指南与共识 | 新型感染患者的围手术期管理

● 陈向东（共同执笔人），刘艳红（共同执笔人），龚亚红（共同执笔人），郭向阳，左明章，李军，时文珠，李皓，徐宵寒，米卫东（共同负责人），黄宇光（共同负责人）

The outbreak of Coronavirus disease (COVID-19) that began in December 2019in Wuhan, China, has attracted great attention from the internationalcommunity. By February 24, 2020, more than 77,000 cases including 2,595 deathshave been reported in China and in 27 other countries worldwide. Because theoutbreak of COVID- 19 has required many healthcare workers to provide directcare to infected patients, they are at high risk of infection. Despite greatefforts to control the spread of the disease and minimize human-to-humantransmission, more than 3,000 healthcare workers have been infected accordingto reports by the Chinese Center for Disease Control as of February 12, 2020.1 The risk of gettingCOVID-19 for healthcare workers is much greater than that of the generalpopulation. Anesthesiologists likely have an even higher risk than healthcare workersof other subspecialties because anesthesiologists manage the airway andventilation. This requires them to be adjacent to the airway of patients duringemergency airway intubation outside the operating room, while taking care ofcritically ill patients in the intensive care unit (ICU) and while providingperioperative care for patients undergoing urgent and emergency surgeries.Several anesthesiologists have been infected after providing trachealintubation for confirmed COVID-19 patients, although the exact number ofinfected anesthesiologists is yet unknown. Meanwhile, because the operatingroom is a busy environment, it further increases the risk of nosocomialinfections of the perioperative team including anesthesiologists. Therefore,urgent development of safe medical practices and infection prevention protocolsfor the perioperative management of patients with COVID-19 is needed. Tosummarize best practices, the Chinese Society of Anesthesiology (CSA) and theChinese Association of Anesthesiologists (CAA) jointly formed this task forceand drafted these recommendations. This document was created based on WorldHealth Organization2 and National HealthCommission guidelines for the prevention and treatment of COVID-19,3 clinical experiences fromthe most frontline care providers,4–6 and a comprehensive review of updated literature on theperioperative management of infectious patients.7–9 This first edition is not intended to replace anyexisting guidelines on anesthesia care and infectious disease control. Rather,it is aimed at providing recommendations on how to manage this specific patientpopulation when anesthesiologists provide care either in the perioperativesetting or in the management of the airway of patients outside the operatingroom. We hope the recommendations from the experts who have managed patients onthe frontlines and who have firsthand experience can help our colleaguesprovide the best care to our patients, including the care of providersthemselves, and prevent those who are not infected from becoming infected. Werealize that there is a lack of well-designed and executed studies to supportthese recommendations. However, these recommendations are based on theexperience of the frontline healthcare workers who have observed its effectiveness.This task force will be continuously working on and updating the followingversions in a timely manner.

COVID-19

PathogenicCharacteristics

The causative agent of COVID-19, also called 2019-nCov or SARS-CoV-2,belongs to the cluster of Betacoronavirus in the family of Coronaviridae of theorder Nidovirales, which includes Bat-SARS-like (SL)-ZC45, Bat-SL ZXC21,SARS-CoV, and MERS-CoV.10 The diameter of 2019-nCoV varies from about 60 to 140 nm.The virus particles have quite distinctive spikes of 9 to 12 nm in length,which gives the virus the appearance of a solar corona. When isolated andcultured in vitro, the virus can be found in human respiratoryepithelial cells in about 96 h.11 The 2019-nCoV virus is sensitive to ultraviolet light andheat and can be inactivated at 56°C for 30 min. Ethyl ether, 75% ethanol,chlorine disinfectant, peracetic acid, and chloroform are effective ininactivating the virus. However, chlorhexidine has been found to beineffective.3

