M.L scopic surgeries in DMH during

COVID-19 pandemic

Dr Sachin Gandhi

MS ENT, FRCS

Dr Subash Bhatta

Senior Clinical RCS Fellow Laryngology

Deenanath Mangeshkar Hospital, Pune, India

Contents

Indication of M.L scopy during COVID 19 pandemic

Risk of COVID 19 during M.L scopy

Pre Operative preparation

Intubation

Risk of LASER plume

Extubation and patient transfer

OT disinfection

Airway

Tracheostomy(PI)

EXIT, CHAOS

Stridor with respiratory distress (BVCP, Congenital SGS, LSCTS….)

Congenital malformations with FTT (LM, clefts….)

FBs: Flex. Bronchoscopy avoids dry run Vs. Upfront rigid bronchoscopy

Aerodigestive FBs

Trauma (neck trauma, burns, inhalation, caustic injuries, epistaxis)

Deterioration of a compromised airway (past operated)

ABCESSES; SEVERE DYSPHAGIA (Zenkers) Other ENT emergencies

Laryngeal carcinoma

Dr Kishore Sandhu Lecture, APLA webinar

Indication of M.L scopy during COVID 19 pandemic

Risk of COVID 19 during M.L scopy

▪ Maximum aerosol generation due

to transmucosal airway

involvement during M.L scopy

▪ Exposure to LASER plume which

may contain COVID 19 virus adds to

the risk

Anaesthesist

during intubation and extubation exposure to aerosols

circuit, ventilators may get infected

Surgeon

exposed while introducing and removing D.L scope

during surgery due to air leak along the inflated cuff of ET tube

exposure to LASER plume

Health workers spread of aerosols in the OT room

instruments, Linen exposure, OT surfaces

Patient’s coughing and gagging may spread the aerosols, risk to all

Risk of COVID 19 during M.L scopy contd..

Pre Operative preparation

Avoid Pre and post op nebulization

Give betadine gargle to the patient*

Consider all patients as positive

Minimize the staff in OT

*The Use of Povidone Iodine Nasal Spray and Mouthwash During the Current COVID-19 Pandemic May Reduce Cross Infection

and Protect Healthcare Workers

Justin Kirk-Bayley, San Sunkaraneni, Stephen Challacombe

Pre Operative preparation contd..

Full PPE should be used by all

personals in the OT

Patient shifted in OT only when

personals and instrumentations are

ready

Negatively pressurized OT ideal, if

not then Laminar flow

Full PPE

❑ Laryngeal procedures considered aerosol generating

procedures

❑ all team members should wear PPE

❖ Gloves (double)

❖ Anesthesiologist should remove his outer glove after

intubation)

❖ Fluid resistant long sleeve gown

❖ N 95 mask fit tested, fit checked

❖ Eye protection- goggles, visors

❖ If the team or any member is using space suit, motorized

fan should not be used

Intubation

❑ use of rapid sequence preoxygenation followed by rapid sequence induction

❑ close circuits with cuffed ET tube, cuff pressure 20-30 mmhg

❑ apnea technique in selected cases

❑ use of breathing filter system

❑ use of long acting muscle relaxant like atracuronium

❑ intubation to be done with videolaryngoscope

A Framework for Prioritizing Head and Neck Surgery during the COVID-19 Pandemic

Michael C. Topf MD1, Jared A. Shenson MD1, F. Christopher Holsinger MD1, Samuel H. Wald, MD2,3, Lisa J. Cianfichi, N.P.3, Eben L. Rosenthal MD1, John B. Sunwoo MD1

Perioperative Care Provider’s Considerations in Managing Patients with the COVID-19 Infections Xiangdong Chen1 , You Shang1 , Shanglong Yao1 , Renyu Liu2 and Henry Liu3*

Techniques to be avoided

Spontaneous ventilation

high frequency jet ventilation (HFJV) and high frequency

nasal oxygen (HFNO)

bag and masking, laryngeal mask airway

positive pressure ventilation with inadequate seal

awake intubations as it involves atomized analgesia that

promotes coughing

short acting muscle relaxant, like Scoline

A Framework for Prioritizing Head and Neck Surgery during the COVID-19 Pandemic

Michael C. Topf MD1, Jared A. Shenson MD1, F. Christopher Holsinger MD1, Samuel H. Wald, MD2,3, Lisa J. Cianfichi, N.P.3, Eben L. Rosenthal MD1, John B. Sunwoo MD1

Perioperative Care Provider’s Considerations in Managing Patients with the COVID-19 Infections Xiangdong Chen1 , You Shang1 , Shanglong Yao1 , Renyu Liu2 and Henry Liu3*

