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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 4-11

Operating room preparedness to manage future pandemics of airborne infectious diseases: What is needed?


Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India

Date of Submission17-Apr-2021
Date of Decision03-Jun-2021
Date of Acceptance11-Jun-2021
Date of Web Publication30-Jun-2021

Correspondence Address:
Dr. Medha Mohta
28 B, Pocket-C, SFS Flats, Mayur Vihar Phase III, Delhi - 110 096
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijamr.ijamr_88_21

Rights and Permissions
  Abstract 

The entire world has been in the grip of COVID-19 for more than a year and is susceptible to have further pandemics in future. Although elective surgical procedures should be postponed in infected patients, they may require emergency surgeries. At the beginning of the COVID-19 pandemic, most operating room (OR) setups were not as per the requirements. Hence, several modifications and innovations were made to handle the situation. The existing ORs were converted temporarily into COVID ORs using these modifications. However, now it is well understood that the world is quite susceptible to these types of infectious diseases, and special ORs will be required for surgical management of infected patients. Therefore, it becomes extremely important to prepare dedicated ORs for emergency surgeries in patients with airborne infectious diseases, which can be readily used to manage infected or suspected patients in the event of any future pandemic. We aim to review the current relatively scarce literature and answer some questions about the readiness and methods required for conducting safe surgery during the COVID-19 pandemic, as well as any other such pandemic in future. The preparations are needed in the field of infrastructure, staff requirements and management, equipment and other supplies, and formulation of guidelines for clinical management. The ultimate aim is to prevent spread of infection from the patient to the staff members, OR environment, and other patients without compromising the care of the infected patient. This review highlights these issues and also discusses specific concerns in some special patient populations.

Keywords: Aerosol-generating medical procedures, airborne infection, COVID-19, negative pressure ventilation, operating room preparedness, pandemic, personal protective equipment, surgical practice


How to cite this article:
Mohta M, Chilkoti GT. Operating room preparedness to manage future pandemics of airborne infectious diseases: What is needed?. Int J Adv Med Health Res 2021;8:4-11

How to cite this URL:
Mohta M, Chilkoti GT. Operating room preparedness to manage future pandemics of airborne infectious diseases: What is needed?. Int J Adv Med Health Res [serial online] 2021 [cited 2021 Nov 29];8:4-11. Available from: https://www.ijamhrjournal.org/text.asp?2021/8/1/4/319768


  Introduction Top


It has been more than a year since COVID-19 was declared a pandemic. It is a highly infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 caught the world unaware and unprepared. However, the entire medical system geared up to devise ways to fight this disease and save humanity from this deadly virus. New information emerged every day and led to the development of newer treatment strategies. Huge efforts were put in to develop vaccines and now with all the global endeavors, many vaccines against COVID-19 have been launched. All this progress increases the hopes to overcome this pandemic. However, at the same time, COVID-19 has demonstrated the susceptibility of the entire world to get infected by rapid spread of infectious organisms across international boundaries. This highlights the risk of further waves of COVID-19 and other future pandemics of airborne infectious diseases and hence a need to be adequately prepared to handle them.


  Search strategy Top


We conducted a comprehensive literature search using PubMed database from December 1, 2019, to May 15, 2021. The following search strategy was used: ”(COVID-19 OR 2019 novel coronavirus OR SARS-CoV-2) AND (surgical practice OR operation theater OR elective/emergency surgery OR operating room [OR] preparation). The filters applied were Case Reports, Clinical Trial, Journal Article, Meta-Analysis, Multicenter Study, Randomized Controlled Trial, Review, and Systematic Review. The titles and abstracts of each article were reviewed to evaluate their relevance to our review. Full-text articles were retrieved for further consideration for inclusion. Additional publications were identified in the references cited in the initial papers and recommendations of scientific organizations.

A total of 1287 articles were retrieved on PubMed search. Out of these, 57 were found to be directly relevant and were finally included in this review.


