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Effectiveness of simulation based teaching of ventilatory management among non-anaesthesiology residents to manage COVID 19 pandemic - A Quasi experimental cross sectional pilot study
research-article
Author(s):
Tatikonda Chandra Mouli ,
Anjani Davuluri ,
Sana Vijaya
1 ,
Avala Devi Yamini Priyanka ,
Sushant Kumar Mishra
2
Publication date (Electronic):
23 May 2020
Journal:
Indian Journal of Anaesthesia
Publisher:
Wolters Kluwer - Medknow
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There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.
Abstract
Background and Aims:
Simulation is one of the important learning tools when it comes to skill acquisition and as a supplemental tool for training in high stake situations like COVID-19. The aim of this study is to meet the global requirements of knowledge on ventilatory management, prepare and to evaluate the effectiveness of the teaching module for non-anesthesiology trainees on COVID-19 patients.
Methods:
Quasi experimental cross sectional pilot study was conducted with a sample of twenty-six trainees. A teaching module was prepared and validated which consisted of lectures, audio-video sessions, demonstrations with hands-on training, debriefing, analytical-phase and reflection. Pre and Post evaluations from student t-test and direct observation of procedural skills (DOPS) were used for knowledge and skill assessment respectively and feedback obtained from Likert's score.
Results:
Pre- and Post-tests had a mean score of 7.42 ± 2.12 and 14.92 ± 2.9 respectively ( P value 0.00001). DOPS included 16 point score, in which 23 trainees (88.4%) met the expectations and above expectations as per training objectives. A five-point Likert's score feedback revealed satisfactory and highly satisfactory scores of 100% (ABG), 96.1% (mechanical ventilation), and 84.6% (ventilation in COVID-19 patients). Overall satisfaction for the workshop among respondents was 100 per cent. Confidences of handling scores were 84.5% (interpreting ABG), 65.3% (maneuvering mechanical ventilation), and 96.15% (intubation in COVID-19 patients).
Conclusion:
A planned teaching module in ventilation management helps to train non-anaesthesiologists more effectively as a part of COVID-19 preparedness. Simulation with debriefing based training to the medical fraternity is the best alternative in the present pandemic and it will also ensure the safety of health care professionals.
Related collections
Most cited references21
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Outbreak of a new coronavirus: what anaesthetists should know
Philip W.H. Peng, Pak-Leung Ho, Susy Hota (2020)
In December 2019, an outbreak of pneumonia of unknown origin developed in Wuhan of Hubei Province, China. 1 By January 7, 2020, Chinese scientists confirmed that the outbreak was caused by a novel coronavirus, initially referred to as the 2019-nCoV, 2 and recently renamed as severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2), and the disease is now termed coronavirus disease 2019 (COVID-19) by the WHO. As of February 20, 2020, more than 75,748 confirmed cases of COVID-19 have been reported in 28 countries (including China) and international conveyance (cruise ship in the Japanese territorial waters), with approximately 99% of cases occurring in mainland China. 3 The WHO declared a public health emergency of international concern (PHEIC) on January 30, 2020 in response to the rapid growth of the outbreak and reports of human-to-human transmission in several countries. 3 Here, we summarise how key events unfolded, review the current understanding of COVID-19, contrast the outbreak of COVID-19 with the experience with severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), and discuss how anaesthetists should prepare themselves in view of this outbreak. Tracking the course of the outbreak The evolving story of the COVID-19 outbreak has advanced over a remarkably short time frame (Fig 1 ). On December 31, 2019, the Wuhan Municipal Health Commission reported a cluster of pneumonia of unknown origin, all linked to the Huanan Seafood Wholesale Market. This market harboured a variety of live and deceased exotic wildlife, including live bamboo rats, palm civets, badgers, and wolf cubs. It is notable that a quarter of the initially reported 27 pneumonia cases presented with severe disease.4, 5 Within days, the cause of the pneumonia was identified as a novel coronavirus (2019-nCoV). 2 On January 19, 2020 the WHO issued a warning that the virus may have the ability to spread from human to human. 3 Figure 1 Timeline of the outbreak of 2019-nCoV/coronavirus disease 2019 (COVID-19). Figure 1 Wuhan is a major transportation hub within China with a population of 11 million. On a typical day, approximately 3500 people take flights to other countries from Wuhan, and the number increases with holidays and the Chinese Lunar New Year. Within 1 month, the number of confirmed COVID-19 cases rose to more than 9000, surpassing the number of SARS and MERS cases reported to date. Similarly, global fears escalated as cases spread to other countries. Extensive control measures were put into place, starting with massive decontamination efforts and, ultimately, closure of the Huanan Seafood Wholesale Market, banning the trade of wildlife and poultry in wet markets, contact tracing of cases, exit screening at airports, lockdown and quarantine measures that progressed to include adjacent cities (an estimated 50–60 million people affected), school closures, extension of the Lunar New Year holiday, prohibition of mass gatherings, and building of two new hospitals (1000 and 1600 beds) to care for infected individuals. Other nations instituted airport screening, travel bans, and evacuating citizens from Hubei Province and quarantining them through the incubation period. 