PSA RECOMMENDATIONS

FOR
STANDARD PRACTICE FOR ANESTHESIOLOGISTS

A Specialty Society of the Philippine Medical Association

HAND HYGIENE (HH)

2020 OFFICERS & • Frequent hand washing must be actively enforced to protect
Members of the
against cross infection.
BOARD OF DIRECTORS
• Alcohol-based hand wash gels should be strategically placed
Benjamin Daniel S. Valera, MD, FPSA
PRESIDENT
near every anesthesia work station.
Edgard M. Simon, MD, FPSA • Hand hygiene should be meticulously performed according to
VICE-PRESIDENT
standard guidelines, specifically after removing gloves; after
Ma. Cristina Danac-Delfin, MD, FPSA
SECRETARY contact with contaminated or soiled areas; before touching
Francis B. Mayuga, MD, FPSA
TREASURER the anesthesia machine, anesthesia cart, or its contents; and
DIRECTORS after every contact with the patient.
Ma. Janetth Betita-Serrano, MD, FPSA
Salvador E. Brodit, Jr., MD, FPSA
Noemi R. Buensuceso, MD, FPSA
Maria Irminia Montecillo-Ocampo, MD, FPSA PERSONAL PROTECTIVE EQUIPMENT (PPE)
Joselito T. Morete, MD, FPSA
Karl Matthew C. Sy Su, MD, DPBA • Personal protective equipment (PPE) SHOULD BE AVAIL-
REGIONAL DIRECTORS
ABLE FOR ALL PROVIDERS.
Godfrey G. Agcon, MD, FPSA • Fit tested N95 masks should be used for all known or
For Luzon
suspected cases of COVID-19.
Jennifer Frances S. Rosello, MD, FPSA
For Visayas • Consider a powered air-purifying respirator (PAPR) for
Ferdinand D. Miranda, MD, FPSA
For Mindanao superior protection during airway procedures.
IMMEDIATE PAST PRESIDENT • Properly worn disposable OR caps reduce the risk of
Angel Joaquin M. Gomez, MD, FPSA
contaminating hands by touching hair which may have
been exposed to droplets
• Disposable fluid-resistant long-sleeved gowns, gloves,
goggles, and disposable full-face shields are recom-
mended for providers at risk for exposure.
• Hand washing is essential before and after donning or doffing
PPE.
• Consider mock intubation/extubation drills using PPE in a
simulated environment.
• Consider avoiding crash intubations where PPE cannot be
fully adhered to.
• Lower threshold for planning elective or semi-elective intu-
bations in all cases.
• Proceed directly to early endotracheal intubation in patients
with acute respiratory failure.

PSA COVID-19 GUIDELINES 1 of 10

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AIRWAY MANIPULATION (INTUBATION AND EXTU-
BATION)

• Prior to intubation, don the appropriate gloves, face mask /

PAPR, eye shields and gown.
• Prepare intubating equipment and plan for its disposal to li-
mit the distance of travel of contaminated equipment.
• Use double gloving technique during intubation. Use the ou-
ter gloves to sheath the laryngoscope blade and change the
inner gloves after intubation as soon as possible.
• During extubation, maintain strict HH, wear a mask with a
face shield and carefully dispose of contaminated equipment.
• Limit the number of staff present during intubation / extuba-
tion to reduce the risk of exposure.
• Consider prophylactic antiemetics to reduce the risk of vomi-
ting and possible viral spread. However, due to potential
risks of steroids in the setting of COVID infection, consider
avoiding the use of dexamethasone in PUI /COVID+ pati-
ents.

RECOMMENDATIONS FOR AIRWAY MANAGEMENT

IN A PATIENT WITH SUSPECTED COVID - 19 INFEC-
TION

General Precautions
• Confirmed or suspected COVID-19 patients SHOULD NOT
be brought to holding or PACU areas.
• A designated operating room should be allocated for such
cases.
• Post signs on the doors to minimize unnecessary staff expo-
sure.
• Infected patients should be recovered in the operating room
or transferred to ICU into a negative pressure room.
• Use a high quality HMEF (Heat and Moisture Exchanging
Filter) placed between the endotracheal tube and reservoir
bag during transfers to avoid contaminating the atmosphere.
• PPE should be available to all providers to ensure achieve-
ment of airborne / droplet / contact isolation precautions.