  General Considerations Top


Although the neglect of non-COVID elective surgeries has led to significant morbidity and mortality, it has been recommended to postpone all elective surgical procedures during a pandemic.[1],[2] This improves the availability of infrastructure as well as manpower to manage acutely ill patients. Moreover, surgery in infected patients may be associated with a poorer outcome due to lowering of cell-mediated immunity following surgery.[3] Lei et al. studied outcome of patients undergoing surgery during incubation period of COVID-19.[4] They conducted a retrospective analysis of clinical data of 34 such patients. All 34 patients developed COVID pneumonia in the postoperative period, 44% of patients required intensive care, and a high mortality rate of 20.5% was noted. This report highlights the importance of avoiding elective procedures and performing only emergency surgeries in infected patients. At the same time, ORs need to be kept ready, however small the number of surgical procedures may be.

As COVID-19 arrived, the OR infrastructure in most of the setups was not ideal or as per the requirements. Hence, several modifications were made to cope up with the situation and convert the existing ORs into COVID ORs. But now, having realized the requisites and the anticipated need of such an OR, it becomes extremely important to prepare ORs which can be readily used to manage infected or suspected patients in the event of any future pandemic.[5]


  Preparation of Isolation Operating Rooms Top


The preparations can be classified under the following headings:[6]

  • Infrastructure
  • Staff requirements and management
  • Equipment and other supplies
  • Formulation of guidelines for clinical management.


Infrastructure

Ideally, the hospital should have a separate block which can be quickly designated to manage infected or suspected patients in case of an infectious disease outbreak or a pandemic. This block should have OR, intensive care unit (ICU), high dependency unit, delivery suite, wards, along with self-sufficient Central Sterile Supply Department (CSSD), waste disposal, and other support services. This block may be in regular use, allocated to a specialized department, for example, obstetrics and gynecology, pediatric, neurosurgery, or endocrinology. In case of a “pandemic” like situation, it may be quickly converted to the 'infectious disease block'.

There should be a minimum distance of 20 m between this block and other nearby buildings.[7] If the hospital is located in a single building, a separate floor with the above mentioned facilities should be allocated for infected patients.

Various organizations across the world have suggested measures for OR management during the COVID-19 pandemic. Indian Society of Anaesthesiologists has also published an advisory and position statement on setting up and functioning of a COVID OR.[7]

A separate OR complex consisting of at least two independent ORs should be available. As we observed that most of the surgical cases performed in COVID-19 patients were obstetric in nature, one of the ORs should be dedicated for obstetric cases. The second OR may be used for surgical procedures from all other specialties. This may vary with the scope of services of the health-care facility.

Ventilation system

There should be separate ventilation system with high-efficiency particulate air (HEPA) filters for each OR.[8] The OR should have a negative pressure ventilation to reduce the viral spread and there should be at least 25 air exchanges per hour to minimize the viral load in the OR.[9],[10],[11] All doors should remain closed, and no personnel should exit the OR during the procedure.

The standard OR is maintained at positive pressure to minimize the risk of infection to the patient. The positive pressure along with adequate air exchanges provides optimal environment by rapidly removing the infectious particles. However, this is associated with a greater risk of infection spreading to adjacent areas. A negative pressure OR prevents dispersion of infectious organisms and improves safety of the staff working in adjacent areas, who may not be adequately protected with personal protective equipment (PPE).[12] Chow et al. described the conversion of a positive pressure OR to a negative pressure environment following SARS crisis in 2003.[13] They changed the pressure differentials by incorporating strong low-level exhaust system and making all the doors airtight and interlocking.

Before the construction of ideal negative pressure ORs is completed, temporary arrangements can be made to manage patients with airborne infections.[7] Most of the ORs have a recirculatory type of heating, ventilating, and air conditioning system that is connected to many other areas. This central air conditioning should be turned off, the return air ducts from the OR should be blocked, and exhaust blowers should be fitted to exhaust air into atmosphere after proper treatment. The air handling unit will need to draw outdoor air from an area which does not contain contaminated air. The volume of exhaust air must be greater than the volume of air supplied, to create a negative pressure of 2.5–5 Pa. Another alternative is to use standalone room air conditioners. Two split air conditioners of 2 tons capacity with 2–3 exhaust fans in each OR will make working conditions better. The exhaust air should be filtered through HEPA filters.[8] If these filters are not available, exhaust air can be treated by chemical disinfection with 1% hypochlorite, ultraviolet irradiation for 15 min, or heating at 75°C for 45 min. If these options are also not possible, the exhaust air may be let off into atmosphere away from the other air intake points at 3 m above the highest point of the building.