6 Despite these measures, the case counts continued to increase in the outbreak epicenter, and countries with imported cases reported clusters of human-to-human transmission. On January 30, 2020, the WHO declared a PHEIC, calling for intensified international collaborative efforts to halt the outbreak. 3 Although Chinese authorities have heavily restricted movement from Wuhan, this austere measure came at the same time as the Spring Festival, a time when the number of outbound travellers from Wuhan is estimated to be more than 15 million. What is 2019-nCoV/COVID-19? The 2019-nCoV or SARS-CoV-2 is an enveloped RNA virus that belongs to the Coronaviridae, a family of viruses that can infect humans and several animal species. To date, seven human coronaviruses have been identified (HCoV-229E, HCoV-NL63, HCoV-OC43, HCoV-HKU1, SARS-CoV, MERS-CoV, and SARS-CoV-2). 7 The SARS-CoV-2 belongs to the subgenus Sarbecovirus and most closely resembles a bat coronavirus, with which it shares 96.2% genetic sequence homology.2, 8, 9 The current belief is that COVID-19 was introduced into humans through an as yet unidentified intermediary animal, and it has since propagated through human-to-human spread. Human-to-human transmission occurs primarily through respiratory droplets that travel up to 2 m and may enter the respiratory tract of individuals within range or contaminated surfaces, leading to infection through contact transmission. 10 The average incubation period is 5 days, but it ranges from 1 to 14 days.10, 11 The basic reproductive number (the number of cases one infected individual generates), R 0, is estimated to be 2.68 (95% confidence interval: 2.47–2.86). 12 Whilst asymptomatic transmission (during the incubation period, before onset of symptoms in infected individuals) has been suggested, it remains controversial and currently does not appear to be a major factor for infection transmission. 10 Infections in humans result in a spectrum of clinical disease, from mild upper respiratory tract infection, mostly commonly characterised by fever (82%) and cough (81%), to severe acute respiratory distress syndrome (ARDS) and sepsis. The median age of infected individuals is between 49 and 56 yr.1, 13 Children are rarely diagnosed with 2019-nCoV, a phenomenon that has not yet been explained. Characterisation of the first 99 cases of 2019-nCoV within Wuhan demonstrated that 33% had severe illness, with 17% developing ARDS, 4% requiring mechanical ventilation, and 4% having sepsis. 13 The case fatality rate is currently estimated at 2% based on the confirmed cases reported for the ongoing outbreak. 3 However, as mild and subclinical infections are currently under-reported, the true case fatality is likely lower than this. 14 People with co-morbidities, such as diabetes mellitus and cardiovascular disease, appear to be at higher risk for death.1, 13 Comparison with the SARS and MERS outbreak Several similarities and differences exist amongst the SARS, MERS, and 2019-nCoV viruses (Table 1 ). All three coronaviruses were introduced into humans from wild animals (masked palm civets in SARS, camel in MERS, and unclear intermediary for 2019-nCoV).15, 16 All three can cause severe respiratory distress symptoms and death, although fatality rates range considerably, with MERS being the most lethal (case fatality rate: 35%). 16 There have been no further documented cases of SARS since July 2003, but MERS continues to be reported sporadically, generally as a result of animal-to-human contact or transmission in healthcare facilities and within families. Compared with SARS, with which it shares nearly 70% genetic homology, 2019-nCoV appears to be more transmissible (higher R 0) but less fatal. 13 Table 1 Comparison of the outbreak from severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and 2019-nCov/coronavirus disease 2019 (COVID-19) respiratory syndrome. CoV, coronavirus. Table 1 SARS MERS COVID-19 Timeline November 2002 to July 2003 June 2012 to present December 2019 to present Location of first detection Guangdong, China Jeddah, Saudi Arabia Wuhan, China Animal origin Civet Camel Non-aquatic animal (?) Confirmed cases 8096 2494 12 404 Fatality 744 (10%) 858 (37%) 259 (∼2%) Global impact 26 countries 27 countries 26 countries Date of virus identification April 2003 October 2012 January 7, 2020 The current outbreak of COVID-19 has benefited from several advancements that have resulted in a different experience from the SARS outbreak in 2002–3. Improved reporting, transparency, and communication Health officials in China exhibited a much higher degree of transparency early in this outbreak and were quicker to notify the WHO after they discovered the cluster of pneumonia of unknown origin. The identification of the aetiological virus occurred promptly in early January, and the full genome sequence data were shared on the Global Initiative on Sharing All Influenza Data platform. 