COVID-19 TREATMENT GUIDELINEIN TANZANIA, MARCH 2021
Posted by ULY CLINIC
25 Machi 2021 06:10:45
The guidance is based on proper case management aspects intended for clinicians involved in the care of patients with suspected or confirmed COVID-19. It is not meant to replace clinical judgment or specialist consultation but rather to strengthen frontline clinical management and the public health response.
NOTE. THIS GUIDELINE IS THE POPERTY OF MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT, GENDER, ELDERLY AND CHILDREN
14.2. SURGERY AND PROCEDURES IN CONTEXT OF COVID-19
Aims
Minimize risk to both patient and health care team, as well as minimizes utilization of necessary resources, such as beds, ventilators, personal protective equipment (PPE), and unexposed health care providers and patients.
• Some adjustment in our routine surgical practices are necessary so as to address the conservation of critical resources such as ventilators and Personal Protective Equipment (PPE), as well as limiting exposure of patients and staff to the SARS-CoV- 2 virus.
• The priorities given below will guide surgeons/physicians on how best to provide surgical /anesthetic services and procedures to save a life, preserve organ function, and avoid further harms from underlying condition.
• There are different levels of urgency related to patient needs, and judgment is required to discern between these. However, if the numbers of COVID-19 patients requiring care escalates, the surgical care of patients should be limited to those whose needs are;
- Imminently life threatening (loss of life, limb),
- LSCS,
- Patients with malignancy requiring curative surgery where option of radiation or chemotherapy to prevent progress does not exist.
• All other procedures should preferably be delayed until after the peak of the pandemic is seen.
• Consent to be taken from Patient/Surrogate to undergo surgery/ procedure during pandemic COVID-19
• All COVID-19 confirmed positive surgeries should be preferably performed on the special allocated OT room or OT. This OT will be considered as CONFIRMED COVID- 19 OT.
A. In theatre
• Minimum number of staff in theatre.
• Full protective PPE including visitors for all staff in theatre.
• Stop positive ventilation in theatre during procedure and for at least 20 minutes after the patient has left theatre
• Only senior and skilled anesthesiologists to intubate and extubate. Endeavour must be to ensure smooth estuation.
• Smoke evacuation for diathermy / other energy sources
• Patients are intubated and extubated in theatre – staff immediately present should be at a minimum. Cases requiring postoperative ventilation should be deferred whenever feasible till after the peak of the pandemic is over, both to
reduce exposure of healthcare workers and to keep resources like ventilators available for pandemic.
B. Operational Principles
These guidelines provide decision support for the perioperative management of patients requiring anesthesia and surgical services. They are prioritized in the context of PPE availability, PPE reuse capability, and testing capacity.
• All perioperative patients will be clinically screened for symptoms of COVID-19 (new cough, shortness of breath, fever in the last 7 days; known exposure to COVID-19 positive person).
• The surgical team should adhere to the universal precautions in all occasions; assume every surgical patient is Covid-19 positive and therefore protect yourself and protect others
• Patients will be categorized as asymptomatic, asymptomatic with exposure risk, or symptomatic
• Pre-symptomatic patients may shed SARS-CoV-2 from the nasopharynx and oropharynx
• Pre-symptomatic patients require appropriate considerations and PPE for Aerosol Generating Procedures (AGP) including intubation.
• All patients undergoing urgent, time sensitive, and elective procedures should preferably undergo laboratory testing for COVID-19
• All COVID laboratory testing must be performed within 72 hours’ pre-procedure
• Time allowing, all medically necessary time-sensitive cases and elective cases will be asked to socially distance for 2 weeks prior to COVID testing and self- quarantine from time of testing until day of their surgical procedure.
• It is recognized that emergency cases and some urgent cases may be time prohibited with respect to testing and social distancing; appropriate PPE and workflow will be required
• The number of providers in any operating room will be minimized
C. Definitions:
Standard COVID PPE:
Team members don full contact, droplet, and airborne PPE. Minimum PPE includes N95 respirator with face shield / goggles, gown and double gloves.
Augmented COVID PPE:
Team members don full contact, droplet, and airborne PPE. This includes PAPR/CAPR plus gown and double gloves.
High-Risk Surgeries:
These procedures require all team members to use of Standard COVID PPE unless patient is known COVID test negative then SOP for OR
• All thoracic surgery requiring lung isolation or tracheal / pulmonary resection
• Flexible Bronchoscopy of lower airways through ETT – Diagnostic (DLT and blocker placement), BAL, brushing, biopsy, transbronchial biopsy or similar.