Zones of operating rooms

Rodrigues-Pinto et al. have described five zones of the COVID-19 OR complex.[14] Zone 1 is the entry room where the staff members don the basic PPE. Zone 2 should be for disinfection and surgical scrubbing and dressing. Zone 3 is the main OR which, on the other end, opens into zone 4, the exit room for removal of PPE. This doffing area must have facility for hand sanitization and bins for waste collection as per the guidelines of biomedical waste management. This room opens into the zone 5, the exit dressing room, which should have the shower facility.

Zone 1 donning must include disposable surgical scrubs, shoes, waterproof shoe covers, N95 mask, and protective glasses or face shield. Surgical hand preparation should be done using chlorhexidine gluconate soap and water. In zone 2, according to Rodrigues-Pinto et al., a surgical space suit or a second layer of sterile protective garment with disposable cap should be put on.[14] Hands must be scrubbed using aqueous alcohol solution followed by donning of first pair of gloves. Finally, the staff should wear a sterile surgical scrub suit followed by the second pair of gloves. The type of surgical gown or space suit may vary depending on the availability in an institution.

Patient transport

The patients should be transported to and from the COVID OR as rapidly as possible through a predefined route and designated elevators. A dedicated ambulance should be used for interhospital transfer.[15]

The patient should be wheeled in the OR through a separate corridor once the OR and the entire operating team are ready. A person with “clean hands” should accompany the transport team to handle elevator buttons.[16] The patient should wear a surgical mask, autoclaved hospital clothes, disposable cap, gloves, and shoe covers during the transport. A plastic sheet may be used to cover the patient. The patient's wounds, if any, should also be covered to contain body fluids.[16] The patients are not kept in the preoperative room and are directly wheeled in the OR.[17] Similarly, after the surgery is over, they are monitored on the OR table and then directly wheeled out to the isolation ward.[18] If the patient's trachea cannot be extubated after surgery, the patient should be shifted to COVID ICU.

Soon after the shifting of patient in OR, it should be kept closed. Any unnecessary trafficking to and from OR should be discouraged.[9],[15] The required items including equipment, drugs, and linen for the surgery must be arranged in anticipation.

Communication

Communication among the staff working in the OR with the PPE on may be difficult. Names of the personnel may be written on PPE to facilitate identification. Sign language should be practiced by the staff to facilitate proper communication. At the same time, communication with the personnel outside the OR is equally important. As the OR staff are not allowed to carry their bags and phones inside, intercom facilities must be there. If these are not available, a mobile phone in a transparent plastic cover may be kept inside the OR to communicate with the support staff and other personnel outside the OR.[7]

Staff requirements and management

Minimum required number of personnel should be present inside the OR.[11],[19] The anesthesiology, surgical, technical, and nursing teams should be as small as possible. The staff must be adequately protected before wheeling in the patient. They must exit only once the case is completed; their movement in and out of OR during the case must be avoided. An assistant from each team should be readily available outside the OR for help in case of any exigency.[20]

Surgeon, anesthesiologist, OR nurse, technician, and their assistants should have a “team huddle” to discuss and understand the plan for surgery and anesthesia.[6],[20] They should confirm the availability of surgical and anesthesia equipment, medications, and adequate PPE. This enables better teamwork, smooth conduct of the procedure, and reduces the need for movement of staff to get more supplies during the procedure.

Surgeons and other staff members whose presence is not required at the time of induction of anesthesia should stay outside and enter the OR only when induction and intubation have been completed.[19],[21] Similarly, they should leave the OR before the tracheal extubation.