8 The update International Health Regulations (2005) was signed 2 yr after the SARS outbreak by 194 member states, with legal binding on the protection of all people of the world from international spread of disease. 17 Global surveillance and alerting systems developed since SARS enabled rapid dissemination of information on the emerging outbreak. Public health officials and the WHO have held numerous press conferences to inform the public on important developments. Scientific papers have been published with rapid peer review to share the clinical and epidemiological characteristics of the virus within the medical community. Technological advancements During the SARS outbreak, the aetiological virus was identified 5 months after the outbreak began. In contrast, the virus and the genomic characteristic were identified within 2 weeks of the discovery of the COVID-19 outbreak. 8 This is very significant, as this information allows rapid development of real-time polymerase chain reaction diagnostic tests specific to SARS-CoV-2. 18 This has allowed some countries to have diagnostic testing available before the first case arrived in their countries—a significant step in curbing the spread of the virus globally. Early identification of the full genome also aids in vaccine development. Companies, such as Tencent (Shenzhen, China) and Alibaba (Hangzhou, China), provide databases running in real time to release the latest statistics needed for contact tracing and for management of essential supplies (such as masks and gowns). Technology has also accelerated information sharing through social media and the internet, which was still in its infancy during the SARS outbreak. Infection prevention and control and public health infrastructure expansion. Since the SARS outbreak, the WHO has declared five PHEIC. As a result of these events, significant investments have been made into public health and infection prevention programmes in many jurisdictions. Public health programmes coordinate rapid case finding, tracing of contacts of cases, and isolation measures to mitigate spread, and guide decision-making on broad public health measures, such as social distancing when required. Hospital infection prevention and control programmes aid with case identification through screening and testing, and they execute isolation infection prevention measures to ensure healthcare settings are safe from infection transmission. The latter is of utmost importance, as both the SARS and MERS viruses have disproportionately infected healthcare providers and healthcare settings have been hotspots of infection transmission. What anaesthetists need to know in response to this outbreak During the SARS outbreak, 21% of the infected individuals globally were healthcare workers. 15 In Canada, a final count of 251 cases of SARS was confirmed; 43% of them were healthcare workers, the majority were from Toronto. 15 Concerns were raised about infections in healthcare workers despite apparently appropriate personal protective equipment (PPE). Analysis of this experience uncovered several important lessons. 19 First, the protection of healthcare workers is not just about PPE; it encompasses all principles of infection prevention and control. 20 Whilst the initial focus for protecting anaesthesiologists or personnel involved in aerosol-generating medical procedures (tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation, and bronchoscopy) was on the need for more stringent PPE, such as powered air-purifying respirators or double gloves during the SARS outbreak, further investigation did not support a risk of transmission with tracheal intubation if appropriate precautions and more standard PPE were used.21, 22 In areas, such as the emergency department or ICU where SARS patients were managed, there were ‘uncontrolled situations characterized by multiple opportunities for extensive contamination and staff exposure prior to the intubation event’. 21 Healthcare workers were exposed to risk of infection before PPE was used. It reflects the importance of triage, early recognition, and prompt isolation for suspected cases of infected patients. 20 Second, a post-SARS investigation interviewing healthcare workers involved in the intubation of SARS patients in Toronto highlighted non-compliance or sub-optimal adherence to the use of PPE. 23 Although much is unknown about the 2019-nCoV, it is believed to spread from person to person amongst close contact via respiratory droplets and contact transmission. Strict adherence to the use of PPE, including procedure mask, eye protection, gown, and gloves, is highly effective in limiting droplet and contact transmission. 