborEpiduralConversion

• AnesthesiaprovidertobegindosingpatientoncetheyarriveintheOR

• Localanestheticchoicedependingonurgencyofcase

o Either3%chloroprocainevs2%lidocainewithepinephrineandbicarb

• Onlyoneprovidertobedosingepiduralandtestingpatient’slevel;otherproviderprovidingsupportwithouttouchingpatient(e.g.hangingdrips,drawingupothermedications,charting)

• OBtobedonningPPEwhiledosingepidural

• Oncepatientwithadequateblock,secondaryanesthesiaprovidershouldleaveOR

o Properwitnesseddoffingtechniqueo HandHygiene(washwithAlcoholbasedHandSanitizerorpurplewipeswithgloveson)o DoffGownwithGloveso HandHygiene(washwithAlcoholbasedHandSanitizer)o Dongloveso Disinfectfrontoffaceshield/goggleswithapprovedpurpletopwipes(whilestillonHCWface)



o Doffgloveso HandHygiene(washwithAlcoholbasedHandSanitizer)o ExitintohallANDHandHygieneo Dofffaceshield/gogglesandplaceinpaperbag,labelo HandHygiene(washwithAlcoholbasedHandSanitizer)o DoffProcedural/Surgicalmask

o HandHygiene(washwithAlcoholbasedHandSanitizer)

SAB/CSE

• Oneprovidertoset-upspinal/CSEkit(sterileglovesovernon-sterilegloves),whiletheotherpassesmedicationsandprimesdrips

• ProceedwithneuraxialtimeoutifnotSTAT

• OBtobedonningPPEwhileblockisbeingplaced

• Nursetohelpwithpositioning,placingmonitors,andhookingupinfusions

• Neuraxialblockplaced,

• ensurehemodynamicstabilityandadequateblock

• Onlyoneprovidertocontactpatientduringplacementandcheckinglevelofblock

• Ifstablethensecondproviderleaves,usesobservedDoffingprocessabove

GAInductioninWICOR

• Prepareallequipmentoutsideroom-takeyourtime-bepurposeful• DonCOVID-19HighRiskPPEpriortoenteringORwithcheckoffbyRN

o ImperviousGownforairwayteam(yellowisolationgownorhigher)o Longcuffedgloveso Secondsetdisposablegloveso N95masko Bouffanthato Eyeshieldo Bouffanthat

• UtilizeRespiratoryintubationtray,HMEantiviralfilter,CMAC,anynecessaryadditionalequipmento Resp.Tray.o HMEFiltero CleanCMACinwrapper-Openbothblades,bothwillrequiredecontam.o Ambubago Suctiono Anyadditionalmedsandequipmento Additionalcleanpairofgloveswithintubationsupplieso Disposablechuckdrapesforpatientchest/head-recommend4ormore



o Clearplasticdrapetobeplaceoverpt.upperbodytoprovideadditionalbarrier(handsandequipunderneath).Recommend4’x4’

o TapeforETTo Eyecare-tegadermandtheratearso Paddedclampsfortubeclampingo Biohazardziplockbagso Nervestimulator

• Only2anesthesiateammembersinroomduringinductiono 1primaryairwayo 1primarymedsandmonitoro ORstaff-maintainasmuchdistanceaspossibleo RNoutsideforpassthrough

Induction/intubationPre-oxygenatefor5minutesRapidsequenceintubationAfterpatientinduced,holdmaskinplacefor30secondsVerifynotwitchespriortoDLDL-donotventilatetodecreasetransmissionifpossible

• RSI-videoDLwithCMAC(CMACwillhaveaRedbag-kickbucketsizewithdrawstringsontoptray)• IfclampedETTutilized(considerneedofstyleyandBougi)unclamponcefilterinplaceonETT

o PlaceCMACbladeinBiohazardziplockbago Maintainglovesandgownatthispoint-alcoholgelo MaintainHMEfilterinplaceBagvalvethentotubewithEtC02inlineo Securetube/eyecareo WipedownworkareawithSani-wipeso Discarddrapesonpatient,attemptrollincleardrapetopreventcontaminationo PlaceCMACbladeintopredlinedbinofCMACo AirwaystaffnowDoff1stlayergloveswhileMedstaffAmbupt.o Swap-MedproviderwillremainbehindwipeCMAC