PSA COVID-19 GUIDELINES 2 of 10

• Prepare a checklist to guide the procedure for donning and
doffing PPE.
• Plan ahead to allow sufficient time for staff to apply PPE and
barrier precautions.
• Careful attention is required to avoid self-contamination.

During Airway Manipulation

1. Apply a fit-tested disposable N95 respirator or a Powered
Air-Purifying Respirator (PAPRs), goggles, gowns, gloves
(preferably long gloves) and protective footwear. Use the
double glove technique.
2. Apply standard monitoring to the patient, as you would for
any induction of anesthesia.
3. Ensure intravenous access, medications, ventilator, anesthe-
sia workstation, and suction equipment are ready and functi-
onal.
4. Designate the most experienced anesthesiologist available to
perform intubation, if possible. Avoid trainee intubations
during this time.
5. Avoid awake fiberoptic intubation unless specifically indica-
ted. An atomized local anesthetic will aerosolize the virus.
Consider using a video laryngoscope to improve intubation
success and minimize direct exposure between the anesthe-
siologist and respiratory aerosols from patients.
6. Preoxygenate patient for a minimum of 5 minutes with 100%
oxygen and perform a rapid sequence induction (RSI) in or-
der to avoid manual ventilation of patient's lungs and poten-
tial aerosolization of virus from airways.
7. Perform an RSI or a modified RSI as clinically indicated. If
manual ventilation is necessary, apply small tidal volumes.
8. Ensure the placement of a high quality HMEF (Heat and
Moisture Exchanging Filter) rated to remove at least 99.97%
of airborne particles 0.3 microns or greater in between the
face mask and breathing circuit or in between face mask and
reservoir bag.
9. Re-sheath the laryngoscope immediately post-intubation us-
ing the outer glove. Seal ALL used airway equipment in a
double zip-locked plastic bag.

PSA COVID-19 GUIDELINES 3 of 10

10. Intubate the patient with an appropriately sized endotrache-
al tube. Inflate the cuff and institute mechanical ventilation.
Consider using a tube clamp immediately after intubation to
prevent potential aerosolization of virus while the endotra-
cheal tube is not yet connected to the breathing circuit.
11.Confirm correct position of endotracheal tube with capno-
graphy and avoid auscultation if possible to prevent conta-
minating stethoscopes.
12.After removing protective equipment, remember to WASH
HANDS before touching your hair or face.
13.Decontaminate and disinfect all airway equipment according
to the manufacturer and hospital policies.
14.Avoid use of high-flow nasal oxygenation and mask for
CPAP or BiPAP due to greater risk of aerosol generation.
15.MINIMIZE suctioning secretions. If suctioning, however,
use a closed suction system to prevent aerosolization of vi-
rus.

RECOMMENDATIONS FOR OBSTETRIC ANESTHE-

SIA MANAGEMENT IN A PATIENT WITH SUSPECTED
COVID-19 INFECTION

Labor and Delivery

1. Implement pre-hospital screening and evaluation.
2. For elective procedures such as elective cesarean delivery,
induction of labor, and cerclage, screen patients and support
persons(s) for symptoms of COVID-19.
3. Consider mock drills to simulate patients with symptoms of
COVID-19 for labor and delivery and possible transport to
the OR.
4. Limit visitors and support people for suspected and confir-
med COVID-19 patients following hospital policy.

General Precautions
• Confirmed or suspected COVID-19 patients SHOULD NOT
be brought to holding or PACU areas.
• A designated operating room should be allocated for cesarean
delivery.

PSA COVID-19 GUIDELINES 4 of 10

• Post signs on the doors to minimize unnecessary staff expo-
sure.
• Infected patients should be recovered in the operating room
or transferred to ICU into a negative pressure room.
• PPE should be available to all providers to ensure achieve-
ment of airborne / droplet / contact isolation precautions.
• Prepare a checklist to guide the procedure for donning and
doffing PPE.
• Plan ahead to allow sufficient time for staff to apply PPE and
barrier precautions.
• Careful attention is required to avoid self-contamination.

