INTRODUCTION:

The World Health Organization (WHO) On 30 January 2020, declared a public health emergency of international concern - the outbreak of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2).¹138-patient case series published in the Journal of the American Medical Association found a mortality rate of 4.3% as of February 7, 2020.²In India, the latest report till the submission of this article is 31,787 confirmed cases, and in the state Maharashtra 9915 are the confirmed cases, active 7980,recovered 1593 and deceased 432.³

Epidemiologic Characteristics:

Source of transmission: The source of transmission are the vectors containing respiratory droplets and/or high concentrations of aerosol propagation in a relatively confined environment, direct or intimate contact with an infected or virus carrier. Individuals of a wide range of

age are susceptible to this corona virus 2019-nCoV specially the elderlies who are above their 5th decade and with major medical comorbidities. If they get infected once, are more vulnerable to fall critically ill. Individuals are susceptable to shed the virus and can play a critical role in the transmission who are asymptomatic but infected.⁴

Incubation period: The incubation period of COVID-19 as per a current epidemiologic data, ranges from 1 to 14 days but mayfall between 3rd to 7th day.^5,6Of all the COVID-19 patients 18%get cured by their own antibodies without showing any symptom even during 14 days of incubation period.⁷

Transmission Rate:

The transmission rate of Covid-19 is between 1.5 and 3 during isolation or 406 if not on isolation, from primary patient to others. Population density in India is 440.29 in comparison to 148.81 of China as person per sqkm. So india is 2.96 times denser than China. Thus, in our perioperative setting, 2019-nCoV poses a high risk to all healthcare professionals as per some documented cases related to human-to- human transmissions.^8,9,10,11

Pathogenic Characteristics:

The causative agent of COVID-19, or 2019- nCov or SARS-CoV-2, belongs to the cluster of Beta coronavirus in the family of Coronaviridae of the order Nidovirales, which includes Bat-SARS-like (SL) -ZC45, Bat-SL ZXC21, SARS-CoV, and MERS-CoV.¹²The virus particles (Fig.1) appear like a solar corona microscopically because of its distinctive spikes of 9 to 12 nm length. The diameter of 2019-nCoV varies from about 60 to 140nm. The 2019-nCoV virus is sensitive to ultraviolet light and heat and can be inactivated at 56°C for 30 min, also by ethyl ether, 75% ethanol, chloroform, peracetic acid, chlorine disinfectant. Chlorhexidine but has been found to be ineffective.⁴The virus 2019-nCoV has been found in respiratory epithelial cells of human in about 96 h ¹³through in vitro isolation and culture. The survival capacity ofthe SARS-CoV, another coronavirus, is for about 24 hours outside of the body, as has been observed. So similar assumptions can also be made for 2019-nCoV.^14,15

Modes of transmission:

Possible modes of transmission include fomites, contact, respiratory droplets and the feco-oral route.^16,17There is no conclusive evidence of airborne transmission of 2019-nCoV [SARS-CoV-2] butpast experience suggests that the virus can be transmitted through tracheal intubation, the most common aerosol-generating procedure.^18,19Infected respiratory droplets, especially if the exposure is within the range of 6 feet cantransmit the pathogen via inhalation and also through contact with mucous membranes. But there is still no confirmatory evidence, whether the pathogen can be transmitted by indirect or direct contact with any contaminated surface.²⁰Most of the respiratory viruses including SARS-CoV-2, are considered to be highly contagious even if the patient is symptomatic.²¹

AIM AND OBJECTIVES:

Identification and set up of

Perioperative setting ,

Ear marked operationtheatre (OT),

Modification of workflow for management of OT staff

Formatting clinical guidelines for anesthetic management. Study design:

This is a retrospective observational study. Carried out in Datta Meghe Institute of Medical Science,Acharya Vinoba Bhave Rural Hospital,Wardha situated in the 'Orange zone' in Maharashtra,India during the period from 30th March 2020 till 20th April 2020.