§ Yellowtopbleachsani-cloth§ 4minutewettime§ Leavetodry

o CinchequipmentinRedbagCMACtrayo AnesthesialabwillcomeretrieveCMAC

§ Coveringarbagebag§ WipedownCMACbag

Forallthisgloveandgelbetweenallsteps

*HMEFiltermustremainattachedtotubeandinplaceatanytimeofdisconnection*



• AfterintubationTeamleadertonotifyanesthesialabinorderforanesthesiaequipmenttobecleaned

• Anesthesiapersonneltohavereadilyavailableitemsmostlikelytobeused

o Minimalanesthesiacartutilized-seerecommendeditemsaddendumo Verifygelpresentforglovechanges

• Extragloveboxesinroomsforfrequentglovechanges

• Oneproviderhasdirectpatientcontact,theotherprovidessupport(e.g.passingequipmenttoprimaryprovider)

• Theproviderresponsibleforpatientcontactwillberesponsibleforassistingwithmovingthepatientandsecuringtheairway

• OutsidecirculatorassignedtoORwithbrickphone.

• Ifanyadditionalsuppliesneeded,circulatingRNwillcalloutsidecirculator

o Outsidecirculatorretrievesitem,donsdoublegloves,passesitemthroughORdooratoutsidehallway

o CirculatingRNwilldonacleanpairoftopglovespriortoopeningdoortoreceivesupplies

• StaffremaininORifpossible

Procedurefinish

• NotifySecondcirculatorbyphoneprocedurefinish

• SecondcirculatorwillnotifyWPACUthatpatientisbeingtransported;willalsoclearhallwaypriortotransport

• PPEdonningforWPACUteam

• Thesurgeryshouldbescheduledattheendofthedayifpossible.• Theroomshouldremainvacantfor30minutesafterthepatientleaves.• Staffshouldweargownandglovestocleantheroomwiththeregularhospitalapproveddisinfectantwipe.• Theroomshouldbeterminallycleaned.

o Aftertheroomisterminallycleaned,doesitneedtoremainvacantforaperiodoftimepriortobringinganotherpatientbacktotheOR?No.

o Forthetrash/medicalwastethatwillberemovedfromtheORafterthesurgicalprocedure—shouldthisbedisposedofwiththesameprocessasanyotherpatient?Alltrashistreatedperthenormalprotocol.

o Additionally,shouldtheinstrumentsbedecontaminatedinthesameprocessasotherpatients?Allinstrumentsaretreatedandcleanedperournormalprotocol.



• TransporttosameWPACU1spot

• CirculatingRNandanesthesiatransportpatient

o CirculatingRNwillverifyarmbandwithPACURNpriortodoffingPPE

• CirculatingRNdoffsPPEinWPACUroom

• TwoACTtoextubatepatient

o NeedrealtimeCO2monitoringforextubation,gaslinebehindfilterIfavailableo HookuptomonitorswithcablesandX2/3utilizedo Drapept.withdisposablechucksandclearplasticdrape(sameasinduction)o Suctionready-utilizeinlineclosedsuctionifavailableo HMEfilterinplaceandinlineo Suctionoralpharynx-closedsuctionifpossibleo Optimizetechniquesforcoughfreeextubation-consider

§ LidocaineIV1%§ Precedex0.4mck/kg/min.30minutespriortoextubation§ Consideropiates

o Cuffdown,removetube-Leave–Nopositivepressureatextubation,goalistominimizecoughandaersolization

o PlaceETTinredbagtrasho Discarddrapesonpatient,attemptrollincleardrapetopreventcontaminationo Afterextubation,facemaskplacedbackonpatientbyanesthesiaovernasalcannulawithsurgical

maskonpt.o ConsiderutilizingBVMmaskwithHMEfilteroverNC.Securemaskwithrubberstrap(blue

tourniquetorsimilar)o GelGlovedhandso CleanareawithSani-wipe

• DoffPPEasappropriatewitnessedbyanobserver

• AftercirculatingRNleavesPACUroom,giveshandoffreporttoPACURN

TheforegoinginformationismeantforeducationalpurposesonlyandisderivedfromthelimitedsourcesofevolvingevidenceandexperienceavailableatthetimeofproductionduringtheCOVID-19pandemic.Thisinformationisnotmeanttocontrolindividualtreatmentdecisionswhicharebasedonanindividualpatient’sspecificcircumstances,norisitmeanttooverridetheclinicaljudgmentofproviderswithinthedoctor-patientrelationship.ThisinformationisrelayedaspartofUAB’sEmergencyOperatingPlan.



