COVID-19: American Society of Anesthesiologists Recommendations for Anesthesia Management

Since ASCs could be called upon to provide time-critical surgeries, ASCA shares these recommendations for anesthesia management during the COVID-19 pandemic prepared by the American Society of Anesthesiologists.

Reduction of Surgical and Interventional Procedures

Urgency of procedures exists along a continuum and those not time-critical should be rescheduled to a date when community transmission is no longer taking place. Time-critical procedures must be prioritized according to patient need and the resources of the facility. Ambulatory settings for surgery should be considered to reduce demand on hospital resources. This patient-centered approach, tempered with public health principles, will reduce the use of crucial protective equipment that might be needed for others, provide time for all health care providers to be oriented to the use of protective practices such as how to “don and doff” protective wear, and reduce exposure of health care workers to patients who might transmit COVID infection.

Prioritization of Procedures

There are many contingencies that an organization must consider, including, but not limited to, patient population, community COVID-19 spread, social distancing, equipment availability and type of elective procedure (Will a delay cause more harm?). Facilities, anesthesiology departments and other healthcare workers should work together to create their own institutional algorithm or decision tree based on these factors.

Anesthesia Work Environment

As there are unconfirmed reports of transmission before symptoms are showing and given the rapid spread, it may be challenging to identify and isolate patients carrying the virus. We, therefore, recommend an escalation of standard of practice during airway management for all patients to reduce exposure to secretions.

Airway Manipulation

ASA guidelines recommendations call for the anesthesia professional to consider measures that limit the potential for aerosolization of droplet particles. These include:

  1. Designating the most experienced anesthesia professional available to perform intubation, if possible.
  2. Wearing personal protective equipment (PPE) including:
    1. Either an N95 mask, for which one has been fit-tested, or a powered air-purifying respirator (PAPR);
    2. A face shield or goggles;
    3. A gown;
    4. Gloves.
  3. Avoid awake fiberoptic intubation unless specifically indicated.
  4. Consider a rapid sequence induction (RSI) in order to avoid manual ventilation of patient’s lungs and potential aerosolization. If manual ventilation is required, apply small tidal volumes.

Anesthesia Machine Maintenance

After the case, clean and disinfect high-touch surfaces on the anesthesia machine and anesthesia work area with an EPA-approved hospital disinfectant. The internal components of the anesthesia machine and breathing system do not need “terminal cleaning” if breathing circuit filters have been used as directed.

Alternative Deployment of Anesthesia Machines as Ventilators          

The ASA does not recommend repurposing anesthesia machines for use in ICUs. The breathing systems and user interfaces of anesthesia machine ventilators are very different from those of intensive care ventilators. Anesthesia machines are also unable to deliver some of the ICU-specific ventilation parameters and modes.

However, if the pandemic overcomes the capacity of the hospital ICUs to provide ventilators, unused operating room anesthesia machines can be repurposed for use in the ICUs.  (Note that this refers to hospitals, not specifically ASCs)

PPE for Anesthesia and Other Providers

Patterns of local COVID-19 infection that suggest transmission to a wider community-based pattern should lead to a reassessment of the risk profile of care provided to elective surgery patients without symptoms of COVID-19. Thus, inclusion of more effective PPE should be discussed with local experts in infectious diseases and infection control, considering local supply availability including N95 masks.

ASA recommends, consistent with the CDC, that an N95 mask be used for protection for aerosolizing procedures that include intubation. Issuance of N95 masks to all clinical anesthesia personnel would be optimal, when integrated with careful reuse following CDC and institutional guidelines. This would include wearing a face shield to protect the N95 mask from large debris.

If dispersion of potentially contaminated exhaled gases from an open airway (e.g. “MAC”) is a risk, consider alternate anesthesia plans. Potential contamination of your workspace and the room should be considered.

Neuraxial Blocks

The ASA unaware of coronavirus is a contraindication to a neuraxial block. Spinals and epidurals should take into consideration appropriate precautions, especially regarding COVID-19 patients or those suspected of having COVID-19. Such precautions may include isolating the infected or suspected patient and placing them in rooms identified for that purpose as well as having a dedicated operating room. Ideally, these operating rooms would be negative pressure rooms. We also recommend the use of N95 masks, double gloves, gowns and protective eyewear as appropriate.