All staff members working in the OR, including cleaners and laundry personnel, should don the complete PPE kit including N95 mask, face shield, goggles, body apron, double gloves, head cover, and shoe cover. They must receive adequate training in appropriate donning and doffing techniques using videos or simulation.[22] It is desirable to have one person to observe and guide them through the appropriate steps. They must change their outer gloves immediately after coming in contact with infected material or surfaces. The staff members should leave all nonessential objects such as pens, keys, or phones outside the OR.[18],[19]

Symptomatic staff members must isolate themselves and get tested.[22] The staff members should be provided with all material and psychological support to allay their anxieties about getting infected or carrying the infection to their families.

Equipment and other supplies

Only the essential equipment or material required on case-to-case basis should be placed in the OR, to minimize the number of items needing disinfection or disposal. The stock inside the OR should be minimal but adequate to carry out the procedure. Anesthetic trolley should also be prepared keeping this principle in mind. Similarly, surgical materials required should also be just enough in quantity and should be kept in sterilizable steel tray or basket.[15] Standby equipment and supplies such as linen and other consumables should be kept outside the OR. All the equipment and devices required during surgery need to be checked using checklists before shifting the patient in OR.[9]

The anesthesia workstation, monitors, and other equipment such as C-arm, laparoscope machines, and ultrasound devices should be covered with transparent water-resistant disposable plastic sheets.[7],[17],[23] These sheets need to be removed and changed after each case. However, extreme caution is needed while removing these sheets; otherwise, this can lead to further spread of infection to the personnel and equipment in the OR.[24]

As far as possible, the disposable equipment is preferred, for example, anesthesia breathing circuits, endotracheal tubes, face masks, and airways.[23] The closed anesthesia circuit should be used. Two high quality heat and moisture exchanging filters (HMEF) should be placed to prevent contamination of anesthesia machine and OR environment: one between the tracheal tube and breathing circuit and the other between expiratory limb of the circuit and the anesthesia machine.[7],[25] The HMEF should be rated to remove at least 99.97% airborne particles of size ≥0.3 μ.[20] A closed suction system, if available, should be used for suctioning.[11],[26] Soda lime and HMEF should be changed after each case.[27]

Medical records must be kept outside the operating area and must be updated and handled only after appropriate doffing.[15]

If active scavenging is not available, the scavenging port may be connected to a corrugated tubing, which may be dipped in a bucket containing 1% hypochlorite solution.[7]

Clinical management

Anesthetic concerns

The main concerns during anesthetic management of these patients revolve around the risk of spread of infection from the patients and the critical nature of the illness.

Special precaution needs to be taken with aerosol-generating medical procedures (AGMPs) such as intubation, extubation, nebulization, fiberoptic bronchoscopy, suctioning, and noninvasive ventilation as the risk of viral transmission to health-care workers is very high due to production of airborne particles and droplets during these procedures. The intubation of trachea is a crucial AGMP during which the risk of virus transmission to the anesthesiologist securing the airway is maximal. Similarly, extubation is also a critical event as it may be associated with a high risk of coughing.[28]

Whenever possible, regional anesthesia should be preferred to reduce aerosolization.[29] Oxygen can be administered by nasal cannula under the surgical mask and postoperative retching, and vomiting can be prevented by prophylactic antiemetic administration.[30]

If administration of general anesthesia is needed, tracheal intubation should be preferred over laryngeal mask airway or face mask ventilation as the latter techniques may be associated with higher risk of viral transmission due to aerosol production. Fiberoptic intubation and other awake intubation techniques should also be avoided, unless specifically indicated, due to risk of aerosolization by coughing and administration of atomized local anesthetic.[31],[32],[33] Rapid sequence intubation avoids the need for mask ventilation before intubation and hence is the preferred technique for tracheal intubation. If mask ventilation is needed, only gentle low tidal volume positive pressure ventilation should be performed.[32] A double layered wet gauze may be kept over nose and mouth of the patient and under the anesthesia mask during preoxygenation to block the patient's secretions.[26] Adequate muscle relaxation during intubation avoids coughing.[26] The most experienced anesthesiologist among the team should perform airway maneuvers and secure airway to avoid multiple attempts.[11],[34] After intubation, the cuff of the tracheal tube must be inflated, and the tube clamped before connecting it to the breathing circuit. Once the airway is secured and the placement of the airway device is confirmed, the person performing the procedure must immediately replace the outer pair of gloves to avoid further contamination.[11] If intubation is not required, the patients must wear N95 or surgical mask throughout their presence in the OR.[26]

During the COVID-19 pandemic, the use of aerosol box, also known as intubation box, made of plastic/acrylic sheet had been suggested to curtail the risk of spread of droplets and viral transmission at the time of intubation.[35] This innovation, however, was later criticized due to multiple factors.