21 The current WHO and Centers for Disease Control and Prevention guidance for the protection of personnel during aerosol-generating medical procedures in patients with confirmed/suspected 2019-nCoV centres around principles of clear communication, minimising personnel in the room during the procedure, appropriate use of PPE, and avoidance of procedures that generate high amounts of aerosols. Some considerations are provided as follows to help prepare for airway management of confirmed/suspected COVID-19 patients.20, 24, 25 These suggestions are by no means comprehensive. Hospitals should develop local plans for aerosol-generating medical procedures in suspected/confirmed COVID-19 patients using a collaborative approach that engages anaesthesiologists, intensivists, emergency medicine physicians, respiratory therapists, resuscitation team members, infection prevention and control, occupational health and safety specialists, and environmental services staff. Preparing the patient and procedure room Transfer of a suspected or infected COVID-19 patient to the room for aerosol-generating medical procedures requires planning. Considerations include: (i) The room should be adequately ventilated; for aerosol-generating medical procedures performed outside the operating theatre, a negative pressure/airborne isolation room with minimum 12 air changes h−1 is preferred. (ii) The patient should wear a face mask during transport to the procedure room. (iii) The staff involved in the care of the patient should don PPE as required by their hospital's policy for management of COVID-19. (iv) Hand hygiene must be performed by staff before and after all patient contact, particularly before putting on and after removing PPE. (v) The number of individual staff members involved in the resuscitation should be kept to a minimum with no or minimal exchange of staff for the duration of the case, if possible. PPE considerations (i) Specific PPE components selected for aerosol-generating medical procedures may vary slightly by hospitals. However, the underlying principles are the same: to protect the healthcare provider from inhalation of and contact with aerosols and droplets that may be generated during the procedure. PPE components that may be used to accomplish this level of protection include: (a) A particulate respirator (US National Institute for Occupational Safety and Health-certified N95, EU standard FFP2, or equivalent); all healthcare workers should have an updated respirator fit test; (b) Eye protection, through the use of goggles or a disposable face shield; (c) Gown with fluid resistance; and (d) Gloves. (ii) Any PPE component that becomes heavily soiled during aerosol-generating medical procedures should be replaced immediately. (iii) Careful attention must be paid to donning and doffing of PPE to avoid potential exposure and self-contamination, which is highest during removal of PPE. All healthcare workers attending to aerosol-generating medical procedures should be trained and comfortable with PPE use, including safe donning and doffing. (iv) After removing protective equipment, the healthcare worker should avoid touching the hair or face before cleaning hands. (v) PPE should be disposed of carefully in a touch-free disposal or laundering bin. Minimisation of the aerosol generation To minimise the aerosols generated during airway instrumentation, some factors to consider include the following: (i) Airway management should be reserved for the most experienced anaesthetist, if possible. (ii) A high-efficiency hydrophobic filter interposed between face mask and breathing circuit or between face mask and airway bag can be used, if available. (iii) A thorough preoxygenation with 100% oxygen and rapid sequence induction (RSI) should be considered to avoid manual ventilation of the patient, which can result in aerosolisation of virus from airways. (iv) RSI may need to be modified if the patient has a very high alveolar–arterial oxygen gradient, is unable to tolerate 30 s of apnoea, or has a contraindication to succinylcholine. If manual ventilation is anticipated, small tidal volumes should be applied. (v) Awake fibreoptic intubation should be avoided unless specifically indicated, as the atomised local anaesthetic and the coughing episode during anaesthetising of the airway can aerosolise the virus. Consider the use of a videolaryngoscopy. (vi) Tracheal intubation rather than the use of laryngeal mask is favoured. (vii) In managing patients with respiratory distress from coronavirus infection outside the operating theatre, non-invasive ventilation should be avoided, if possible, to prevent generation of aerosol of virus in the room, and early intubation should be considered in a rapidly deteriorating patient. Whilst resuscitating the critically ill patient, chest compressions should be held during intubation to avoid exposing the face of the intubating clinician to aerosols, and neuromuscular blockers should be considered before intubation, if possible. Conclusions The current outbreak of COVID-19 has rapidly expanded over a short time. Confirmed cases continue to increase despite austere measures applied by the Chinese government and public health officials around the world. Up to one-third of affected patients may require a higher level of care in hospital, including mechanical ventilation in the early report. Anaesthesiologists are experts in airway management and will be on the frontlines of managing critically ill patients. Learning from previous experiences with SARS and understanding the current epidemiological factors of the COVID-19, anaesthesiologists are much better prepared to protect themselves during aerosol-generating medical procedures. A good knowledge of infection prevention and control, vigilance in protective measures, strict adhesion of donning and doffing of PPE, and preparedness for the care of infected patients are of utmost importance. Authors' contributions Writing/editing of paper: all authors. Approval: all authors. Declarations of interest The authors declare that they have no conflicts of interest.