MATERIAL AND METHOD:

Total of 118 patients aged between 30days-80 yrs, American Society of Anesthesiologists physical status I, II or III, either gender, even from adjoining areas, scheduled for day care or emergency surgeries were catered. The preoperative check (PAC) up room for the surgeries concerned was selected in the unsterile zone of the OT premises. A Standard Operating Procedure (SOP) was formulated because as per some unconfirmed reports, transmission of infection could occur even before the symptoms were evident.

Patients who did not fulfill the criteria for suspected SARS-CoV-2 infection using a prescribed questionnaire while for PAC, were isolated, referred to the infectious diseases specialist, for the test of RT PCR (Reverse transcription polymerase chain reaction) of the RNA virusSARS-CoV-2.

Elective surgery was postponed.

The temperatures of the patients put for for surgery and all the attending staff were taken twice daily using hospital issued digital thermometers in addition to the checking of the investigation reports, general examination and informed consent of the patients.

Frequent hand washing with soap and water and /or (70%) alcohol based hand wash gels according to standard guidelines.

OT personnel to wear disposable OT caps and beard covers to reduce the risk of contamination of hands because touching of hair impulsively could have been exposed to droplets.

At the begining of the day routine checkup and cleaning of the anaesthetic equipments were done and covered with plastic see-through sheets, where feasible.

Pre selected drugs, instruments for surgery and anaesthesia to be kept inside the OT to lessen the items to be cleaned/ discarded after the procedures.

Protocols to be followed for proper donning and doffing of Personal Protective Equipment.

Traffic and the flow of air were minimized by not allowing to open or close the OT doors once the surgery started.

Preoperative fasting guidelines were followed, regional and total intravenous anaesthesia (TIVA) were preferred more over general anaesthesia (G.A). Multipara monitors were attached for heart rate, ECG, blood pressure (MAP), respiratory rate, ETCO₂. Premedication done inside the OT, 30 min prior to the procedure with midazolam 0.04mg/kg, pyrrolate 4mcg/kg, fentanyl 2mcg/kg, anti-emetic ondensetron 0.0016 mg/kg. IV Fluid ringer lactate was started througha cannula of appropriate calibre at the rate of 2ml/kg/hr. Cases done under regional anaesthesia (spinal block) or with TIVA, O₂at the rate of 3L/min was administered through nasal prongs beneath the surgical face masks put on the patients. Before undertaking invasive general anaesthesia, a HEPA filter used to be connected between the patient end and the expiratory limb of the breathing circuit and the anesthetia machine. A perfect sized fitting ventilating mask was used for pre-oxygenation with 100% oxygen for 5 minutes, intubation done under neuromascular blockade and deep sedation with rapid sequence technique to avoid bag -mask ventilation or by a video-laryngoscope as per the case demanded while ventilation done with small tidal volume so that the anaesthesiologist remained further away from the patient’s airway. Before connecting the patient with the breathing circuit and the anaesthetic machine, precaution taken that the cuff was inflated before initiating positive pressure ventilation. Suction done with rigid tube, extubation done with accepted criteria and standard precaution. Patient shifted to the dedicated post operative care unit with surgical mask on. By the end of the day, all instruments were sent for decontamination and sterilisation as per the instiution protocol, cleaning of all medical devices done with quaternary ammonium chloride, the single-use equipments and the properly doffed PPE were put in well- marked biohazard bags for disposal, OT used to be fumigated with sodium hypochlorite 1000 ppm and hydrogen peroxide vapor.