Obstetric Anesthesia Specific Considerations

• AVOID crash situations by anticipating needs.
• Consider early epidural analgesia to reduce the need for gene-
ral anesthesia for emergent cesarean delivery.
• COVID-19 infection is NOT A CONTRAINDICATION to
neuraxial anesthesia. However, assess platelet count since
there are reports of thrombocytopenia among COVID-19 pa-
tients.
• If general anesthesia is indicated, follow recommendations
for airway management in patients with suspected
COVID-19 infection.
• Avoid emergent cesarean deliveries if possible.
• Designate the most experienced anesthesiologist available to
perform procedures, if possible. Avoid use of trainees in di-
rect care of COVID-19 patients during this time.
• Plan with the NICU team for separation of the newborn to
prevent maternal-infant transmission.
• Limit the number of staff present in the room during procedu-
res to reduce the risk of exposure.

PSA COVID-19 GUIDELINES 5 of 10

NOTE: Not all hospitals / health facilities are using the same
PPE. There may be variations in the donning and doffing.
However, there are still standard rules that can be applied in
the use of PPE. Below is a helpful illustration of the Sequence
of Putting on and Removing Safely PPE adopted from CDC,
USA.

PSA COVID-19 GUIDELINES 6 of 10

References
1. Anesthesia Patient Safety Foundation Peri-operative Con-
siderations for the 2019 Novel Coronavirus (COVID-19).
https://www.apsf.org/news-updates/perioperative-consider-
ations-for-the-2019-novel-coronavirus-covid-19/
2. Birnbach DJ, Rosen LF, Fitzpatrick M, Carling P, Arheart
KL, Munoz-Price LS. A new approach to pathogen con-
tainment in the operating room: Sheathing the laryngo-
scope after intubation. Anesth Analg. 2015;121(5):
1209-1214. doi:10.1213/ANE.0000000000000854
3. Booth CM, Matukas LM, Tomlinson GA, et al. Clinical
Features and Short-term Outcomes of 144 Patients with
SARS in the Greater Toronto Area. J Am Med Assoc.
2003;289(21):2801-2809. doi:10.1001/jama.
289.21.JOC30885
4. Caputo KM, Byrick R, Chapman MG, Orser BA, Orser BJ.
Intubation of SARS patients: Infection and perspectives of
healthcare workers. Can J Anesth. 2006;53(2):122-129.
doi:10.1007/BF03021815

5. Centers for Disease Control and Prevention. Interim guid-

ance for healthcare professionals: criteria to guide evalua-

PSA COVID-19 GUIDELINES 7 of 10

 tion of patients under investigation (PUI) for 2019-nCoV.
2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/
clinical-criteria.html
6. CDC: Centers for Disease Control and Prevention. 2019
Novel coronavirus, Wuhan, China: 2019-nCoV situation
summary. January 28 2020. https://www.cdc.gov/coron-
avirus/2019-ncov/index.html
7. Chen R, Zhang Y, Huang L, Cheng BH, Xia ZY, Meng QT.
Safety and efficacy of different anesthetic regimens for par-
turients with COVID-19 undergoing Cesarean delivery: a
case series of 17 patients. Can J Anaesth 2020.https://
link.springer.com/article/10.1007%2Fs12630-020-01630-7.
8. Emergency Caesarean delivery in a patient with confirmed
coronavirus disease 2019 under spinal anaesthesia. https://
bjanaesthesia.org/article/S0007-0912(20)30131-8/pdf.
9. Fuk-Woo Chan J, Yuan S, Kok K-H, et al. A familial cluster
of pneumonia associated with the 2019 novel coronavirus
indicating person-to-person transmission: a study of a fami-
ly cluster. Lancet. 2020;6736(20):1-10. doi:10.1016/S0140-
6736(20)30154-9
10. Huang C, Wang Y, Li X, et al. Clinical features of patients
infected with 2019 novel coronavirus in Wuhan , China.
Lancet. 2020;6736(20):1-10. doi:10.1016/
S0140-6736(20)30183-5
11. Interim Considerations for Infection Prevention and Con-
trol of Coronavirus Disease 2019 (COVID-19) in Inpatient
Obstetric Healthcare Settings.≈. https://bjanaesthesia.org/
article/S0007-0912(20)30131-8/pdf.
12. ISUOG Interim Guidance on 2019 novel coronavirus infec-
tion during pregnancy and puerperium: information for
healthcare professionals. https://obgyn.onlinelibrary.wiley.-
com/doi/epdf/10.1002/uog.22013.
13. Kamming D, Gardam M, Chung F. Editorial I. Anaesthesia
and SARS. Br J Anaesth. 2003;90(6):715-718. doi:10.1093/
bja/aeg173
14. Lidocaine during intubation and extubation in patients with
coronavirus disease (COVID-19). https://link.springer.com/
article/10.1007/s12630-020-01627-2#author-information.
15. Loftus RW, Koff MD, Birnbach DJ. The Dynamics and
Implications of Bacterial Transmission Events Arising from