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Indian Society of Anaesthesiologists (ISA National) Advisory and Position Statement regarding COVID-19
Naveen Malhotra, Muralidhar Joshi, Rashmi Datta … (2020)
PREAMBLE Indian Society of Anaesthesiologists issues the following advisory and position statement to ensure safety of patients and the anaesthesiologists during the “Corona Virus Disease 2019” (COVID-19) in India. Infection Prevention and Control policies have to be followed religiously. Human to human transmission occurs by droplet, contact and fomites and average incubation period is 2-10 days. The mortality rate is 2-3% but infectivity rate is very high, leading to increased morbidity and workload on health care. The mortality is high in immuno-compromised and elderly patients. Anaesthesiologist interaction with patients with COVID-19 can occur in Accident and Emergency Department/Trauma Centre for emergency airway management; Critical Care/Intensive Care Units; Pre-Anaesthetic Check Up (PAC) Clinics and Pain Clinics; Perioperative Anaesthesia Care; and Anaesthesia at remote locations: endoscopy, ECT, Radiology (MRI) etc., The anaesthesiologists have to take care of the patients as well as themselves. As the understanding of COVID-19 is being updated regularly and so are the guidelines, this ISA advisory and position statement is also subject to change and updation. ISA POSITION STATEMENT There can be a sudden surge of patients and health care demands. The hospital resources can get exhausted quickly and medical personnel can be under tremendous work stress, both clinical and psychological. Hence, existing resources have to be preserved and additional generated immediately. In coming days, a large number of patients may suddenly require oxygen therapy, tracheal intubation and ventilatory support. The facilities, devices and equipments for the same should be updated with repairs, services, replacements and fresh purchases as per the demand assessment. There should be adequate oxygen delivery devices, adequate oxygen reserve and multiple tracheal intubation teams have to be designated. A pool of anaesthesiologists has to be created at city branch level so that anaesthesiologists can be immediately shifted to the area of increased demand. Elective and semi-emergency surgeries should be deferred till the outbreak of COVID-19 is contained. Only emergency surgeries should be undertaken. Non-urgent and non-time sensitive consultations; surgical, interventional and diagnostic procedures should be rescheduled to a later date when the COVID transmission is contained in the community. The decision for urgent and time-sensitive procedures (cancer surgeries) should be taken as a team, based on the available resources and patient's clinical condition. This will conserve manpower, personal protective equipment and critical care beds. Transmission of COVID-19 can also occur from the anaesthesia workplace. Frequent hand washing by the anaesthesiologists is essential. Designated operating rooms having a dedicated anaesthesia machine and cart for high infection risk situations has to be done. If need arises, anaesthesia machine ventilators in the operation theatres will be used as ventilators and OT will have to be used as Intensive Care Units. Anaesthesiologists will take care of ventilatory settings and ensure non delivery of anaesthetic gases to the patients. ISA ADVISORY General Preventive Measures to be followed by Anaesthesiologists Anaesthesiologists should maintain Social Distancing. They should lead by example and defer their personal and social engagements. They should focus only on health care responsibilities and duties. Anaesthesiologists should also spread awareness about social distancing amongst patients and their attendants. Wash your hands frequently with soap and water or alcohol based sanitizer. Wash your hands after removing gloves, after contact with the patient or anaesthesia equipment. There can be an interface with droplets, sputum, or bodily fluids while performing routine procedures. Use face masks and N 95 masks. N95 masks offer protection against droplet and airborne transmission of 95% of particles more than 0.3 microns in size. Surgical face masks protect against COVID-19 droplet transmission but do not protect against aerosolized small particles. Wear disposable caps and beard covers to decrease the risk of hand contamination by touching hair that may have been exposed to droplets. Do mock drills for correct donning and doffing of Personal Protective Equipment (PPE) including gown, face mask, eye shields and gloves. Do Mock intubation/extubation drills wearing PPE. Aerosol-generating procedures are tracheal intubation and extubation, suctioning, nebulization, CPAP, BiPAP or high flow nasal oxygen therapy. Aerosolization