• GI Endoscopy, TEE, ECT, cardioversion
• Scheduled cesarean section or other planned regional anesthetic with high likelihood of requiring conversion GA (mask or intubation)
Ultra-High-Risk Surgeries:
These procedures require all team members to use of Augmented COVID PPE unless patient is known COVID test negative then SOP for OR
• Any procedures on the glottis, oropharynx, nasopharynx, mastoid, or sinuses
• Any ENT/OMFS procedures using cautery, laser, drill or saw use within airway/oral cavity
• Any procedures utilizing operative rigid laryngoscopy or rigid bronchoscopy
• Any procedures on the subglottic airway involving incision of the airway (tracheostomy), dilation of the airway, laser or electrocautery debridement of the airway.
D. SCENARIO WHEN COVID LAB TESTING IS ABSENT
SCENARIO D1
• Asymptomatic. No exposure. Low risk procedure emergent or urgent
OR
• Asymptomatic with positive exposure, no symptoms after 14 days quarantine urgent low risk procedure
ANESTHESIA PROVIDER PPE
• N95 plus face shield/goggles or PARP/CARP
• Gown
• Double gloves
SURGEON/NURSING PPE
• SOP if not present for intubation otherwise the same as anesthesia providers
NOTES
• Minimize number of providers’ present
• 15 minutes wait time {following intubation for entry}
• 15 minutes wait time for egress following extubation
SCENARIO D2
• Asymptomatic, No exposure, emergent high risk procedure
ANESTHESIA PROVIDER PPE
• N95 plus face shield/goggles or PARP/CARP
• Gown
• Double gloves
• Augmented PPE indicated if ultra- high risk procedure
SURGEON/NURSING PPE
• N95 plus face shield/goggles or PARP/CARP
• Gown
• Double gloves
• Augmented PPE indicated if ultra-high risk procedure
NOTES
• PPE to be worn by all members throughout procedure
• Minimize number of providers present
SCENARIO D3
• Asymptomatic positive exposure emergent procedure OR
• Symptomatic emergent procedure
ANESTHESIA PROVIDER PPE
• N95 plus face shield/goggles or PARP/CARP
• Gown
• Double gloves
• Augmented PPE indicated if ultra- high risk procedure
SURGEON/NURSING PPE
• N95 plus face shield/goggles or PARP/CARP
• Gown
• Double gloves
• Augmented PPE indicated if ultra-high risk procedure
NOTES
• Presume positive
• PPE to be worn by all members throughout procedure
• 15 minutes wait time for egress following extubation or leave intubated based on the medical condition
• Minimize number of providers’ present
• COVID unit post op for R/O
F. SCENARIO WHEN COVID LAB TESTING IS PERFORMED
SCENARIO F1
• Asymptomatic, No exposure, urgent high risk procedure
• COVID negative
ANESTHESIA PROVIDER PPE
• SOP
SURGEON/NURSING PPE
• SOP
NOTES
• Post op home or non COVID unit
SCENARIO F2
• Asymptomatic, No exposure, urgent high risk procedure
• COVID positive
ANESTHESIA PROVIDER PPE
• N95 plus face shield/goggles or PARP/CARP
• Gown
• Double gloves
• Augmented PPE indicated if ultra- high risk procedure
SURGEON/NURSING PPE
• N95 plus face shield/goggles or PARP/CARP
• Gown
• Double gloves
• Augmented PPE indicated if ultra-high risk procedure
NOTES
• Minimize number of providers’ present
• 15 minutes wait time
• {following intubation for entry}
• 15 minutes wait time for egress following extubation
SCENARIO F3
• Symptomatic urgent procedure
• Outpatient
• COVID positive
ANESTHESIA PROVIDER PPE
• N95 plus face shield/goggles or PARP/CARP
• Gown
• Double gloves
• Augmented PPE indicated if ultra- high risk procedure
SURGEON/NURSING PPE
• N95 plus face shield/goggles or PARP/CARP
• Gown
• Double gloves
• Augumented PPE indicated if ultra-high risk procedure
NOTES
• Minimize number of provider’s present
• 15 minutes wait time
• {following intubation for entry}
• 15 minutes wait time for egress following extubation
SCENARIO F4
• Symptomatic urgent procedure
• Inpatient
• COVID positive
ANESTHESIA PROVIDER PPE
• N95 plus face shield/goggles or PARP/CARP
• Gown
• Double gloves
• Augmented PPE indicated if ultra- high risk procedure
SURGEON/NURSING PPE
• N95 plus face shield/goggles or PARP/CARP
• Gown
• Double gloves
• Augmented PPE indicated if ultra-high risk procedure
NOTES
• Minimize number of providers’ present
• 15 minutes wait time
• {following intubation for entry}
• 15 minutes wait time for egress following extubation
• Proceed to COVID unit
Updated,
25 Machi 2021 06:49:48
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