Ophthalmic Surgery, Lasers and Imaging Retina

Technique 

Use of a Modified Plastic Viewing System for Safer General Anesthesia Care in Pediatric Ophthalmic Surgery During the COVID-19 Pandemic

Noy Ashkenazy, MD; Giuliana Orihuela, MD; Luis Ignacio Rodriguez, MD; Catherin Isabel Negron, MBA; J. William Harbour, MD; Audina M. Berrocal, MD

Abstract

Certain pediatric ophthalmology procedures require time-sensitive surgical care to prevent long-term morbidity and mortality. In the era of the COVID-19 pandemic, it has become increasingly important for anesthesia and surgical care providers to protect themselves during medically necessary procedures requiring general anesthesia care. In this study, an intubating viewing system with plexiglass shield and drape was designed. The viewing system allowed effective and safe intubation of pediatric patients for ophthalmological surgery while minimizing the risk of disseminating aerosolized droplets. The authors concluded that this viewing system and modified intubation technique may reduce the risk of transmitting SARSCoV-2 and other highly transmissible pathogens to operating room personnel. The continued study of measures to protect operating room personnel is encouraged to provide more evidence-based recommendations.

[Ophthalmic Surg Lasers Imaging Retina. 2020;51:651–652.]

Abstract

Certain pediatric ophthalmology procedures require time-sensitive surgical care to prevent long-term morbidity and mortality. In the era of the COVID-19 pandemic, it has become increasingly important for anesthesia and surgical care providers to protect themselves during medically necessary procedures requiring general anesthesia care. In this study, an intubating viewing system with plexiglass shield and drape was designed. The viewing system allowed effective and safe intubation of pediatric patients for ophthalmological surgery while minimizing the risk of disseminating aerosolized droplets. The authors concluded that this viewing system and modified intubation technique may reduce the risk of transmitting SARSCoV-2 and other highly transmissible pathogens to operating room personnel. The continued study of measures to protect operating room personnel is encouraged to provide more evidence-based recommendations.

[Ophthalmic Surg Lasers Imaging Retina. 2020;51:651–652.]

Introduction

Urgent and emergent ophthalmological care continues to be performed during the COVID-19 pandemic era.1 Pediatric eye surgery typically requires general anesthesia, even for rapid procedures.2 Health care workers are at high risk for SARS-CoV-2 infection, especially when performing potentially droplet- and aerosol-generating procedures, such as intubation.3 Asymptomatic or pre-symptomatic COVID-19 infection occurs in 5% to 80% of cases, and testing may be falsely negative up to 30% of the time.4,5 We herein describe a technique that the surgical care team may utilize in order to reduce potential exposure to contaminated secretions during pediatric procedures requiring general anesthesia.

Technique

We routinely perform preoperative rapid testing for COVID-19 at our institution.5 All persons in our operating rooms wear a fitted N95 respirator, covered by a surgical mask. Anesthesia providers wear a face shield, gown, hair cover, and double gloves. We transformed a section of our surgical wing into a negative pressure space.6 We fashioned an intubating shield design (Figure 1) with a clear acrylic viewing panel (Reverso Pumps, Davie, FL) for protection when intubating pediatric ophthalmology patients.

(A) The anesthesiologist administers anesthetic gas using a mask, with direct visualization through the clear pane in the prototype of our modified plastic viewing system. (B) The airway is secured with an laryngeal mask airway while the clear plastic draping system protects the operating room team from contaminated droplets.

Figure 1.

(A) The anesthesiologist administers anesthetic gas using a mask, with direct visualization through the clear pane in the prototype of our modified plastic viewing system. (B) The airway is secured with an laryngeal mask airway while the clear plastic draping system protects the operating room team from contaminated droplets.

Steps for its use are outlined below. Steps 1 through 8 are also illustrated in a video (See Video below).

  1. Tape a fresh, clear draping (can be made from a cut plastic bag) to all three edges of the plexiglass frame. This will serve as a reservoir for droplets.

  2. Position the shield under the patient's head and mattress, with the curved, rectangular, clear panel facing the provider sitting superiorly.

  3. Insert hands into the lateral edge of the apparatus for manipulation of the patient's airway under direct visualization.

    1. Start gas induction under the clear tent.

    2. Add suction in one to two locations near the patient's face.

    3. Following intravenous access and sedation administration, place a large soft-suction catheter inside the mouth.

  4. Proceed with direct laryngoscopy, glydescope, or laryngeal mask airway (LMA) insertion under the tent.

  5. Remove the outer gloves and tape the endotracheal tube (ETT) and LMA.

  6. Remove tape and shield for cleaning.

  7. Tape the plastic bag to cover the patient's nose and mouth.

  8. Sterile draping and ophthalmic surgery are performed, as indicated.

  9. Extubate under plastic bag and keep ETT/LMA inside it.

  10. Dispose of all contaminated equipment in red bio-hazard trash bag.

Conclusion

Certain pediatric eye conditions require time-sensitive surgical care to prevent long-term morbidity, blindness, and even mortality (as in retinoblastoma).1 Considering the risk of asymptomatic transmission of SARS-CoV-2, meticulous safety protocols should be undertaken to supplement personal protective equipment and protect the health care team during cases requiring general anesthesia. We have designed an easy-to-use intubating plexiglass shield to contain contaminated respiratory droplets with potential viral load inside the plastic bag. This technique may also reduce transmission of other highly transmissible pathogens. The continued study of measures to protect operating room personnel is encouraged to provide more evidence-based recommendations.

References

  1. List of urgent and emergent ophthalmic procedures. American Academy of Ophthalmology. March27, 2020. https://www.aao.org/headline/list-of-urgent-emergent-ophthalmic-procedures
  2. Waldschmidt B, Gordon N. Anesthesia for pediatric ophthalmologic surgery. J AAPOS. 2019;23(3):127–131. doi:10.1016/j.jaapos.2018.10.017 [CrossRef] PMID:30995517
  3. Odor PM, Neun M, Bampoe S, et al. Anaesthesia and COVID-19: infection control. Br J Anaesth. 2020;125(1):16–24. doi:10.1016/j.bja.2020.03.025 [CrossRef] PMID: 32307115
  4. Yang Yang M, Shen Chenguang FW, Jing Yuan JL, et al. Evaluating the accuracy of different respiratory specimens in the laboratory diagnosis and monitoring the viral shedding of 2019-nCoV infections. Preprint. Posted online February 17, 2020. medRxiv 2020.02.11.20021493; doi:10.1101/2020.02.11.20021493 [CrossRef]
  5. Recommendations for conducting vitreoretinal surgery during the COVID-19 pandemic. American Society of Retina Specialists. April30, 2020. https://www.cosprc.ca/wp-content/uploads/2020/04/asrs_recommendations_conducting_vr_surgery_during_covid_19_pandemic.pdf
  6. COVID-19: American Society of Anesthesiologists Recommendations for Anesthesia Management. Ambulatory Surgery Center Association. https://www.ascassociation.org/asca/resourcecenter/latestnewsresource-center/covid-19/covid-19-anesthesia-recommendations
Authors

From the Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida (NA, CIN, JWH, AMB); the Department of Anesthesiology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida (GO, LIR); and Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida (JWH).

Supported in part by the NIH Center Core Grant P30EY014801, Research to Prevent Blindness Unrestricted Grant.

The authors report no relevant financial disclosures.

Address correspondence to Audina M. Berrocal, MD, Bascom Palmer Eye Institute, 900 N.W. 17th Street, Miami, FL 33136; email: aberrocal@med.miami.edu.

Received: May 01, 2020
Accepted: August 20, 2020

10.3928/23258160-20201104-08

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