EpidemiologicCharacteristics

Currently, individuals infected with 2019-nCoV are the main source oftransmission. Even individuals who are infected but asymptomatic can shed thevirus and play a critical role in its transmission.3 The vectors of transmission are respiratory droplets or close/directcontact. Aerosol propagation is also possible in the case of prolonged exposureto high concentrations of the aerosols in a relatively closed environment.Individuals of all ages are susceptible to 2019-nCoV. The elderly or those withmajor medical comorbidities are more vulnerable to become critically ill oncebecoming infected. By January 31, 2020, more than 20 pediatric cases have beenreported in China. Fortunately, children often have mild clinicalpresentations.1,12

ClinicalManifestations and Treatment

Based on current epidemiologic data, the incubation period of COVID-19ranges from 1 to 14 days, mostly ranging from 3 to 7 days.1,13 The most commonmanifestations in patients are fever, weakness, and dry cough. However, a smallfraction of patients present with nasal congestion, runny nose, sore throat,and diarrhea. Severe cases often develop dyspnea and/or hypoxemia a week afterthe onset of the first symptom. In critically ill cases, it progresses rapidlyto acute respiratory distress syndrome, septic shock, refractory metabolicacidosis, coagulopathy, and multiorgan failure. The chest x-ray film orcomputed tomography imaging is characterized, in the early phase, by multiplesmall band film shadows and interstitial changes (obvious in the extranodallung), which then develop into multiple ground glass shadows and infiltrationin both lung fields. In severe cases, lung parenchymal pathology may occur, butpleural effusion is scarcely observed. Based on the clinical presentations, laboratorytests, and imaging studies, the severity of illness in patients infected with2019-nCoV can be categorized as mild, moderate, severe, and critical.Currently, there is no effective drug to prevent its transmission or to treatinfected patients. Patients in the mild category are managed mainly with restor antibiotics if a secondary bacterial infection is suspected or evident.Severe and critically ill patients should be admitted to an ICU promptlybecause patients in this category often require respiratory and/or circulatorysupport.

Currently, antiviral medications including α-interferon (5 million U or equivalent dose foradults, 2 ml of sterile water for injection, twice a day), lopinavir andritonavir tablets (200 mg/50 mg, twice a day), ribavirin (500 mg, intravenous   injection, twice a day for adults), and chloroquine phosphate (500 mg,twice a day for adults) have been recommended by the Chinese National HealthCommission.3 Infusion plasma frompatients who have completely recovered from infection with 2019-nCoV andtraditional Chinese medications have also been attempted. However, theeffectiveness of these therapies for COVID-19 remains to be determined.

Precautions for 2019-nCoV Infection

(1) 2019-nCoV can cause severe acute respiratory infection, and inhalingdroplets generated from the respiratory tract of the individuals infected withthe virus has been identified as the primary route of transmission. 

(2)Healthcare workers should receive systemic training on in-hospital infectioncontrol, strictly implement standard prevention protocol, and apply correctisolation and protective measures in order to safely provide care to patients.Psychological support may also be needed for healthcare workers providingdirect care to infectious patients (fig. 1).

Figure 1.Psychological preparation and self-encouragement

(3) When a healthcare worker provides care to the patient, he or sheshould immediately implement and strictly adhere to the standard infectionprevention and control measures and assess and triage the patient according tohis or her severity.

(4)   Standard prevention measures include 

•  universal precaution, 

• handwashing with soap or hand hygiene with 2 to 3% hydrogen peroxide, 

•  use of personal protective equipment (gloves, mask, and goggles), 

• standardhandling of medical waste disposal to prevent needle stick or cutting injury, 

• equipment cleaning anddisinfection, as well as environment disinfection (2 to 3% hydrogen peroxide spraydisinfection, 2 to 5 g/l chlorine disinfectant, or 75% alcohol wiping of solidsurfaces of the equipment and floor).

Precautions in Perioperative Settings When Caring for Patients with Suspected or Confirmed COVID-19

AnesthesiaPreoperative Evaluation Clinic

(1) Recommended personal protective equipment for healthcare workers inthe anesthesia preoperative evaluation clinic should include white medicalgowns, medical gloves, eye protection shields, disposable surgical caps, andsurgical masks or test-fit N95 masks or respirators.

(2) Patients receiving an anesthesia preoperative evaluation should enterthe consulting room one by one to minimize close contact with the clinician andother individuals.