is also increased when more than one attempt at intubation is required. Pre- Anaesthetic Check Up (PAC) Clinics/Pain Clinics Every patient entering the hospital should be considered as COVID-19 positive and anaesthesiologists should wear mask all the time. Wash your hands with alcohol based sanitizer or soap and water frequently. Restrict the number of attendants coming to OPD. Only one attendant to be allowed with the patient. Manage inflow of patients and prevent crowding inside the PAC and Pain Clinics. History of fever should be elicited/record patients' body temperature before entering the PAC Clinic/Pain Clinic. If the body temperature is higher than 37.3°C, patient should be asked to restrict him/herself at home and report to flu clinics in case of worsening of symptoms. All patients with cough should be immediately provided with a surgical mask at the reception and they should not be made to wait in queues. Do detailed PAC of all patients. Ask specifically about international travel or domestic travel in the affected areas in last fortnight by the patient or his family members. It is reemphasized to enquire about history of cough, fever and sore throat and a careful chest auscultation. All reusable equipment stethoscopes, BP instruments etc., should be frequently sanitized. At the end of the day, clean and disinfect PAC clinics and Pain clinics by thoroughly wiping the surfaces of furniture, equipment and floor with 2 to 3% hydrogen peroxide. Learn the correct method of using and disposing surgical masks. All PPEs after exposure should be locked in a double zip lock plastic bag and discarded in a touch-free disposal. After returning from hospital, take bath before greeting family members. Change the clothes and keep them in wash bucket. Institutes should counsel patients actively to reschedule elective/semi-emergency surgical procedures. This is especially for the elderly, paediatric and immuno-compromised patients. Defer interventional chronic pain procedures. Only emergency procedures to be done. Peri-Operative Anaesthesia Care Any patient with history of cough, fever or sore throat is usually investigated before surgery. Such patients should not undergo elective surgery and be investigated appropriately. Suspected cases should be kept in designated isolation area by the institute and reported to appropriate authorities. Emergency Surgery in suspected/confirmed COVID 19 Patients: Dedicated Operation Theatres to be used for all confirmed or suspected COVID-19 infected patients. These operation theatres should be labeled “COVID-19 Operation Theatre” and large clear bill boards and signage, visible from a distance, should be placed outside such OTs. COVID-19 infected patients should be wheeled through separate/isolated corridors to the operation theatre. The patients should be wheeled directly in to the OT. They should not stay in pre-medication room at all. Since majority of operation theatres in India are not negatively pressurized, the positive pressure system and air conditioning must be turned off. Laminar flow and the functional high-efficiency filters are preferable. All operation theatre staff should wear PPE including anaesthesiologists, surgeons, nurses, technician, bearer, sweeper, etc. PPE included one piece special gown, properly fitted N95/N99 mask, eye shield and double gloves. Wear hospital scrubs inside and protective coveralls outside; wear a medical protective mask, disposable surgical cap, and goggles/face shield; and wear disposable medical latex gloves and boot covers. The suggested sequence for putting on personal protective equipment is as follows: putting on scrubs and hair cover → performing hand hygiene → putting on the mask → putting on inner gloves → putting on the coverall → putting on eye protection (goggles/face shield) → putting on foot protection → putting on the isolation gown → putting on outer gloves → test the fit of the personal protective equipment components. Place all equipments and drugs required for the anaesthetic management in a tray and avoid handling of the drug trolley during the case. Place two high quality Heat and Moisture Exchange Filters (HMEFs). First, between tracheal tube and breathing circuit; and the second between expiratory limb and anaesthesia machine. These HME filters can remove up to 99% of airborne particles 0.3 microns or greater, thus help in preventing contamination of OT atmosphere. Standard routine anaesthesia monitoring to be instituted. Prefer regional anaesthesia, where ever possible. A surgical mask or N95 mask must be applied to the patient throughout the length of stay in the operating room. In case supplementary oxygen is needed, the oxygen mask is applied over the surgical mask or N95 mask. For general anaesthesia, pre-oxygenate for five minutes with 