▪ Preoxygenation by covering the patients with

plastic sheet

▪ Intubation with the help of videolaryngoscope

reduces the direct exposure of the

anesthetist to aerosol

▪ Surgical team should wait outside

the operating rooms during

intubation and extubation

Induction of the patient

Intubation simulation in lab

Plastic hood made with holes for

intubation

To reduce the aerosol spread in the OT

M.L scopy

▪ Microlaryngeal tube with cuff

inflated at 20-30 mmhg

M.l scopy with LASER

▪ Flexometallic double cuff ET

tube used

▪ Cuff inflated with saline mixed

with methylene blue

Cuff pressure should be more enough to prevent the

leak

At the same time it should be less enough not to cause

injury Double cuffed flexometallic tube

Microlaryngeal tube

Goggles to be used to allow visualization

through microscope as visualization may be

difficult due to hood or face shield

Avoid fogging of goggles/ face shield/ hood

with tight fitting mask over the nose

Endoscopic approach could be alternative

to microscopic for surgeryUse of monkey cap reduces fogging

M.L scopic approach

For air leakage, to reduce fogging

Endoscopic approach

▪ Rigid endoscope used along with

fiber transmission LASER such as

diode, KTP, CO2

▪ Surgeon is placed away from the D.L

scope which prevents direct

exposure to aerosol and LASER

plume

▪ Better visualization in video monitor

Inserting laryngoscope

Gamjee pad used while insertion and removal of the D.L

scope

It reduces the aerosol generation and spread into the OT

Gamjee pad should be removed during surgery to avoid the

LASER fire

Reduction of aerosol generation during

M.L scopy

Subglottis should be packed with cold saline soaked guage

during surgery to prevent the aerosol leak from lower airway

Microscope to be covered with drape, space left through the

drape for instrumentation and visualization

This reduces the generation of the aerosols in the OT

Reduction of aerosol generation during

M.L scopy contd..

Risk of LASER plume

risk of virus shedding (proved for

HPV, HIV)

controversial risk in COVID*

may spread throughout OT

*COVID-19 Pandemic: What Every Otolaryngologist–Head and Neck Surgeon Needs to Know for Safe Airway Management

Karthik Balakrishnan, MD, MPH*, Samuel Schechtman, MD*, Norman D. Hogikyan, MD Norman D. Hogikyan

*Coronavirus Disease 2019 (COVID-19) and dermatologists: Potential biological hazards of laser surgery in epidemic area

Seyed-Naser Emadia and Bahareh Abtahi-Naeinib

Double suction technique

One suction catheter to be placed

outside of D.L scope throughout

the surgery, another suction

catheter inside D.L scope

surgeon to use suction for

retracting tissues

To reduce the LASER plume

Fast extubation done, by covering the

patient with plastic sheet

Nobody allowed in the room during

extubation

Recommendations for Surgery During the Novel Coronavirus (COVID-19) Epidemic Zheng Liu1 & Yawei Zhang2,3 & Xishan Wang1 & Daming Zhang2,4 & Dechang Diao5 & K.

Chandramohan6 & Christopher M. Booth

Surgical management of cancer during the COVID-19 pandemic

Amar Prem, Swapnil Patel, Esha Pai, Durgatosh Pandey

Extubation and patient transfer

Shift the patient to recovery

❑ Infection isolation room

Disposal of PPE in designated place

Note writing and paper work, to be

done outside OT

Recommendations for Surgery During the Novel Coronavirus (COVID-19) Epidemic Zheng Liu1 & Yawei Zhang2,3 & Xishan Wang1 & Daming Zhang2,4 & Dechang Diao5 & K.

Chandramohan6 & Christopher M. Booth

Surgical management of cancer during the COVID-19 pandemic

Amar Prem, Swapnil Patel, Esha Pai, Durgatosh Pandey

Extubation and patient transfer contd..

Laminar flow in the OT to be closed after surgery

All surfaces cleaned

❑With detergent and 1000 ppm bleach

❑For atleast 30 minutes

Fumigate the OT with Peroxyacetic acid air

OT closed for 2 hours

Recommendations for Surgery During the Novel Coronavirus (COVID-19) Epidemic Zheng Liu1 & Yawei Zhang2,3 & Xishan Wang1 & Daming Zhang2,4 & Dechang Diao5 & K.

Chandramohan6 & Christopher M. Booth

Surgical management of cancer during the COVID-19 pandemic

Amar Prem, Swapnil Patel, Esha Pai, Durgatosh Pandey

OT disinfection

Thank you, Stay safe and alert

Operate only in dire emergency

Operate only with full Precautions