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A patient infected with the Ebola virus is admitted to your hospital’s intensive care unit. You are called to intubate the Ebola patient for respiratory failure. What do you do?
Discussion: The first patients infected with Ebola virus entered the United States in 2014. American physicians are inexperienced with caring for patients with this disease. Because of physicians’ commitments to care for the sick and injured, individual doctors will have an obligation to provide urgent medical care during disasters. This will include Ebola patients.
The American Society of Anesthesiologists (ASA) published Recommendations From the ASA Ebola Workgroup on October 24, 2014.
Select information in my column today is abstracted, copied, and summarized from this detailed publication. Let’s begin by reviewing some facts about the disease.
Ebola is an enveloped, single-stranded RNA virus, one of several hemorrhagic viral families first identified in a 1976 outbreak near the Ebola River in the Democratic Republic of the Congo.
Transmission of Ebola is via direct contact, droplet contact, or possibly contact with short-range aerosols. The virus is carried in the blood and body fluids of an infected patient (i.e. urine, feces, saliva, vomit, breast milk, sweat, and semen). Risky exposures include exposure of your broken skin or mucous membranes to a percutaneous contaminated sharps injury, to contaminated fomites (a fomite is an inanimate object or substance, such as clothing, furniture, or soap, that is capable of transmitting infectious organisms from one individual to another), or to infected animals.
The case definition for Ebola includes fever, an epidemiologic risk factor including travel to West Africa (or exposure to someone who has recently traveled there), and one or more of these symptoms: severe headache, muscle pain, vomiting, diarrhea, stomach pain, unexplained bleeding or bruising (appearing anywhere from 2 to 21 days after exposure), a maculopapular rash, disseminated intravascular coagulation, or multi-organ failure.
Although coughing and sneezing are not common symptoms of Ebola, if a symptomatic patient with Ebola coughs or sneezes on someone and saliva or mucus come into contact with that person’s eyes, nose or mouth, these fluids may transmit the disease. Ebola can survive outside the body on dry surfaces such as doorknobs and countertops for several hours. Virus in body fluids (such as blood) can survive up to several days at room temperature.
The treatment for Ebola is symptomatic management of volume status using blood bank products as indicated, and management of electrolytes, oxygenation, and hemodynamics.
Healthcare professionals must wear protective outfits when treating Ebola patients. Routine Personal Protective Equipment (PPE) must include the following (when properly garbed, there should be no exposed skin):
- Surgical hood to ensure complete coverage of head and neck,
- Single-use face shield (goggles are no longer recommended due to issues with fogging and difficulty cleaning),
- N95 mask,
- An impermeable gown (with sleeves) that extends at least to mid-calf or coverall without a one-piece integrated hood (consideration should be given to wearing a protective coverall layer under the impermeable gown, which allows for layered protection and progressively less contaminated layers when doffing),
- Double gloves (i.e., disposable nitrile gloves with a cuff that extends beyond the cuff of the gown), the cuff of the first pair is worn under the gown and the second cuff should be over the gown, impermeable shoe covers that go to at least mid-calf or leg covers (there must be overlap of the impermeable layers),
- Impermeable and washable shoes,
- An apron that is waterproof and covers the torso to the level of the mid-calf should be used if Ebola patients have vomiting or diarrhea.
Enhanced Precaution PPE is advised for aerosol generating procedures such as intubation, extubation, bronchoscopy, airway suction, and surgery. This is the recommended level of PPE for anesthesiologists. Enhanced Precaution PPE includes:
- Personal Air-Purifying Respirator (PAPR) with full face piece mask,
- A disposable hood that extends to the shoulders and is compatible with the selected PAPR,
- A coverall without one-piece hood,
- Triple gloves (i.e., disposable nitrile with a cuff that extends beyond the cuff of the gown), the cuff of the first pair is worn under the gown and the second cuff should be over the gown and taped, and a third pair of disposable extended cuff nitrile gloves,
- Impermeable and washable shoes,
- Impermeable shoe covers, and
- Duct tape over all seams.