(3) Patients’ body temperatures should be measured (electronic earthermometer) before entering the consulting room. If the body temperature ishigher than 37.3°C, he or she must be escorted to the clinics for feverdisorders immediately and should be reported to the infection control officeron duty of the hospital. Patients with normal body temperature can proceed withthe evaluation at the anesthesia clinic.

(4) During the first encounter, the anesthesiologists should take adetailed history and conduct a thorough physical examination, particularly acareful chest examination.

(5) Hand hygiene must be performed after contact with each patient with 2to 3% hydrogen peroxide solution or gel, or by washing hands with soap andwater.

(6) Suspected cases of infection with 2019-nCoV even with normal bodytemperature should be reported to the infection control officer on duty at thehospital immediately.

(7) At the end of a shift, cleaning and disinfection procedures areapplied in the anesthesia clinic appropriate for 2019-nCoV by thoroughly wipingthe surfaces of furniture, equipment, and floor with 2 to 3% hydrogen peroxide.

Patient Preparation for Emergency Surgeries

(1) Patients requiring emergency surgery should complete the primarytriage before being admitted to the hospital. A secondary triage beforeentering the operating room should be performed by anesthesiologists, includingreviewing the medical history, a brief physical examination, and reviewing thechest computed tomography and/or chest x-ray. The body temperature should beretaken. Individuals who are ruled out of COVID-19 should undergo the surgicalprocedure normally if the surgery is urgent or emergent.

(2) If COVID-19 is suspected or confirmed, nonemergency surgicalprocedures should be canceled or postponed. In cases of urgent or emergencyprocedures, patients should be placed in the isolation holding area andtransferred to the operating room dedicated to the patients with COVID-19.

(3) Patients with suspected or confirmed infection with the virusidentified in a nondedicated hospital for COVID- 19 must be reported to theinfection office of the institution and transferred to a designated hospitalprovided the patient is stable for transfer.

AnesthesiaManagement in the Dedicated Operating Room

PreoperativePreparation

(1) The in-room anesthesia care team should communicate with the officerin charge of infectious disease control at the hospital level and inform him orher that the patient with COVID-19 is to be transferred to the dedicatedoperating room.

(2) The dedicated operating room and anteroom should be equipped with anegative pressure system, and an appropriate level of negative pressure must beensured. In a hospital where negative pressure operating rooms are unavailable,the positive pressure system and air conditioning must be turned off.

(3) A dedicated operating room only for patients with COVID-19 must belabeled “infectious surgery” on the door of the operating room. Only personnelinvolved in direct care are allowed to enter the dedicated operating room. Thefunctionality of the operating room must be ensured by technical personnelincluding the appropriate operation of laminar flow and the functionalhigh-efficiency filter.

(4) An anesthesia machine is dedicated to the dedicated operating room.There is a lack of a consensus for now on how to perform disinfection before itis used for noninfected patients. However, feedback from the practice providersin Wuhan, China, suggests that after disinfection as recommended in this paper(refer to “Anesthesia Equipment Care and Operating Room Disinfection,” below),the anesthesia machine can be used in other non–COVID-19 patients, and nocross-infection has been reported so far.

(5) Artificial nose (also called breathing circuit filter) must beinstalled between the proximal end of the endotracheal tube and the distal endof the circuit. The filter can also be placed on each limb of the circuit atthe interface of the circuit and the anesthesia machine. Because thespecifications of the filter vary from different manufacturers, the anesthesiacare team should check with the manufacturer and learn its effectiveness inblocking pathogens. It is recommended to replace the filter after every 3 to 4h of anesthesia use.

(6) Personal protective equipment that the in-room anesthesiologist wearsmust meet the following protective standards:

• wear hospital scrubs insideand protective coveralls outside; 

• wear a medical protective mask,disposable surgical cap, and goggles/face shield; 

• wear disposablemedical latex gloves and boot covers. The suggested sequence for putting onpersonal 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 eyeprotection (goggles/face shield) → putting on foot protection→ putting on the isolation gown → putting on outer gloves → test the fit of thepersonal protective equipment components → ready to pass through the yellow zone and enterthe red zone.