PSA COVID-19 GUIDELINES 8 of 10

 the Anesthesia Work Area. Anesth Analg. 2015;120(4):853-
860. doi:10.1213/ANE.0000000000000505
16. Management of pregnant women with known or suspected
COVID-19. https://icmanaesthesiacovid-19.org/obstetric-
anaesthesia.
17. Medical A. British journal of anaesthesia. Anesth Analg.
2004;92(1):1-3. doi:10.1093/bja/aeh173
18. Munoz-Price LS, Bowdle A, Johnston BL, et al. Infection
prevention in the operating room anesthesia work area. In-
fect Control Hosp Epidemiol. 2019;40(1):1-17. doi:
10.1017/ice.2018.303
19. Phan LT, Nguyen T V, Luong QC, et al. Importation and
Human-to-Human Transmission of a Novel Coronavirus in
Vietnam. N Engl J Med. 2020;(Panel D). doi:10.1056/NE-
JMc2001272
20. Preparing for a COVID-19 pandemic: a review of operating
room outbreak response measures in a large tertiary hospi-
tal in Singapore. https://link.springer.com/article/10.1007/
s12630-020-01620-9.
21. Rational use of personal protective equipment for coron-
avirus disease 2019 (COVID-19). https://apps.who.int/iris/
bitstream/handle/10665/331215/WHO-2019-nCov-
IPCPPE_use-2020.1-eng.pdf.
22. Rowlands J, Yeager MP, Beach M, Patel HM, Huysman
BC, Loftus RW. Video observation to map hand contact
and bacterial transmission in operating rooms. Am J Infect
Control. 2014;42(7):698-701. doi:10.1016/j.ajic.
2014.02.021
23. Safety and efficacy of different anesthetic regimens for par-
turients with COVID-19 undergoing Cesarean delivery: a
case series of 17 patients. https://link.springer.com/article/
10.1007/s12630-020-01630-7.
24. Strategies for Optimizing the Supply of N95 Respirators:
Crisis/Alternate Strategies. https://www.cdc.gov/coron-
avirus/2019-ncov/hcp/respirators-strategy/crisis-alternate-
strategies.html.

25. Ti LK, Ang LS, Foong TW, Ng BSW. What we do when a

COVID-19 patient needs an operation: operating room

PSA COVID-19 GUIDELINES 9 of 10

 preparation and guidance. Can J Anaesth 2020. https://
www.ncbi.nlm.nih.gov/pubmed/32144591
26. Wang D, Hu B, Hu C, et al. Clinical Characteristics of 138
Hospitalized Patients With 2019 Novel Coronavirus-Infect-
ed Pneumonia in Wuhan, China. Journal of the American
Medical Association 2020. Published online ahead of print.
doi:10.1001/jama.2020.158
27. Wen X, Li Y. Anesthesia Procedure of Emergency Opera-
tion for Patients with Suspected or Confirmed COVID-19.
Surg Infect (Larchmt) 2020. https://www.ncbi.nlm.nih.gov/
pubmed/32096692.

*NB: The PSA Officers and Board of Directors hope that the
members will find these guidelines straightforward, informative
and instructive in addressing the issues on Airway Management
for COVID-19 patients. Special thanks to Dr. Karl Matthew Sy
Su for drafting these guidelines in collaboration with the PSA
Officers and Board of Directors.

March 24, 2020

PSA COVID-19 GUIDELINES 10 of 10