Coronavirus (2019-nCoV) Information for Health Care Professionals

While it is not possible for ASA to timely develop an official policy statement or guideline for this emergent crisis, we believe it is critical that we provide immediate resources to help mitigate risks associated with the coronavirus outbreak on the provision of safe anesthesia care. The following information was prepared by members of ASA's Committee on Occupational Health and is based upon our current understanding of the crisis.

The recent outbreak of respiratory illness, first detected in Wuhan City, Hubei Province, China, is caused by a newly detected corona virus named “2019-nCoV.” To date, health officials have reported thousands of infections with 2019-nCoV in China, and infections are being reported in a growing number of international locations, including the United States.

Limited information is available to characterize the spectrum of clinical illness associated with 2019-nCoV; however, infection is generally associated with cough, shortness of breath and, in many cases, fever. No vaccine or specific treatment for 2019-nCoV infection is available; care is supportive. The severity of the illness ranges from mild symptoms of short duration to severe symptoms with respiratory failure that may be fatal.

Epidemiologic evidence demonstrates that person-to-person spread of the virus is occurring. However, the exact mode of viral transmission, the ease by which the virus is transmitted, and the sustainability of ongoing person-to-person transmission is not known at present.

Chinese health officials posted the full genome of the 2019-nCoV; this information suggests that the virus recently emerged from a virus related to bat coronaviruses and the severe acute respiratory syndrome (SARS) coronavirus.

This “newly emerged” coronavirus is similar to the coronavirus that causes SARS and Middle Eastern respiratory syndrome (MERS). The Centers for Disease Control and Prevention (CDC) clinical criteria for a patient known or suspected to be infected with the 2019-nCoV are based on what is known about MERS-CoV and SARS-CoV and are subject to change as additional information becomes available. Detailed epidemiologic information regarding SARS and MERS is available as an addendum below.

Epidemiologic information from SARS and MERS outbreaks suggests that the maximum apparent incubation period would be about about 10 days. Until better evidence is available, suspect infection with the 2019-nCoV in patients reporting new fever or respiratory symptoms occurring within 10-14 days of contact with suspected coronavirus-infected patients. Patients known or suspected of infection should be asked to wear a surgical mask and be evaluated in a private room with the door closed. Ideally, they should be placed in an airborne infection isolation room, if available. An airborne isolation room has a negative pressure relative to the surrounding area, and the outgoing air is passed through a high-efficiency particle air (HEPA) filter. In contrast, a typical operating room is designed to provide positive-pressure relative to the outside, with flow-directed, filtered, temperature- and humidity-controlled incoming air.

A reverse transcriptase test is available for positive identification of the virus. Currently, this test is only done at the CDC in Atlanta.

SARS and MERS are known to be primarily transmitted by droplets. Droplets are larger liquid particles that settle from the air rapidly and typically do not travel more than 3-6 feet from the source. Droplets may be transmitted directly by settling on a potential host’s mucous membranes or indirectly by settling on surrounding environmental surfaces and then spread by hand contact to vulnerable hosts. Hand hygiene and other contact precautions are important ways to prevent spread of droplet infections.

Droplets may be “aerosolized” into smaller particles by coughing or sneezing. Importantly, procedures such as intubation, airway suctioning, bronchoscopy or extubation also may generate aerosols. The smaller particles may become suspended in air currents in which they may travel longer distances. The particles may not be effectively filtered by a surgical mask. For these reasons, the CDC recommends that health care professionals employ airborne precautions (see below) when caring for patients with a known or suspected infection with the 2019-nCoV virus, and especially when performing airway procedures on them.

Further details regarding the symptoms associated with 2019-nCoV can be found on the CDC website; this CDC link also provides guidance in evaluating, treating and reporting patients known or suspected of infection. The World Health Organization (WHO) also provides a document titled, “Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected.”  Timely information on the outbreak can be obtained from the WHO website.

Recommendations:

Personal protection

• Health care professionals entering the room should use airborne precautions. Wear an N95 respirator mask, which filters 95 percent of particles > 0.3 microns in diameter. Airborne precautions also call for the use of eye protection (e.g., goggles or a face shield), gowns and gloves to prevent the transmission of droplets and smaller airborne particles that settle on environmental surfaces and mucous membranes. Hand hygiene (using an alcohol-based hand rub) is essential before and after donning gloves.

Procedural planning

• If anesthesia or surgery is planned
• Postpone non-urgent surgical procedures until the patient is determined to be non-infectious or not infected.
• When surgery cannot be postponed, schedule procedures when a minimum number of health care workers and other patients are present in the surgical suite.
• Leave as much time as possible before subsequent patient care (for the removal of airborne infectious contamination)
• When possible, perform minor procedures in the patient’s room.

Transport

• When transporting these patients for a procedure, don a fresh, clean gown and gloves to reduce contamination of environmental surfaces.
• When using a bag-valve-mask device on these patients, a HEPA filter should be inserted between the breathing device and the patient.

Procedures

• If general anesthesia is not required, the patient should continue to wear the surgical mask.
• If general anesthesia is used:
• Place a HEPA filter between the Y-piece of the breathing circuit and the patient's mask, endotracheal tube or laryngeal mask airway.
• Alternatively, for pediatric patients or other patients in whom the additional dead space or weight of the filter may be problematic, the HEPA filter should be placed on the expiratory end of the corrugated breathing circuit before expired gas enters the anesthesia machine.
• The gas sampling tubing should also be protected by a HEPA filter, and gases exiting the gas analyzer should be scavenged and not allowed to return to the room air.
• If available, use a closed suction system during airway suctioning. Closed suctioning systems may only be available in the critical care setting.
• After the patient has left the operating room, keep the room vacant until 99.9 percent air turnover is achieved (e.g., for an operating room with a minimum of 15 air exchanges per hour, 28 minutes at minimum are needed).
• After the case, clean and disinfect high-touch surfaces on the anesthesia machine and anesthesia work area with an Environmental Protection Agency-approved hospital disinfectant.
• Consider disposable covers (e.g., plastic sheets for surfaces, long ultrasound probe sheath covers) to reduce contamination of equipment and other environmental surfaces
• Point of care ultrasound
• A long sheath cover of the ultrasound unit and cable should be used for both vascular access procedures and regional blocks (contact with non-intact skin) and trans thoracic exams (intact skin) to minimize contamination of the equipment.
• Non-essential parts of the ultrasound cart may best be covered with drapes to minimize droplet exposure of other attached ultrasound probes, the electrical cords and supply bins that are frequently handled or accessed.

Addendum
SARS is also a severe acute respiratory illness with symptoms of fever, cough and shortness of breath. SARS was first reported in Asia in February 2003; the illness subsequently spread to more than two dozen countries in North America, South America, Europe and Asia. The outbreak was eventually contained, and SARS has not been reported anywhere in the world since 2004. In 2003, the WHO reported SARS mortality by age as follows: 6 percent for 25-44 years; 15 percent for 45-64 years; 50 percent for over 65 years.

MERS was first reported in Saudi Arabia in September 2012. Symptoms were similar in nature to those associated with SARS. In closed high-contact settings, MERS coronavirus is considered highly infectious and pathogenicity is relatively low. To date, independent risk factors for infection with MERS were direct contact or sharing a room with a confirmed case-patient. Few outbreaks of MERS-CoV outside of healthcare settings have been documented. Limited transmission within families has been reported, but secondary attack rates in households or in settings outside of health care facilities (e.g., farms) are uncommon.