PPE donning (i.e. dressing in PPE outfit) must be performed in the proper order and monitored by a trained observer using a donning checklist. There should be separate designated areas for storage and donning of PPE (an adjacent patient care area), one-way movement to the patient’s room, and an exit to a separate room or anteroom for doffing procedures and disposal.
Doffing (i.e. PPE removal) is a high-risk process that requires a structured procedure, a trained observer (also in PPE), and a designated removal area. Doffing needs to be a slow and deliberate process and must be performed in the correct sequence using a doffing checklist.
Let’s return to our original question. What about that stat intubation you were called to perform in the ICU?
Stat intubations are not to be attempted on Ebola patients by anesthesiologists until the physician has properly donned the Enhanced Precaution PPE outfit. This necessitates significant time. Full Enhanced Precaution PPE precautions are mandated regardless of an emergency status or acute deterioration in patient status. Fiberoptic bronchoscopes are not recommended as aerosolization will occur and adequate cleaning is difficult. All equipment brought into the patient’s room must remain there and will be unusable for an indefinite period of time. Due to the extended time necessary to properly don and doff Enhanced Precaution PPE, an intubation of an Ebola patient could potentially take ninety minutes or longer when accounting for proper donning and doffing procedures.
What about performing surgery and anesthesia on Ebola patients? Patients with severe active disease would not likely tolerate an operation due to the severity of their disease. Any decision to operate should weigh all risks and benefits, specifically the risk of death from the current severity of the Ebola disease, the risk of death from their surgical disease, and the risk of exposure to the operating room team against the likelihood of potential benefit of emergency surgery.
Every effort should be given to keeping the patient in their own isolation room, and moving surgical and anesthetic equipment to the bedside. If possible, all procedures should be performed in the patient’s room. Every effort should be given to keeping the patient in their own isolation room and moving surgical and anesthetic equipment to the bedside.
If it’s not feasible to perform the procedure or surgery in the intensive care unit room, an operating room should be designated for the patient. Preferably, this operating room should be away from traffic flow, have an anteroom, and not be connected to a clean core.
Transportation to and from the operating room hallways near the designated operating room should be blocked off. Adjacent operating rooms will be closed. Traffic flow must be limited to only essential personnel involved with the case. PPE must be donned prior to entering the patient’s room.
Recovery from anesthesia will occur in the operating room or the patient’s hospital room, and not in the Post Anesthesia Care Unit (PACU).
These are the recommendations regarding operating room anesthesia set-up:
- Drawers of the anesthesia machine should be emptied except for the bare minimum of supplies.
- All additional items from atop the machine removed.
- The drawers should not be accessed unless absolutely necessary.
- All paperwork/laminated protocols and non-essential items must be removed from the machine.
- The anesthesia cart should be removed from the room and will not be directly accessible once the patient enters.
- An isolation cart (stainless steel or other easily cleanable table) should be stocked with all anticipated medications, emergency medications, syringes, needles, I.V. fluids (multiple), I.V. supplies, arterial line supplies, tubing, suction catheters, NG tubes, endotracheal tubes of appropriate size, additional ECG electrodes, gauze, chlorhexidine or alcohol pads, saline flushes, an extra BP cuff, a sharps container, additional gloves, and any additional equipment and supplies which the anesthesia attending for the cases requests.
Once the patient enters the operating room, absolutely no entry or exit from the operating room will occur without following PPE protocols. As such, bathroom and personal needs should be attended to prior to transporting the patient.
These are recommendations from The American Society of Anesthesiologists Ebola Workgroup. American physicians hope the number of Ebola cases in the United States will approach zero. As anesthesiologists we hope we’ll never be called to intubate or perform anesthesia on a patient infected with Ebola, but we understand our commitment to care for the sick and injured, and we understand that we have an obligation to provide urgent medical care during disasters.
Every hospital in America is in the process of understanding and implementing the above procedures regarding the isolation and protection of healthcare providers from the Ebola virus. If an Ebola patient is admitted to your hospital, I refer you to the Association for Biosafety and Biosecurity.
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