Perioperative Management in an Emergency Operating Theater in Bali during COVID-19 Pandemic

At the end of 2019, a new type coronavirus, severe acute respiratory syndrome?coronavirus?2, first appeared in the city of Wuhan, China, and has currently spread to more than 200 countries in the world as a COVID?19 disease.[1] The WHO has announced the COVID?19 as a pandemic, and worldwide cases passed three million by April 2020, with a mortality rate of more than 300,000. In Indonesia, this virus started to emerge in March. Until April, there have been more than 10,000 cases with a mortality rate of 9%. The nature of an emergency is an important aspect that must be considered. An operating room is a high?risk area for the transmission of respiratory tract infections.[2] In response to this pandemic, several world surgeon associations agreed on the guidelines for surgical procedures to protect both medical personnel and patients. However, if the surgery is an emergency and life?saving procedure, essential considerations must be taken into account for patient safety, the safety of the medical team, and all people who involved perioperative care.[3] In the operating room, in addition to an operator, the anesthesia team makes it possible for many people to be exposed to the virus if proper drops’ precautionary or proper decontamination is not followed. The aerosolization process of sputum in infected and potentially infected individuals in the perioperative setting is a potential source of exposure to healthcare workers. For anesthesiologists and intensivists, the vulnerable periods of the highest risk of exposure are when in direct contact with respiratory droplets during airway management, especially during intubation and extubation. Besides, lack of personal protective equipment (PPE), inadequate PPE, inappropriate PPE use, and poor hand hygiene are potential factors that can cause the transmission to healthcare workers during the COVID?19 pandemic. Before initiating the surgery procedure, it is crucial to do a preoperative assessment to identify high?risk patients and decide the proper anesthesia technique. For patients who are identified positive with COVID?19, evaluating airway patency, oxygen demand, chest X?rays abnormalities, and blood gas analysis is critical. Ideally, all patients must be tested for COVID?19. Otherwise, they should be treated as positive for COVID?19 until proven otherwise, and Level 3 PPE is recommended. Bali, the famous island of Indonesia, has a limited Polymerase chain reaction (PCR) and rapid test kits. We employed the early warning score COVID?19, proposed initially by Song et al.,[4] to initially assess if a person has COVID?19. The major parameters include signs of pneumonia (5 points), history of closes contact with confirmed patients (5 points), and fever (3 points). One point is assigned for each of the following parameters: aged >44 years, male sex, highest body temperature ?38°C, presence of respiratory symptoms, and neutrophile?to?lymphocyte ratio of ?5.8. A score of ?10 indicates a likeliness to have COVID?19. A designated operating theater for COVID?19 patients is the one closest to the entrance of the operating room complex. The operating room should be as close as possible to the entrance of the operating room to minimize contamination of the surrounding environment.[5] Unfortunately, the emergency operating complex is currently lacking negative pressure. This is something that must be addressed in the near future. We set a predefined direct, shortest path, to and from the operating theater, to minimize the chances of infection.[5] We always opt for regional over general anesthesia. We use video laryngoscopy for all intubations to avoid repeated airway instrumentation. More liberal use of intubation might be justified in patients with acute respiratory failure, bypassing noninvasive ventilation techniques to minimize the transmission risk. Awake intubation must be avoided because it stimulates coughing, vomiting, and sputum secretion. An aerosol box is always used in all airway?manipulating procedures. Perioperative care in emergency patients during this COVID?19 pandemic is complicated. Adjustments and preparations must be made to this condition, and new guidelines must be learned and employed. Nevertheless, we must believe that those changes and new guidelines are set to ensure the safety of all parties involved, including the safety of all healthcare workers.