m.l scopy during covid-19 pandemic · dr kishore sandhu lecture, apla webinar indication of m.l...
TRANSCRIPT
M.L scopic surgeries in DMH during
COVID-19 pandemic
Dr Sachin Gandhi
MS ENT, FRCS
Dr Subash Bhatta
Senior Clinical RCS Fellow Laryngology
Deenanath Mangeshkar Hospital, Pune, India
Contents
Indication of M.L scopy during COVID 19 pandemic
Risk of COVID 19 during M.L scopy
Pre Operative preparation
Intubation
Risk of LASER plume
Extubation and patient transfer
OT disinfection
Airway
Tracheostomy(PI)
EXIT, CHAOS
Stridor with respiratory distress (BVCP, Congenital SGS, LSCTS….)
Congenital malformations with FTT (LM, clefts….)
FBs: Flex. Bronchoscopy avoids dry run Vs. Upfront rigid bronchoscopy
Aerodigestive FBs
Trauma (neck trauma, burns, inhalation, caustic injuries, epistaxis)
Deterioration of a compromised airway (past operated)
ABCESSES; SEVERE DYSPHAGIA (Zenkers) Other ENT emergencies
Laryngeal carcinoma
Dr Kishore Sandhu Lecture, APLA webinar
Indication of M.L scopy during COVID 19 pandemic
Risk of COVID 19 during M.L scopy
▪ Maximum aerosol generation due
to transmucosal airway
involvement during M.L scopy
▪ Exposure to LASER plume which
may contain COVID 19 virus adds to
the risk
Anaesthesist
during intubation and extubation exposure to aerosols
circuit, ventilators may get infected
Surgeon
exposed while introducing and removing D.L scope
during surgery due to air leak along the inflated cuff of ET tube
exposure to LASER plume
Health workers spread of aerosols in the OT room
instruments, Linen exposure, OT surfaces
Patient’s coughing and gagging may spread the aerosols, risk to all
Risk of COVID 19 during M.L scopy contd..
Pre Operative preparation
Avoid Pre and post op nebulization
Give betadine gargle to the patient*
Consider all patients as positive
Minimize the staff in OT
*The Use of Povidone Iodine Nasal Spray and Mouthwash During the Current COVID-19 Pandemic May Reduce Cross Infection
and Protect Healthcare Workers
Justin Kirk-Bayley, San Sunkaraneni, Stephen Challacombe
Pre Operative preparation contd..
Full PPE should be used by all
personals in the OT
Patient shifted in OT only when
personals and instrumentations are
ready
Negatively pressurized OT ideal, if
not then Laminar flow
Full PPE
❑ Laryngeal procedures considered aerosol generating
procedures
❑ all team members should wear PPE
❖ Gloves (double)
❖ Anesthesiologist should remove his outer glove after
intubation)
❖ Fluid resistant long sleeve gown
❖ N 95 mask fit tested, fit checked
❖ Eye protection- goggles, visors
❖ If the team or any member is using space suit, motorized
fan should not be used
Intubation
❑ use of rapid sequence preoxygenation followed by rapid sequence induction
❑ close circuits with cuffed ET tube, cuff pressure 20-30 mmhg
❑ apnea technique in selected cases
❑ use of breathing filter system
❑ use of long acting muscle relaxant like atracuronium
❑ intubation to be done with videolaryngoscope
A Framework for Prioritizing Head and Neck Surgery during the COVID-19 Pandemic
Michael C. Topf MD1, Jared A. Shenson MD1, F. Christopher Holsinger MD1, Samuel H. Wald, MD2,3, Lisa J. Cianfichi, N.P.3, Eben L. Rosenthal MD1, John B. Sunwoo MD1
Perioperative Care Provider’s Considerations in Managing Patients with the COVID-19 Infections Xiangdong Chen1 , You Shang1 , Shanglong Yao1 , Renyu Liu2 and Henry Liu3*
Techniques to be avoided
Spontaneous ventilation
high frequency jet ventilation (HFJV) and high frequency
nasal oxygen (HFNO)
bag and masking, laryngeal mask airway
positive pressure ventilation with inadequate seal
awake intubations as it involves atomized analgesia that
promotes coughing
short acting muscle relaxant, like Scoline
A Framework for Prioritizing Head and Neck Surgery during the COVID-19 Pandemic
Michael C. Topf MD1, Jared A. Shenson MD1, F. Christopher Holsinger MD1, Samuel H. Wald, MD2,3, Lisa J. Cianfichi, N.P.3, Eben L. Rosenthal MD1, John B. Sunwoo MD1
Perioperative Care Provider’s Considerations in Managing Patients with the COVID-19 Infections Xiangdong Chen1 , You Shang1 , Shanglong Yao1 , Renyu Liu2 and Henry Liu3*
▪ Preoxygenation by covering the patients with