What personal protective equipment (PPE) should be worn when transporting patients who are confirmed or under investigation for COVID-19?

.

• Transport and movement of the patient outside of their room should be limited to medically essential purposes.

o Consider providing portable x-ray equipment in patient cohort areas to reduce the need for patient transport

• Procedure should be scheduled as the last case of the day if possible • Notify receiving department of isolation status in advance

For transport

• If patient requires assistance from the bed to the wheelchair or stretcher, transporting staff should wear all recommended PPE : gloves, gown, surgical mask, and eye protection (goggles or face shield).



• Patient should wear a surgical mask (if tolerated) and be covered with a clean sheet

• Prior to exiting the room, transporters should remove all PPE except mask and face shield according to Doffing procedure

• Perform hand hygiene.

Additional PPE is not required unless there is an anticipated need to provide medical assistance during transport.

Receiving Department:

• Receiving department prepares room. • Don all recommended PPE: surgical mask, gown, gloves and face shield/eye

protection, while awaiting patient’s arrival.

If transporter has to assist patient:

The transporter is still wearing their original respirator or surgical mask, therefore, the transporter should take care to avoid self-contamination when donning the remainder of the recommended PPE.

Inside procedural room:

• Have patient perform hand hygiene if able • Place a new, clean sheet over patient

Transporter:

• Clean and disinfect all high touch surfaces of the occupied bed, stretcher or wheelchair, such as hand rails, side rails, head board, foot board, and steering mechanism

• Doff PPE according to Doffing Procedure, perform hand hygiene o If you are returning the transport vehicle without the patient back to the

department: Perform low level disinfection of all transport vehicle surfaces prior to returning to department

Cleaning of Procedure Room:

• Clean all horizontal and high touch surfaces with approved disinfectant.



• Room should be thoroughly cleaned • Linen to be completely removed from the room after each patient according to

routine procedures • Medical waste to be completely removed from the room and handled according

to routine procedures

MinimalistAnesthesiaCartforIn-Room(Onlythefollowingitems!)

Tape

• 1rollpinkplastictape• 1roll½in,1roll1in,and1roll2intape

1nervestimulatorwith1setPNSelectrods

1pkgECGelectrods

1disposablepulseox

5smallTegederms

5largeTegederms

3Chloroprepsticks

3Benzoinsticks

1regbougieand1stylette

1esophagealtempprobe;1NPtempprobe,and1skintempprobe

2suctioncatheters

1Yankauertipsuction

1upperbodywarmer

ExtraETTcircuitfilter

Syringes

• 8of10mlsyringes• 5of3mlsyringes• 3of1mlsyringes• 120mlsyringe• 1ABGsyringe

IVsupplies



• 2stopcocks• 4redsterilecaps• 2extensionsets• 2secondarysets/piggyback• 2IVregularsets• 1bloodset• 4IVcaths18g• 4IVcaths20g• 2IVcaths22g• 2IVcaths16g• 1IVcath14g• 2needlelessshieldcaps(forIV)

Needles

• 4needles18g• 4bluntfillneedles• 416gneedles• 1IMneedles

2nasaltrumpets1eachsizeoralairways1eachof6.5;7.0;7.5;8.0ETT1omniflexconnector1toothguard4tonguebladesWhitepapertowels*thebigonesStethoscopeETTtubetree2bagsofsaline1000ml2bagsofLR1000ml2bagsofIsolyte1000ml2bagssaline100ml2bagssaline250ml4bluelabslips/4whitelabslips/6biohazardbagsECGpaperextraroll1BISprobePURPLEWIPESHANDSANITIZER



TheforegoinginformationismeantforeducationalpurposesonlyandisderivedfromthelimitedsourcesofevolvingevidenceandexperienceavailableatthetimeofproductionduringtheCOVID-19pandemic.Thisinformationisnotmeanttocontrolindividualtreatmentdecisionswhicharebasedonanindividualpatient’sspecificcircumstances,norisitmeanttooverridetheclinicaljudgmentofproviderswithinthedoctor-patientrelationship.ThisinformationisrelayedaspartofUAB’sEmergencyOperatingPlan.

Documents

UAB COVID-19 Cesarean Section OR Management Step-By-Step · 2020-03-29 · COVID-19 Cesarean Section OR Management ... • Prepare all equipment outside room-take your time-be purposeful