RESULT AND OBSERVATION:

Types of anaesthesia conducted

Table 1: Anaesthesia conducted

Parameters	General anaesthesia % with intubation [Gr A]	Total intravenous % anaesthesia [Gr B]	Spinal anaesthesia block [Gr C] %
No. of surgeries done	31 26.27	8 6.77	79 66.96
Out come of anaesthesia	5 Shifted intubated, others eneventful	Eneventful	Eneventful

Table 2: Age and gender of total cases done

Age range (yrs)	No. of patients	% Of patients ____________________ M F
1/12 - 20	24	33.33 66.67
21 - 40	71	14.08 85.92
41 - 60	18	55.56 44.44
61 - 80	5	80 20

Table 3: Types of surgery catered

Types of surgery catered	Anaesthesia chosen	No. of patients	Percentage (%)
OBGY	Spinal TIVA G.A.	67 1 1	84.81 12.50 3.22
General surgery	G.A. Spinal TIVA	3 1 2	9.67 1.26 25
Orthopaedic surgery	Spinal G.A.	8 4	10.12 12.90
Urosurgery	Spinal G.A.	3 1	3.79 3.22
Paeditric surgery	G.A.	1	3.22
Neurosurgery	G.A.	14	45.16
Maxillo facial surgery	G.A.	6	19.35
Cath lab	G.A. TIVA	1 2	3.22 25
Ophthalmic	TIVA	2	25

DISCUSSION:

In the first week of April 2020, Indian Council of Medical Research (ICMR), the apex body and the largest medical research organisation for the formulation, promotion and coordination of the bio-medical research, announced a zone wise distribution [red, orange, green] of the infected COVID-19 cluster / hot spot in India. The present study was done in a medical college hospital which is situated in an Orange zone (Fig. 2) as per the ICMR where '0' case of COVID-19 was identified till the lockdown continued in this area. The premises of operation theatre puts the members of the faculty of anesthesia, nurses and other personnel at the highest risk of exposure involving direct contact with patients' body fluids/secretion while performing routine procedures and their respiratory droplets during airway management of intubation and extubation.^22,23So dedicated OT personnel were protected with appropriate donning of personal protective equipments (PPE).²⁴(Fig.3). To reduce the transmission and dissemination of any environmental virus, an OT with negative pressure flow management is ideal.^25,26So, one of our modular OTs which is with laminar flow exchange exhaust ventilation system (Fig. 4) was earmarked for use during the scenario. We emphasised on IV prophylactic antiemetics so that the tendency for retching and vomiting was reduced.²⁷We used single use disposable anaesthetic equipments such as spinal needle, anaesthetic face mask, endotracheal tube, suction tube which supported the study of Tan TK et al.²⁸It is by now well accepted that 85% to 90% of Covid-19 patients have mild to non-existance symptoms . We avoided direct contact with the patients by covering 66.96% of our cases under regional and 6.77% under TIVA. Only 26.27% of cases were done under G.A. We preferred rapid sequence induction²⁹, video laryngoscopy with small tidal volume ventilation²⁹and fiber optic intubation without transtracheal block to avoid open airway suctioning and patient coughing.³⁰A recent review reports that an endemic human coronavirus, Middle East Respiratory Syndrome (MERS) coronavirus or coronaviruses such as SARS-CoV, can stay active on inanimate surfaces such as plastic, glass or metal for atleast up to nine days as far as its morphology or ability to infect cells are concerned. The virus can be efficiently inactivated by surface disinfection procedures. Our Operation theatre premises used to be cleaned and wiped with quaternary ammonium chloride and 62–71% ethanol, fumigated with 0.1% sodium hypochlorite 1000 ppm and 0.5% hydrogen peroxide vapor which is as per the works done by Kampf G et al.³¹

CONCLUSION:

The study was carried out in the least infective zone of COVID-19, still all precautions were undertaken against any suspected infection .We took the challenge in an environment of operation theatre complex where the lives of a host of personnel and expensive equipments are involved and the hall mark of our success was the optimisation of utmost quality of care.

CONFLICT OF INTEREST:

The authors declare no conflict of interest.

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Received on 26.05.2020 Modified on 21.06.2020

Research J. Pharm. and Tech 2020; 13(9):4399-4402.

DOI: 10.5958/0974-360X.2020.00778.7