plastic sheet
▪ Intubation with the help of videolaryngoscope
reduces the direct exposure of the
anesthetist to aerosol
▪ Surgical team should wait outside
the operating rooms during
intubation and extubation
Induction of the patient
Intubation simulation in lab
Plastic hood made with holes for
intubation
To reduce the aerosol spread in the OT
M.L scopy
▪ Microlaryngeal tube with cuff
inflated at 20-30 mmhg
M.l scopy with LASER
▪ Flexometallic double cuff ET
tube used
▪ Cuff inflated with saline mixed
with methylene blue
Cuff pressure should be more enough to prevent the
leak
At the same time it should be less enough not to cause
injury Double cuffed flexometallic tube
Microlaryngeal tube
Goggles to be used to allow visualization
through microscope as visualization may be
difficult due to hood or face shield
Avoid fogging of goggles/ face shield/ hood
with tight fitting mask over the nose
Endoscopic approach could be alternative
to microscopic for surgeryUse of monkey cap reduces fogging
M.L scopic approach
For air leakage, to reduce fogging
Endoscopic approach
▪ Rigid endoscope used along with
fiber transmission LASER such as
diode, KTP, CO2
▪ Surgeon is placed away from the D.L
scope which prevents direct
exposure to aerosol and LASER
plume
▪ Better visualization in video monitor
Inserting laryngoscope
Gamjee pad used while insertion and removal of the D.L
scope
It reduces the aerosol generation and spread into the OT
Gamjee pad should be removed during surgery to avoid the
LASER fire
Reduction of aerosol generation during
M.L scopy
Subglottis should be packed with cold saline soaked guage
during surgery to prevent the aerosol leak from lower airway
Microscope to be covered with drape, space left through the
drape for instrumentation and visualization
This reduces the generation of the aerosols in the OT
Reduction of aerosol generation during
M.L scopy contd..
Risk of LASER plume
risk of virus shedding (proved for
HPV, HIV)
controversial risk in COVID*
may spread throughout OT
*COVID-19 Pandemic: What Every Otolaryngologist–Head and Neck Surgeon Needs to Know for Safe Airway Management
Karthik Balakrishnan, MD, MPH*, Samuel Schechtman, MD*, Norman D. Hogikyan, MD Norman D. Hogikyan
*Coronavirus Disease 2019 (COVID-19) and dermatologists: Potential biological hazards of laser surgery in epidemic area
Seyed-Naser Emadia and Bahareh Abtahi-Naeinib
Double suction technique
One suction catheter to be placed
outside of D.L scope throughout
the surgery, another suction
catheter inside D.L scope
surgeon to use suction for
retracting tissues
To reduce the LASER plume
Fast extubation done, by covering the
patient with plastic sheet
Nobody allowed in the room during
extubation
Recommendations for Surgery During the Novel Coronavirus (COVID-19) Epidemic Zheng Liu1 & Yawei Zhang2,3 & Xishan Wang1 & Daming Zhang2,4 & Dechang Diao5 & K.
Chandramohan6 & Christopher M. Booth
Surgical management of cancer during the COVID-19 pandemic
Amar Prem, Swapnil Patel, Esha Pai, Durgatosh Pandey
Extubation and patient transfer
Shift the patient to recovery
❑ Infection isolation room
Disposal of PPE in designated place
Note writing and paper work, to be
done outside OT
Recommendations for Surgery During the Novel Coronavirus (COVID-19) Epidemic Zheng Liu1 & Yawei Zhang2,3 & Xishan Wang1 & Daming Zhang2,4 & Dechang Diao5 & K.
Chandramohan6 & Christopher M. Booth
Surgical management of cancer during the COVID-19 pandemic
Amar Prem, Swapnil Patel, Esha Pai, Durgatosh Pandey
Extubation and patient transfer contd..
Laminar flow in the OT to be closed after surgery
All surfaces cleaned
❑With detergent and 1000 ppm bleach
❑For atleast 30 minutes
Fumigate the OT with Peroxyacetic acid air
OT closed for 2 hours
Recommendations for Surgery During the Novel Coronavirus (COVID-19) Epidemic Zheng Liu1 & Yawei Zhang2,3 & Xishan Wang1 & Daming Zhang2,4 & Dechang Diao5 & K.
Chandramohan6 & Christopher M. Booth
Surgical management of cancer during the COVID-19 pandemic
Amar Prem, Swapnil Patel, Esha Pai, Durgatosh Pandey
OT disinfection
Thank you, Stay safe and alert
Operate only in dire emergency
Operate only with full Precautions