How to prepare the operating room for COVID-19 patients

The pandemic caused by the new Coronavirus (SARSCoV-2), the agent of the disease called Covid-19, generated an exponential increase in information, with the production of more than 2.000 scientific articles, technical standards, manuals and newsletters worldwide1. To interpret this information to transform it into operational and care actions has been a challenge for health services around the world, with an emphasis on job security, patient care assurance, avoidance of disregardful consumption of personal protective equipment (PPE), and especially combat against anxiety among health professionals.


INTRODUCTION
T he pandemic caused by the new Coronavirus (SARS-CoV-2), the agent of the disease called Covid-19, generated an exponential increase in information, with the production of more than 2.000 scientific articles, technical standards, manuals and newsletters worldwide 1 .
To interpret this information to transform it into operational and care actions has been a challenge for health services around the world, with an emphasis on job security, patient care assurance, avoidance of disregardful consumption of personal protective equipment (PPE), and especially combat against anxiety among health professionals.

RESULTS
We found 19 articles in the search base. After reading the abstracts, we selected six articles, of which we could access five full texts, in addition to four others chosen for dissemination, totaling nine full articles.
We also included official regulations and technical standards.

Operating room
• There should be a dedicated room for COVID patient care, preferably an easily accessible area, with a minimal contact possible with other rooms, to prevent contamination of large extension the [11][12][13] .
• The patient should arrive through an exclusive door (when possible), located next to the dedicated room for the Covid-19 patient. The patient must leave through the same access 11,12 .
• The dedicated room for the Covid-19 patient should have an anteroom 11,14 .
When there is no negative pressure option, it is important to allow at least 30 minutes between cases for complete exchange of the ambient air 15 .
• Doors should remain closed during the procedure 13,16 .
• There should be a sign at the room's door regarding the recommended precaution (contact and aerosol).

Equipments
• Only equipment, furniture and necessary medicines should be taken to the procedure room, to reduce the number of items that need to be cleaned or discarded 12,13 .
• The anesthesia machines, monitors, ultrasound devices and such should be protected with disposable plastic to reduce equipment contamination 12 .
• High-Efficiency Particulate Air (HEPA) filters should be used in the anesthesia circuit, with the capnography system set between the circuit and the filter 12 .

General care
• Wash hands before and after placing and removing the PPE 11-13,16-18 .
• No use of adornments 18

Transportation/Reception
• Any transport of a suspected or confirmed COVID-19 patient to the OR must be previously communicated in order for the team to gear up.
• Put a surgical mask on the patient during transfer between areas 12,13,19 .
• Professionals who perform patient transport to the OR and vice versa should use PPE (N95 masks, face shield/goggles, aprons and gloves) 11,13,16,19 .
• Ensure there is no obstruction in the patient's way 11 .
• Reserve the elevator next to the OR to carry the patient and block its use for hygiene after transport 11,13 .
• The OR staff should wait for the the patient properly vested 11,16,19 .
• The patient should not remain in the reception or preoperative area, being taken directly to the OR 11,13 .
• During airways manipulation (intubation and extubation), the team not involved in the procedure should stay out of the room 13,21 .
• A support professional should be available outside the room, ensuring compliance to precaution techniques 11,13,15,17 .
• Surgeons and assistants should wear an N95 mask with a surgical mask on top, complete face shield, apron, gloves and shoe protection 13,19 .

Disrobing
• All PPEs, including N95 masks, but excluding goggles, face masks, and waterproof shoes, should be discarded (preferably in the anteroom) after use in procedures that generate aerosolization (ie: intubation, extubation, aspiration, cardiopulmonary resuscitation, non invasive ventilation, and bronchoscopy) or in the presence of contamination by blood or other body fluids 11 .
• Preferably remove the PPEs in the anteroom 11,19 . • No touching the face before sanitizing the hands 19 .
• Cleaning of goggles with soap and water, applying 70% alcohol after drying 19 .

Hygiene and Disposal
• Provide one hour between procedures for patient transfer and cleaning and decontamination of all surfaces, screens, keyboard, computers, cables, monitors, anesthesia machines, and furniture 11,15 .
• Leave the room prepared for the next procedure 11,15 .
• Change the whole circuit, the filter, the soda lime, and disinfect the anesthesia machine, as well as the soda lime compartment after each surgery 11 .
• Thorough cleaning of the equipment and furniture of the operating room, using PPE (n95 masks, faceshield / goggles, aprons and gloves) 11,13 .
• Discard all unused items from the medicine tray and airways car, since they should be considered contaminated 11,12 .
• All materials and instruments should be sent to the purge inside large plastic boxes with the lid completely closed and with written identification that is easy to be seen by the team of the Material and Sterilization Center (MSC).