AnesthesiaManagement

Types ofAnesthesia

(1) General anesthesia is recommended for patients with suspected orconfirmed COVID-19 to reduce the risk of patients coughing and bucking, whichcan generate airborne material and droplets. Other types of anesthesia can beselected dependent on the type of surgery and the individual patient’s need. Ifthe patient is not intubated, a surgical mask or N95 mask must be appliedto thepatient throughout the length of stay in the operating room.

(2) Spinal anesthesia is still recommended as the primary choice ofanesthesia for cesarean delivery in a mother with COVID-19. The infected mothermust wear a surgical mask or N95 mask all the times. In case supplementaryoxygen is needed, the oxygen mask is applied over the surgical mask or N95mask. General anesthesia can be used as a backup plan in case spinal anesthesiafails or intraoperative conversion to general anesthesia is indicated.

GeneralAnesthesia Induction

(1) It is recommended that rapid sequence induction should beused, and appropriate preparation for rapid sequence induction should besimilar to that of an ordinary patient. Induction must be initiated after a completesatisfactory check of personal protective equipment for every person in theoperating room. The complete check includes a self-check and, more importantly,a check by another colleague (fig. 2).

Figure 2. PPE Self-check and inspected by another colleague

(2) During preoxygenation, it is recommended to cover the patient’s noseand mouth with two layers of wet gauze to block some of the patient’ssecretions and place the anesthesia mask superimposed onto the wet gauze.Caution should be taken to ensure that the wet gauze does not obstruct thepatient’s airway. Sufficient muscle relaxation should be obtained to preventcoughing during intubation.

(3) Oral intubation with a video laryngoscope or bronchoscope, ifavailable, is preferred. For physicians who are very familiar with the use ofthe fiberscope, the fiberscope can also be used for intubation after inductionof anesthesia because it may significantly increase the distance between thepatient’s airway and that of the anesthesiologist who performs the intubation.One disposable fiberscope should be dedicated to a single given patient. If anondisposable fiberscope is used, cleaning and disinfection should be conductedafter completion of each case using ethylene oxide or hydrogen peroxide plasma.When using a direct laryngoscope for intubation, extra attention is needed toreduce patients’ coughing and/or bucking. Transnasal bronchoscopic intubationcould be an alternative option when oral intubation is impossible orcontraindicated.

(4) A closed airway suction system, if available, is recommended to reduceviral aerosol production. If it is not available, the team should keep theminimal but necessary number of suctions using a nonclosed suction system.

Recovery fromAnesthesia

It is recommended that patients with COVID-19 should be sent to anisolation room in the ICU after surgery, bypassing the postanesthesia careunit. Once the patient meets the criteria for extubation, he or she should beextubated in the operating room. Before extubation, two layers of wet gauze canbe used to cover the patient’s nose and mouth to minimize exposure to thepatient’s secretions during extubation.

PatientTransfer

(1) If a suspected or confirmed COVID-19 patient is stable after surgeryand does not meet the criteria for admission to the ICU, he or she should betransferred directly back to the negative-pressure ward or isolation ward afterextubation in the operating room.

(2) During transfer, the circulating nurse and anesthesiologist shouldwear proper personal protective equipment outside the operating room. Thepatient should be covered with one disposable operating sheet and then transferredto the negative-pressure or isolation ward through a dedicated lobby andelevator. The patient must wear a surgical mask or N95 mask during transfer. Thesurfaces of passageways and the elevator should be cleaned and covered.

(3) If the patient is kept intubated, a single-patient-use respiratory bagmust be used during transfer. It is not recommended to use a ventilator duringtransfer.

Disposal

Anesthesia Equipment Care and Operating Room Disinfection

(1) All of the anesthesia equipment, supplies, and medications must beused for only one patient exclusively. Anesthesia supplies that directlycontact the patient’s skin or mucosa should be single use, including the videolaryngoscope blade, reinforced tubes, anesthesia masks, filters, breathingballoons, suction tubes, and/or catheters, end-expiratory carbon dioxidesampling tubes, water traps, etc.