In an in situ simulation study assessing the use of two designs of aerosol boxes, these boxes were found to raise the level of procedural difficulty and the intubation time due to increased distance between the airway and the laryngoscopist, and the inability to perform various maneuvers to secure airway.[36] These factors in turn could increase the risk of hypoxia in critically ill patients. Moreover, there may be a risk of damage to the PPE as the arms are passed in and out through the holes in the box. In addition to the above factors, Kearsley also expressed concerns regarding the risk of spread of airborne particles after removal of the box.[37] Another simulated study examined the degree of contamination of health-care workers during intubation with or without aerosol box.[38] The use of aerosol box decreased the contamination of PPE; however, with an increased intubation time and restricted mobility and visibility of the person performing the intubation. No difference was seen in postdoffing contamination. The authors warned the clinicians to be cautious while using aerosol box and consider the risks to patient safety in cases with difficult airways or hypoxia. Thus, proper donning and doffing of PPE is more important than use of such boxes. Some other publications have also echoed these opinions.[39],[40]

Keeping the risk of viral transmission at the time of intubation into consideration, the use of video laryngoscopes (VLs) has been recommended.[9],[11],[33],[41] VL is an established airway adjunct in both anticipated and unanticipated difficult airway situations as it improves the glottic view and increases the first attempt intubation success rate. It has gained a lot of popularity for airway management during the COVID pandemic as it allows the laryngoscopist to secure airway from a distance from the patient due to its inherent design.[33] It also places the laryngoscopist's face above the line of sight to the glottis.[42] However, the persons performing the intubation must use the airway device and the technique to secure the airway which is most familiar to them and is expected to result in successful intubation on first attempt.[31] The laryngoscope blade should be re-sheathed with the outer glove of the operator immediately following intubation.[7],[28] The tracheal tube position is confirmed by EtCO2 monitoring and chest rise, and chest auscultation may be avoided.[7]

If an intubated patient is shifted to or from the OR, a dedicated transport ventilator should be used. While shifting the patient from one ventilator circuit to another, the tracheal tube must be clamped with a forceps and the gas flow switched off, to reduce the risk of aerosol spread.[27]

The postoperative nausea and vomiting prophylaxis must be administered to minimize the risk of vomiting and thus the risk of aerosolization and ultimately viral transmission. As far as the intraoperative blood transfusion is concerned, there have been no reports of COVID-19 transmission through blood transfusion or blood donation process. There are no contraindications of blood transfusion to these patients.[7]

Sterilization and disinfection

After the surgery is over, all exposed surfaces in the OR, equipment, and linen must be sanitized and disinfected,[7] thus increasing the turnaround time.[6] Therefore, adequate interval of approximately 1 h must be kept between the two cases to allow patient transfer and surface cleaning.[27] Enough time, depending on the number of air changes per hour, should be allowed for the removal of infectious organisms from the OR environment.[43]

Before starting decontamination, the staff must change the outer gloves. All disposable items such as breathing circuit, sodalime, HME filters, endotracheal tubes, face masks, disposable laryngoscope blades, sampling line for capnometry, and linens must be put in labeled, double zip-lock bags, and discarded as biohazardous waste.[6],[7] All remaining unused drugs, surgical linen, and dressings are also discarded.

The reusable infected OT equipment should be packed in clearly labeled double plastic bags and sealed.[7] It is then sent to CSSD while being segregated from the noninfected items. There must not be any mixing of equipment from infected and noninfected areas. The isolation OR should ideally be near the CSSD or a separate autoclave machine is placed in the isolation OR itself. caution needs to be exercised during transfer of these infected items for sterilization to the designated area.

