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Year : 2020  |  Volume : 64  |  Issue : 14  |  Page : 146-147  

Simple innovations in the operating room amid the COVID-19 pandemic

Department of Anaesthesiology, Government Medical College, Thiruvananthapuram, Kerala, India

Date of Submission06-Apr-2020
Date of Decision04-May-2020
Date of Acceptance09-May-2020
Date of Web Publication23-May-2020

Correspondence Address:
Dr. Varun Suresh
Department of Anaesthesiology, Government Medical College, Thiruvananthapuram, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ija.IJA_353_20

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How to cite this article:
Suresh V. Simple innovations in the operating room amid the COVID-19 pandemic. Indian J Anaesth 2020;64, Suppl S2:146-7

How to cite this URL:
Suresh V. Simple innovations in the operating room amid the COVID-19 pandemic. Indian J Anaesth [serial online] 2020 [cited 2020 Oct 29];64, Suppl S2:146-7. Available from: https://www.ijaweb.org/text.asp?2020/64/14/146/284908

Personal Protective Equipment (PPE) is imperative to ensure the safety of health care workers (HCW) in infection scenarios. Shortage of PPEs can endanger HCWs worldwide. As COVID-19 tightens its grip relentlessly, overwhelming mankind with its sinister spread that spares none, it is the sacrosanct responsibility of every institution to act in earnest – not only to contain, but also to conquer the scourge that threatens our very survival. We had been quick to hear and respond to the call of duty at this hour of crisis in providing early guidelines to HCWs of our institution;[1] and now here we bring forward 5 new PPE strategies. The first 3 techniques have been implemented in our institution, whereas the other 2 are our postulates for a forlorn circumstance of unavailability of PPEs.

The optimal way to prevent aerosol transmission is to use a combination of interventions and not just the PPE alone. Applying a combination of protective strategies can provide added safety even if one intervention fails or is not available.

Protective goggles offer considerable eye protection and are an indispensable part of any PPE kit. Though it is advised that HCWs using spectacles to use goggles over those spectacles, this is usually cumbersome. Protective face shields are a good alternative to this but are of limited availability. We made an indigenous single-use face shield at our institution using a simple technique. A transparent A4-size Over Head Projector (OHP) display plastic sheet was stitched with cloth/water proof drape sheets on to tailor-made sponge such that the ends of the cloth can be used as strap to tie this around the user's forehead [Figure 1]a. The A4 size is suitable in that it does not swipe on the users shoulder or chest and the cushions ensure comfort by avoiding contact with the user's face, thereby preventing fogging while providing an unobstructed view even for the HCW wearing prescription spectacles. The cost of production is very cheap and affordable.
Figure 1: (a) Single use face-shield made of transparent over-head projector display foil. (b) Improvised aerosol-box with arm-ports (the transparent acrylic box is covered with brown paper to enhance visibility of the image). (c) The patient side of aerosol-box – note the curved margins aids the ease of use in obese patients and for transfer of airway adjuncts (the transparent acrylic box is covered with brown paper to enhance visibility of the image). (d) Covering the patient head-end extensively with transparent plastic drapes prevents aerosol dissemination. (e) A high quality bacterial/viral filter attached to a non-vented non-invasive ventilation/anaesthesia face mask

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Endo-tracheal intubation generates the highest quantity of aerosols (Odds ratio 6.6).[2] Intubation by an expert anaesthesiologist with a video-laryngoscope is recommended for a COVID-19 case.[3],[4] The second PPE we implemented is a transparent, light-weight and durable “improvised aerosol-box” made of acrylic [Figure 1]b and [Figure 1]c. The improvement we made in the standard aerosol-box[5] is that it has a curve on each side to facilitate its use in obese patients and for the ease of providing cricoid pressure. The anaesthesiologist can perform endo-tracheal intubation through the 2 arm-ports at the proximal end in a reasonable time-frame, while he is shielded from droplets and macro-aerosols. Intubation using video-laryngoscope with detachable display module can provide enough working space inside the aerosol-box.[3],[4] Placing an active suction inside the box will aid in removal of aerosols collected within. The average cost of production of one such unit in our setting is between INR 2500-3000. The advantage with this device is that it is reusable after dis-infection with any of the virucidal disinfectants.

The third PPE we implemented is the use of a transparent plastic drape that covers extensively the patient's head-end during endo-tracheal intubation [Figure 1]d. An expert anaesthesiologist can perform endo-tracheal intubation manoeuvring the Video-laryngoscope below this drape having unobstructed vision through it. Preferring a video-laryngoscope with detachable display module can avoid dissemination of aerosols as much as possible. After the surgery the drape can be safely rolled outside-in and discarded. These are readily available as c-arm covers or drape sheets for surgical use at an affordable cost.

The fourth strategy we hypothesise is the use of a transparent c-arm cover or theatre top-light cover, to screen the head to mid-trunk of the anaesthesiologist performing intubation. The safety of this procedure is amended by the anaesthesiologist breathing oxygen delivered through a venti-mask with a reservoir-bag while performing the procedure. This way, a positive pressure atmosphere is generated inside the transparent screen which disperses the aerosols away while removing the cover. Compared to the previous techniques we described, this is a crude method which requires to be used only in an outrageous circumstance of unavailability of PPE. However, scenarios requiring use of even bin-bags as PPE is reported recently even in developed nations when resources got depleted amid the COVID-19 pandemic.[6]

Unavailability of N95 masks is a concern during pandemics like COVID-19. We postulate a personal protective intervention using the anaesthesia face mask or a non-vented non-invasive mechanical ventilation face mask attached to a high quality bacterial/viral filter [Figure 1]e fastened with a harness while the anaesthesiologist perform airway procedures. The face mask and the harness can be disinfected after the procedure though the single-use filter need be discarded, escalating the cost of use when compared to the N95 mask. This further is among the last resort techniques for personal protection from infective aerosols.

The best practice models have reiterated that preserving available resources is the need of the hour during this pandemic.[7] We hope that our experience in implementing “home-made” PPE's shall serve as guidance to future efforts on breaking the chain of COVID-19 spread.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Suresh V. The 2019 novel corona virus outbreak – An institutional guideline. Indian J Anaesth 2020;64:242-3.  Back to cited text no. 1
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Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: A systematic review. PLoS One 2012;7:e35797.  Back to cited text no. 2
Malhotra N, Joshi M, Datta R, Bajwa SJ, Mehdiratta L. Indian society of anaesthesiologists (ISA national) advisory and position statement regarding COVID-19. Indian J Anaesth 2020;64:259-63.  Back to cited text no. 3
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Bajwa SJ, Sarna R, Bawa C, Mehdiratta L. Peri-operative and critical care concerns in coronavirus pandemic. Indian J Anaesth 2020;64:267-74.  Back to cited text no. 4
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Canelli R, Connor CW, Gonzalez M, Nozari A, Ortega R. Barrier enclosure during endotracheal intubation. N Engl J Med2020. doi: 10.1056/NEJMc2007589. [Epub ahead of print]  Back to cited text no. 5
Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A,et al. Fair allocation of scarce medical resources in the time of Covid-19. N Engl J Med 2020. doi: 10.1056/NEJMsb2005114. [Epub ahead of print]  Back to cited text no. 7


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