(2) All anesthesia equipment should be cleaned and disinfected promptly.The carbon dioxide absorber is recommended to be replaced between cases as itprovides a large surface area in the anesthesia machine. The respiratorycircuit within the anesthesia machine should be disinfected between cases andat the end of the shift. The recommended disinfection procedure of theventilator on the anesthesia machine consists of either disassembly andsterilization with high temperature, if feasible, or disinfection with 12%hydrogen peroxide or ozone (≥100 mg/m3) using a disinfection machine. The surface of theanesthesia machine, laryngoscope handles, and other nondisposable equipmentshould be cleaned and disinfected with 2 to 3% hydrogen peroxide, 2 to 5 g/lchlorine disinfectant wipes, or 75% alcohol wipes after the completion of eachcase and again at the end of the shift.

(3) The anesthesia cart and other anesthesia facilities must be cleanedand disinfected following the same process. The infection control team of theoperating room keeps a checklist and tracks the cleaning and disinfection ofequipment and facilities in a timely manner.

(4) The operating room used for patients with confirmed or suspectedCOVID-19 pneumonia should be fully disinfected with 2 to 3% hydrogen peroxidesprays, and then wiped with 2 to 3% hydrogen peroxide, 2 to 5 g/l chlorinedisinfectant, or 75% alcohol. The cleaning personnel should complete sufficienttraining on cleaning, disinfection, and self-protection before work in thededicated operating room.

(5) The transfer bed used for patients with COVID-19 should be cleaned anddisinfected with 2 to 5 g/l chlorine disinfectant.

Disposal of MedicalWaste

(1) Medical waste should be sorted and disposed of without delay. All themedical waste should be double-bagged and labeled “COVID-19,” along with thename of the department, institute, date and time, and the category.

(2) Before being taken out of the contaminated area, all the packing bagsshould be sealed and sprayed with chlorinated disinfectant or covered with anadditional bag and sealed. Medical waste produced in the clean area can betreated in a routine fashion.

(3) All healthcare workers participating in the surgery should removetheir personal protective equipment and place the personal protective equipmentin a designated waste bag in an anteroom. Personal protective equipment shouldbe removed in the following order: 

shoe covers → gloves → hand hygiene → goggles/face shield → hand hygiene → the gown → hand hygiene → the protective mask → hand hygiene → the head cover → hand hygiene → shower and change into personal clothing.Nondisposable personal protective equipment should be packed into medical wastebags and placed in a designated area.

Considerations for Emergency Tracheal Intubation of Suspected or Confirmed COVID-19 Patients outside the Operating Room

The proportion of patients infected with 2019-nCoV and requiring trachealintubation outside the operating room is high. It is estimated that more than70% of patients with COVID-19 in the ICU in Wuhan, China, are intubated. Therisk of exposure to healthcare workers during tracheal intubation outside theoperating room appears to be higher than in the operating room, as intubationis frequently emergent and the intubation condition is suboptimal. Therefore,it is critical to apply precautions during airway management outside theoperating room.

Indications for Endotracheal Intubation

Our criteria for intubation include acute respiratory distress with arespiratory rate greater than 30 per minute, acute hypoxemic (Pao2/inspired oxygenfraction (Fio2) less than 150 mmHg) orhypercarbic respiratory failure, no improvement after 2 h of high-flow oxygentherapy or alternative methods of noninvasive ventilation, or loss ofconsciousness and/or inability to protect the airway.

Preintubation Preparation

(1) Endotracheal intubation is an aerosol-producing highrisk procedure.Therefore, intubating patients warrants specific precautions and should beundertaken in an airborne isolation room. All healthcare workers involved inintubation must use appropriate airborne/droplet personal protective equipment.The personal protective equipment with specifications described above (step 6,“Preoperative Preparation” section under “Anesthesia Management in the DedicatedOperating Room”) should be applied properly, including the test-fit N95 mask,protective whole-body garment, two layers of gloves, goggles or face shield,and the waterproof gown.