All contaminated linens should be handled wearing PPE during the collection and also during the transport. They must be kept in dedicated containers which must be sealed and immediately sent for sterilization. However, disposable laundry is preferred, when feasible.

Decontamination of all surfaces such as anesthesia machines, screens, cables, oxygen/nitrous oxide cylinders, and switches must be done using 1% sodium hypochlorite solution or 75% alcohol.[7] Following surface cleaning, hydrogen peroxide vaporization or ultraviolet radiation may be used for OR sterilization.[6],[23]

Histopathological specimen

No data are available pertaining to the virus load of various body secretions and in tissue specimens. However, caution must be exercised while sending the histopathological specimens for examination. These must be kept in plastic boxes with tightly closed lids and sealed in plastic bags. The outer surface of these bags is then cleaned with 75% alcohol.[7]

Continuing education

All doctors, nurses, technicians, and other staff required to work in OR must receive regular training in infection prevention and control practices including the proper use of PPE with safe donning and doffing techniques. Simulation sessions should be carried out to train all the staff members in airway management and other essential skills in infected patients.[28] Drills must be conducted at regular intervals to check for readiness of the infected or suspected patient flow in the scenario of an infectious disease outbreak or a pandemic. In addition, staff from all specialties must be trained in basic critical care and airway management to help the directly involved departments, i.e., anesthesia and medicine.[28]

Tong et al. described in situ simulations to assess and improve OR preparedness.[44] They found these exercises very helpful in improving their workflows, developing checklists, defining roles and responsibilities of the staff, revising their protocols, and ultimately increasing the confidence and capability of the staff in managing COVID-19 patients.


  Special Situations Top


Laparoscopic procedures

Various factors may contribute to viral transmission during laparoscopic surgeries. These include surgical smoke due to surgical dissection and cauterization of blood vessels using electrocautery, expulsion of secretions from the body during tissue extraction due to high intra-abdominal pressure, and carbon dioxide desufflation at the end of surgery.[45] The risk of leakage of gases is also high at the time of exchange of instruments through one-way valve trocars.[9],[45]

The specific measures to avoid aerosol production during laparoscopic surgery include the use of proper filters and mechanical evacuation systems for both smoke evacuation and CO2 desufflation.[46],[47] Use of lower pressures during the procedure also helps in decreasing aerosolization.[9] On comparing laparoscopic and open surgeries, the risk of smoke and air evacuation has been found to be comparable.[48] The risk of blood splash is also not very different with laparoscopic surgeries compared to open surgery, i.e., 48.5% versus 45%.[49],[50] In addition, there is minimal evidence in the context to the actual risk of contamination of health-care workers during laparoscopic surgery.[48] Considering the known advantages of laparoscopic procedures over open ones, there is no reason to abandon laparoscopic surgery during pandemic.[48]

Trauma and orthopedic procedures

Trauma and orthopedic surgical procedures are very common in the emergency setting. During the pandemic, testing for the infectious disease may not be available readily in emergency scenario. Hence, these patients may be treated as either suspected or confirmed cases. Nonoperative treatment should be strongly considered.[51] The surgery, when planned, should be minimally invasive.

Orthopedic surgical procedures frequently involve the use of aerosol-generating procedures due to the use of power tools, pulsatile lavage, and electrocautery.[52],[53] The commonly used power tools include bone saws, drills, and reamers. These are needed for performing osteotomies and joint arthroplasty for bone preparation. Saline irrigation is often done to reduce local tissue thermal damage but can significantly add to aerosol generation. Electrocautery generates smoke along with bioaerosols posing a risk of blood borne infections such as human immunodeficiency virus and hepatitis B virus and may also cause lung irritation.[52] To curtail the risk of viral transmission, it has been recommended to avoid the use of electrocautery and power tools as far as possible. If use of power tools is necessary, minimal required power should be used.[14] The wound irrigation should be done with bulb syringes instead of pulsed irrigation.[54]

The anesthetic technique should be kept as simple as possible, i.e., local anesthesia, nerve block, or regional anesthesia. General anesthesia should be avoided as it is associated with aerosol generation and increased risk of viral transmission, however, may be deemed essential in trauma patients with hemodynamic perturbations.[51]

Obstetrics

Obstetric procedures, especially cesarean sections, have been the most frequently performed surgeries during the COVID-19 pandemic. It may be difficult for a pregnant patient to remain away from her close relatives. However, the infected patient needs to be isolated, and frequent video calls and messaging may be allowed for emotional support.