100% oxygen. Avoid high flow oxygen to prevent aerosolization. Ask the patient not to cough. It is prudent to cover the patient's nose and mouth with two layers of wet gauze to block some of the secretions. Rapid sequence induction and tracheal intubation (with cricoid pressure) to be done in the first attempt. Ensure adequate neuromuscular blockade to avoid bucking that can increase aerosolization. Immediately inflate the tracheal tube cuff before starting ventilation. The choice of induction drugs is dictated by haemodynamic considerations. Midazolam with etomidate or propofol, depending upon patient's haemodynamic condition, can be used for induction. Fentanyl is recommended for analgesia. If no contraindications are present, succinylcholine 1 mg/kg should be administered for tracheal intubation. Avoid manual ventilation to prevent aerosolization of virus from airways. If manual ventilation is required, apply small tidal volumes. Tracheal intubation should be done by experienced anaesthesiologists. Limit the number of anaesthesia team personnel (maximum three) inside the OT. Second clinician with PPE can be available outside the OT for immediate assistance. Avoid awake fibreoptic intubation whenever possible. Nebulization with local anesthetic will aerosolize the virus. Video-laryngoscope (if available) can be used to improve intubation success. Also, it may increase the distance between the patient's airway and that of the anaesthesiologist who performs the intubation. Re-sheath the laryngoscope blade immediately post intubation with the outer glove worn by the operator. Use low gas flows and closed circuits. Limit the ventilatory disconnections and, if needed, do at end expiratory phase. A closed airway suction system, if available, is preferable to decrease viral aerosol production. If it is not available, the suction should be done by minimum members of the team. Supraglottic airway devices should be used only in 'cannot ventilate' situations. This will avoid manual bagging and provide rescue oxygenation. Prophylactic administration of anti-emetic drug is preferred to reduce the risk of vomiting and viral spread. Tracheal extubation should be done on table, as far as possible. After tracheal extubation, patient to be transferred to the isolation ward. If tracheal extubation is not feasible, then shift the patient to designated Intensive Care Unit (ICU). During transfer, the team should wear proper PPE outside the operating room. The patient should be covered with one disposable operating sheet and then transferred through a dedicated lobby and elevator. The patient must wear a surgical mask or N95 mask during transfer. The surfaces of passage ways and the elevator should be cleaned. If the patient is kept intubated, a single-patient-use Ambu bag with HME filter attached must be used during transfer. Do not use a ventilator during transfer. Discard breathing circuit, mask, tracheal tube, HME filters, gas sampling line and soda lime after every patient. Water trap to be changed if it becomes potentially contaminated. Seal all used airway equipment in a double zip-locked plastic bag. It must then be removed for decontamination and disinfection. After removing protective equipment, avoid touching your hair or face before washing hands. A minimum of one hour is planned between cases to allow OT staff to send the patient back to the ward, conduct through decontamination of all surfaces, screens, keyboard, cables, monitors and anaesthesia machine with 2 to 3% hydrogen peroxide spray disinfection, 2-5 g/l chlorine disinfectant, or 75% alcohol wiping of solid surfaces of the equipment and floor. The hydrogen peroxide vaporizer is an added precaution to decontaminate the OT. All unused items on the drug tray and airway trolley should be assumed to be contaminated and discarded. All staff has to take shower before resuming their regular duties. In resource limited settings, where adequate personal protective equipments are not available, it is imperative to refer the patient to a centre with such facilities. Intensive Care/Critical Care Unit The case must be reported by the local health authorities to the national body within 24 hours in their own jurisdiction and transferred to isolation cabin in the ICU. As many ICUs are not equipped with negative and positive pressure regulations in India, an alternative approach is using HEPA-Carbon-Photocatalysis air purification systems as alternate means of source control. Supportive therapy in the form of supplemental oxygen and antipyretics should be immediately started. Liberal fluid administration should be avoided for risk of worsening oxygenation and periodic hemodynamic assessment used to guide goal-directed therapy. Along with it, adequate nutritional support with balanced proportions of proteins, carbohydrates, vitamins