(2)When possible, intubation should be performed by an experiencedanesthesiologist assisted by another clinician (anesthesiologist or intensivecare physician) in order to minimize the number of attempts and production ofairborne material/droplets from the patient.

(3) Equipment preparation for intubation is similar to that of an ordinarycase including laryngoscope, endotracheal tube, anesthetics, vasoactive drugs,suction device, ventilators, standard monitoring, and venous access. However,the organization of the equipment drugs must be sufficient as visualization andaccess to the equipment and drugs are often suboptimal due to restricted spaceand vapor condensation on the eye shield (fig. 3).

Figure 3. Emergency intubation cart

(4) The team should choose the airway devices that they are most familiarwith, including but not limited to: 

• a video laryngoscope with disposableblades;

• a disposable video-optic stylet or disposable video endotrachealtube; 

• a disposable second-generation intubating laryngeal mask; 

• a kitfor emergency cricothyroidotomy; 

• if available, preparation of a disposableflexible video bronchoscope; 

• if available, preparation of supraglotticand subglottic airway compatible with the insertion of an endotracheal tube.Periodical injection of 2% lidocaine 2 to 3 ml or 1% lidocaine 4 to 6 mlthrough the working channel can reduce irritation and minimize the coughing ofthe patient. For physicians who are very familiar with the use of the videolaryngoscope or fiberscope, the video laryngoscope or fiberscope is recommendedbecause it may significantly increase the distance between the patient’s airwayand that of the anesthesiologist who performs intubation (fig. 4).

Figure 4. Intubation with video laryngoscopes andkeeping distance from the head of patient  

(5) A high efficiency breathing circuit filter should be installed betweenthe mask and the breathing circuit or respiratory bag, and at the proximal endof the breathing circuit as well. However, the efficiency of the filter inblocking the virus is undetermined. Therefore, once the ICU ventilator is usedfor a patient confirmed with COVID-19, it should be dedicated to patients withCOVID-19 only. The disinfection of the ICU ventilator for use on a patient notinfected with the virus is the same as described in “Anesthesia Equipment Careand Operating Room Disinfection.”

(6) A closed airway suction system is, if available, recommended to reduceviral aerosol production. If it is not available, the team should keep theminimal but necessary number of suctions using a non-closed suction system.

Precautionsfor Intubation

(1) Intubation should be performed by experienced anesthesiologists, andrepeated intubation attempts should be minimized to reduce the risk ofexposure.

(2) Oral intubation with a video laryngoscope or bronchoscope, if available,is preferred. When using a direct laryngoscope for intubation, extra attentionis needed to reduce patients’ coughing and/or bucking. Transnasal bronchoscopicintubation could be an alternative option when oral intubation is impossible orcontraindicated.

(3) The team should remove the outer gloves immediately after completionof intubation and put on a fresh pair of gloves.

(4) Be aware that adequate mask seal and minute alveolar ventilationresults in adequate preintubation oxygenation. If high flow oxygenation isrequired, the providers should be cautious as high flow oxygen increases theproduction of viral droplets and aerosol. The patient’s mouth and nose shouldbe covered with two layers of wet gauze, ensuring that it does not obstruct theairway. The preoxygenation mask is superimposed over the gauze. For patientsalready on noninvasive mechanical ventilation, preoxygenation can be achievedwith 100% oxygen for 5 min without alternating the ventilatory settings. Thebag-mask ventilation setting can be useful as a backup option.

(5) For patients with a normal airway, modified rapid sequence inductionis recommended. Sufficient muscle paralysis should be achieved after loss ofconsciousness. However, the team must be aware that the apnea oxygenation timeis often extremely short, and great effort is needed to avoid severe hypoxemia.The choice of induction drugs is dictated by hemodynamic considerations.Midazolam 2 to 5 mg with etomidate (10 to 20 mg) or propofol, if the patient’shemodynamics allow, can be used for induction. Fentanyl 100 to 150μg orsufentanil of 10 to 15 μg is recommended to be administered intravenously foran adult patient to suppress laryngeal reflexes and provide optimal conditionsfor intubation. If no contraindications are present, succinylcholine 1 mg/kgshould be administered immediately after loss of consciousness, and intubationcan be carried out after muscle fasciculation is completed. If rocuronium 1mg/kg is used, sugammadex should be immediately available in case “cannotintubate/cannot oxygenate” is encountered. For critically ill patients withCOVID-19 pneumonia, patients may develop pulmonary hypertension. The care teammust make a great effort to avoid or minimize hypercarbia. 