Neuraxial anesthesia remains the anesthetic technique of choice and must be administered by an experienced anesthesiologist. During cesarean delivery, carboprost may be avoided due to the exaggerated risk of developing bronchospasm. There is insufficient data on the aerosolization potential while using nitrous oxide for labor analgesia, and the cleaning systems after its use. Therefore, the risks/benefits of this technique may be considered.[55]

Neonatal resuscitation is another important aspect during cesarean section. It has been suggested to perform it preferably in the second OR, if available, to reduce the exposure risk to the neonate as well as the pediatrician. Otherwise, the area just outside the isolation OR may be used.[7] The newborn of an infected patient should also be isolated from other neonates and tested.[56]

Interventional radiology

For any kind of interventional radiology (IR) procedures, the first choice remains the patient's bedside in the isolation ward to avoid patient transfer and therefore the risk of viral transmission, for example, ultrasound-guided procedures such as pleural taps and ascites drainage. The next choice may be the designated COVID OR having a mobile fluoroscopy (C-arm) unit. Third, procedures which require angiography or computed tomography (CT) will be performed at specific designated IR suites.[6] The recovery area may be turned into a PPE donning and removal area and the shortest path may be planned so that the patients directly enter the procedural suite.[57] The procedures such as intervention cardiology and neurology, for example, stroke thrombectomy, coiling of cerebral aneurysm, and hybrid CT/angiography suite could be undertaken here. Unlike routine, patients are directly transferred to the IR suite from inpatient wards, emergency areas or other hospitals. In the procedural room, nonessential movable items are removed, and the others are covered with a transparent disposable plastic sheet. Depending on the procedure, various anesthetic techniques employed could be local anesthesia, conscious sedation, general anesthesia, or simply oxygen therapy. The biological waste should be double bagged and treated as biohazardous waste. Special caution is needed for procedures requiring intraprocedural CT scan, during these procedures, the team should exit through the main door and must stand in a designated area which is later disinfected.[57] All waste from the room is considered contaminated and disposed of appropriately. The general principles of disinfection and sterilization would prevail.

Although there is a meager possibility of performing IR during pandemic, the modifications may be planned in advance. The future IR suites must consider the variation in the design and conception keeping the possibility of future pandemics.

Limitations

We carried out a narrative review and tried to include all directly relevant articles from literature. However, narrative reviews are associated with the limitation of having a subjective methodology for inclusion of studies and analysis of available information. They lack evaluation of validity of the selected papers. The qualitative appraisal may be biased by the authors' personal views. Thus, the narrative reviews are prone to selection bias.[58] Moreover, they have broader scope. Hence, further systematic reviews with stringent inclusion criteria, a more comprehensive literature search, and having specific research questions pertaining to various aspects of OR preparedness for patients with airborne infectious diseases would be useful.


  Future Research Top


Future research in this field should focus on the concerns related to airway management such as use of different types of VLs and other airway devices, safety during laparoscopic procedures, methods to improve safety during AGMPs, and OR preparedness for procedures in various disciplines such as emergency orthopedic or neurosurgical procedures in patients having COVID-19 or other airborne infectious diseases.


  Conclusion Top


The pandemic entails the postponement of elective surgical procedures among infected patients. However, the emergency surgeries are inevitable and involve the most vulnerable patient population undergoing surgery in an emergency setting. The OR setup for patients with airborne infectious diseases requires infrastructural modifications including changes in ventilation system, the workflow and transport of the patients; involvement of minimum required number of personnel and equipment in the management of a patient; the need for adequate protection of the staff with PPE and their training in correct donning and doffing techniques; and cleaning and sterilization of the equipment and the entire operating area after the procedure. The concerns during anesthetic management involve the risk of spread of infection from the patients and the critical nature of the illness. Clear institutional guidelines must be formulated to address all these issues and be ready to face any future pandemics.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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