and minerals boosts immunity to fight the infection. Empirical antimicrobials must be given within one hour based on the clinical diagnosis, local epidemiology and susceptibility data to cover all likely pathogens causing community acquired pneumonia even if suspected to have COVID. Post tracheal intubation by rapid sequence intubation, lung protective strategies involving use of lower tidal volumes (4–8 ml/kg predicted body weight), high PEEP and lower inspiratory pressures (plateau pressure <30 cmH2O) for meeting the pH goal of 7.30-7.45 have been postulated to prevent volutrauma, barotraumas, atelectotrauma and biotrauma. Deep sedation with midazolam, propofol or fentanyl infusions are recommended to curb patient's respiratory drive and prevent dyssynchrony. The few indications of continuous neuromuscular blockade in the setting of severe ARDS are ventilator dyssynchrony, inability to achieve target tidal volumes or refractory hypoxemia/hypercapnia. In fulminating cases, prone ventilation for 12-18 hours per day is useful. Cardio Pulmonary Resuscitation “Protected Code Blue” should be followed, with emphasis on use of N-95/N-99 masks and specialized PPEs during resuscitation due to high risk of airborne transmission. There should be disposable resuscitation packages instead of trolley. All the team members should wear PPEs and then enter the isolation bringing the defibrillator and packages along with. It is reemphasized that wear masks, do regular hand wash and maintain social distancing. Let's work together to maintain health of our great nation India. Long Live ISA ! Jai ISAian !! Jai Hind !! Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
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Simulation-based training in anaesthesiology: a systematic review and meta-analysis.
Bruce Cook, Christopher Brydges, Leslie Lorello … (2014)
Simulation has long been integrated in anaesthesiology training, yet a comprehensive review of its effectiveness is presently lacking. Using meta-analysis and critical narrative analysis, we synthesized the evidence for the effectiveness of simulation-based anaesthesiology training. We searched MEDLINE, ERIC, and SCOPUS through May 2011 and included studies using simulation to train health professional learners. Data were abstracted independently and in duplicate. We included 77 studies (6066 participants). Compared with no intervention (52 studies), simulation was associated with moderate to large pooled effect sizes (ESs) for all outcomes (ES range 0.60-1.05) except for patient effects (ES -0.39). Compared with non-simulation instruction (11 studies), simulation was associated with moderate effects for satisfaction and skills (ES 0.39 and 0.42, respectively), large effect for behaviours (1.77), and small effects for time, knowledge, and patient effects (-0.18 to 0.23). In 17 studies comparing alternative simulation interventions, training in non-technical skills (e.g. communication) and medical management compared with training in medical management alone was associated with negligible effects for knowledge and skills (four studies, ES range 0.14-0.15). Debriefing using multiple vs single information sources was associated with negligible effects for time and skills (three studies, ES range -0.07 to 0.09). Our critical analysis showed inconsistency in measurement of non-technical skills and consistency in the (ineffective) design of debriefing. Simulation in anaesthesiology appears to be more effective than no intervention (except for patient outcomes) and non-inferior to non-simulation instruction. Few studies have clarified the key instructional designs for simulation-based anaesthesiology training.
Author and article information
Journal
Journal ID (nlm-ta): Indian J Anaesth
Journal ID (iso-abbrev): Indian J Anaesth
Journal ID (publisher-id): IJA
Title:
Indian Journal of Anaesthesia
Publisher:
Wolters Kluwer - Medknow
(India
)
ISSN
(Print):
0019-5049
ISSN
(Electronic):
0976-2817
Publication date
(Print):
May
2020
Publication date
(Electronic):
23
May
2020
Volume: 64
Issue: Suppl 2
Pages: S136-S140
Affiliations
Author notes
Address for correspondence: Dr. Tatikonda Chandra Mouli, Department of Anaesthesiology and Critical Care, GSL
Medical College, Rajahmundry - 533 296, Andhra Pradesh, India. E-mail:
chandradasavatar@
123456gmail.com
Article
Publisher ID: IJA-64-136DOI: 10.4103/ija.IJA_452_20
PMC ID: 7293371
PubMed ID: 32773853
SO-VID: de0e1aeb-e30b-475f-adf9-c48fe2010bd0
Copyright © Copyright: © 2020 Indian Journal of Anaesthesia
License:
This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
History
Date
received
: 26
April
2020
Date
revision received
: 04
May
2020
Date
accepted
: 15
May
2020
Categories
Subject:
Original Article
ScienceOpen disciplines: Anesthesiology & Pain management