(6) For patientswith an anticipated difficult airway and awake intubation is unavoidable, awakeoral fiberoptic or video laryngoscopy intubation can be done with sufficientsedation and topicalization with lidocaine or tetracaine through thecricothyroid membrane, pharyngeal cavity, oral cavity, and airway cathetersurface.

(7) Be prepared for an unanticipated difficult airway. This is similar tothat for the care of an ordinary patient. However, the preparation should bemore robust as help is limited and equipping personal protective equipment istime consuming. In addition, obtaining a clear view of the glottis is extremelychallenging due to vapor condensation on the eye shield or goggles.

(8) Confirm the correct position of the endotracheal tube. In many cases,personal protective equipment and reduced breathing sounds may limit the roleof auscultation. Proper positioning of the endotracheal tube can be confirmedby direct visualization of the endotracheal tube passing through the vocalcords, observing bilateral chest rise and proper capnography waveform, andperforming bronchoscopy if necessary. The appropriate depth of the endotrachealtube can be determined by the insertion markers at the upper incisors in adult men (22 to 23 cm) and women (20 to21 cm), respectively. Chest radiography should be performed at the earliestavailability.

AirwayManagement after Intubation

(1) Oral or tracheal suction should be performed with a closed suctionsystem after intubation.

(2) Appropriate cleaning and disinfection of patient-care equipment andenvironmental surfaces are mandatory to reduce transmission (refer to“Postanesthesia Equipment Care and Medical Waste Disposal”).

(3) Personal protective equipment removal should refer to “Disposal ofMedical Waste.” Personal protective equipment should be removed appropriatelyunder the careful supervision of an infection control officer. Hand hygienemust be performed after removing personal protective equipment. Do not touchthe hair or face before proper hand hygiene. A thorough whole-body shower isalso highly recommended after removing personal protective equipment, includingoral, nasal, and external auditory canal disinfection.

(4) Personal protective equipment used during intubation must be kept in acontaminated area and must not be taken back to the operating room.

Surveillance of Anesthesia Providers after Caring for Confirmed or Suspected Patients

(1) If healthcare workers who had direct contact with confirmed orsuspected patients develop fever, cough or fatigue, they must inform the occupationalhealth department of the hospital. Complete blood tests including C-reactiveprotein and chest computed tomography should be performed. If a healthcareworker meets the criteria for medical observation, he or she should beself-isolated at home.

(2) The criteria of medical observation for COVID-19 are as follows:         

• epidemiologic history: travel within 14 days to the city of Wuhan or contactwithin 14 days with confirmed or suspected COVID-19 cases; 

• clinicalmanifestations: fever, radiological characteristics of viral pneumonia, reducedlymphocyte count and normal or reduced leukocyte count in the early phase, andunresponsiveness or even deterioration after a 3-day regular antibiotictreatment.

(3) All cases under medical observation should be reported to the officeof infection control and rounded on by a dedicated team. The level of care mustbe adjusted promptly based on the assessment.

References

1. The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team:The epidemiological characteristics of an outbreak of 2019 novel Coronavirusdiseases (COVID-19) — China, 2020. China CDC Wkly 2020; 2:113–22

2. World Health Organization: Rational use of personal protectiveequipment for coronavirus disease 2019 (COVID-19). Interim guidance. Availableat: https://www.who.int/emergencies/diseases/novel-coronavirus-

2019/technical-guidance/infection-prevention-and-control. AccessedFebruary 27, 2020.

3. National Health Commission and National Administrative Office ofChinese Tradition Medicine: National Recommendations for Diagnosis andTreatment of Pneumonia Caused by 2019-nCoV (6th edition). Available at:http://www.nhc.gov.cn/yzygj/s7653p/202002/8334a8326dd94d329df351d-7da8aefc2.shtml.Accessed February 18, 2020. [Chineseonly]

4. Jin Y-H, Cai L, Cheng Z-S, Cheng H, Deng T, Fan YP, Fang C, Huang D,Huang L-Q, Huang Q, Han Y, Hu B, Hu F, Li B-H, Li Y-R, Liang K, Lin L-K, LuoL-S, Ma J, Ma L-L, Peng Z-Y, Pan Y-B, Pan Z-Y, Ren X-Q, Sun H-M, Wang Y, WangY-Y, Weng H, Wei C-J, Wu D-F, Xia J, Xiong Y, Xu H-B, Yao X-M, Yuan YF, Ye T-S,Zhang X-C, Zhang Y-W, Zhang Y-G, Zhang H-M, Zhao Y, Zhao M-J, Zi H, Zeng X-T,Wang Y-Y, Wang X-H, Management for the Zhongnan Hospital of Wuhan UniversityNovel Coronavirus Research Team, Evidence-Based Medicine Chapter of ChinaInternational Exchange, Promotive Association for Medical and Health Care: Arapid advice guideline for the diagnosis and treatment of 2019 novelcoronavirus (2019-nCoV) infected pneumonia (standard version). Mil Med Res2020; 7:4. Accessed February 6, 2020.

5. Chinese Society of Anesthesiology Task Force on Airway Management:Expert recommendations for tracheal intubation in critically ill patients withnovel Coronavirus pneumonia (version 1.0). Chin J Anesthesiol 2020; 40 [Epubahead of print, Chinese only]

6. Perioperative Infection Control Society of Chinese Society ofCardiothoracic and Vascular Anesthesia, PLA Society of Anesthesiology andResuscitation: Guidelines and recommendations for perioperative infectioncontrol in patients with 2019 novel coronavirus. Perioper Saf Qual Assur2020;4:63–6 [Chinese only]

7. Wax RS, Christian MD: Practical recommendations for critical care andanesthesiology teams caring for novel Coronavirus (2019-nCoV) patients. Can JAnesth 2020:1–9 [Epub ahead of print]

8. Park J, Yoo SY, Ko JH, Lee SM, Chung YJ, Lee JH, Peck KR, Min JJ:Infection prevention measures for surgical procedures during a Middle EastRespiratory Syndrome outbreak in a tertiary care hospital in South Korea. SciRep 2020;10:1–8

9. Missair A, Marino MJ, Vu CN, Gutierre J, Missair A, Osman B, GebhardRE: Anesthetic implications of Ebola patient management: A review of theliterature and policies. Anesth Analg 2015;121:810–21

10. Chen Y, Liu Q, Guo D: Emerging coronaviruses: Genome structure,replication, and pathogenesis. J Med Virol 2020; 92:418–23

11. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, Zhao X, Huang B, Shi W,Lu R, Niu P, Zhan F, Ma X, Wang D, Xu W, Wu G, Gao GF, Tan W; China NovelCoronavirus Investigating and Research Team: A novel Coronavirus from patientswith pneumonia in China, 2019. N Engl J Med 2020; 382:727–33

12. Chen ZM, Fu JF, Shu Q, Chen YH, Hua CZ, Li FB, Lin R, Tang LF, WangTL, Wang W, Wang YS, Xu WZ, Yang ZH, Ye S, Yuan TM, Zhang CM, Zhang YY: Diagnosisand treatment recommendations for pediatric respiratory infection caused by the2019 novel coronavirus. World J Pediatr 2020 [Epub ahead of print]

13. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, GuX, Cheng Z, Yu T, Xia J, Wei Y, Wu W, Xie X, Yin W, Li H, Liu M, Xiao Y, Gao H,Guo L, Xie J, Wang G, Jiang R, Gao Z, Jin Q, Wang J, Cao B: Clinical featuresof patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497–506

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