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FAQs: Confronting COVID-19 in the Clinical Setting

The American Association of Nurse Anesthetists (AANA) continues to monitor the Coronavirus Disease 2019 (COVID-19).

Excellence in care, safety, and continuous improvement of care are hallmarks of the anesthesia profession. Nurse anesthetists may be called upon to care for patients infected with COVID-19. The AANA is committed to supporting Certified Registered Nurse Anesthetists (CRNAs) and the healthcare team to safely deliver patient care while maintaining the health of the nurse anesthetist and the families and the community they serve.  

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Patient Care

What is the recommendation for LMA use?

Updated 4/3/20

  • A risk assessment should be performed based on the COVID community-wide transmission. Currently, no studies exist that assess risk of various airway techniques and anesthetic choices.  However, expert opinion suggests that LMA use may carry greater risk of generating aerosols when compared to tracheal intubation. While LMA usually seals the airway at low pressures, there is concern that higher positive pressure, if used, might create a leak with aerosol production. LMA may be an acceptable option with selected patients because of the lower risk of coughing. Non-airway MAC cases with spontaneous ventilation may be acceptable if fresh gas flows are low, but consider the anesthesia provider’s proximity for jaw lifts or potential intermittent positive pressure ventilation if brief apnea occurs. Therefore, PPE for aerosol-generating procedures should be worn.

How do we care for patients with known COVID-19?

Updated 3/20/20
  • Place patients in an airborne infection isolation room.
  • Upon entering the patient’s room, use airborne and contact precautions, including eye protection.
  • Wear PPE, including:
    • Fit-tested N95 mask or a powered air-purifying respirator (PAPR).
    • Face shield or goggle.
    • Gown, impervious if possible.
    • Gloves.
  • Perform hand hygiene before donning and after doffing PPE.
    • Use alcohol-based hand rubs or wash hands with soap and water.
    • If hands are visibly soiled, wash hands with soap and water.

How do we transport a patient with known or suspected COVID-19?

Updated 3/20/20
  • Transport patients only for essential procedures.
  • Collaborate with local infection control experts for current advice.  
  • Insert a “high quality” viral filter between the bag-valve-mask breathing device for intubated patients.
  • Non-ventilated patients should wear a surgical mask.
  • Do not routinely wear gowns and gloves for transport.  If direct contact with the patient or contaminated equipment is anticipated, one transport team member should perform hand hygiene, don a fresh gown and gloves, and wear appropriate PPE.  Ideally, another member who is not wearing a gown and gloves should accompany the transport to interact with the environment.

How do we perform a procedure for a patient with known or suspected COVID-19?

Updated 3/20/20
  • Consider postponing non-urgent procedures until the patient is non-infectious or not infected.
  • Designate an operating room (OR) for this purpose and post appropriate signage to minimize personnel exposure. 
  • If postponing a procedure or performing the procedure at the bedside is not possible, minimize the number of healthcare team members and other patients present in the operative suite. 
  • Do not bring the patient to the holding area, induction room, or post anesthesia care unit (PACU). 
  • If respiratory support is necessary, prepare in order to avoid the need for rescue interventions (e.g., crash intubations), which increase COVID-19 transmission risk if barrier protections fail.
  • If the patient has acute respiratory failure, proceed directly to endotracheal intubation; non-invasive ventilation (e.g. CPAP or biPAP) could increase the risk of infection transmission.
  • If possible, perform the procedure in an airborne infection isolation room rather than an OR. Airborne isolation rooms have negative-pressure relative to the surrounding area. ORs generally have positive-pressure and incoming air is usually flow-directed, filtered, and temperature and humidity controlled.
  • Collaborate with local infection control experts (e.g., state and county health departments, nearby healthcare systems and facilities) for additional guidance.
  • For performing procedures without general anesthesia:
    • The patient should continue to wear the surgical mask.
  • For performing procedures with general anesthesia:
    • Insert a “high quality” viral filter between the Y-piece of the breathing circuit and the patient’s mask, endotracheal tube, or laryngeal mask airway.
    • For pediatric patients or patients that may experience problems with the additional space/weight of the filter, place the “high quality” viral filter on the expiratory end of the corrugated breathing circuit before expired gas enters the anesthesia machine.
    • Ensure that the gas sampling tubing is protected with a “high quality” viral filter.
    • For further details, see APSF FAQ on Anesthesia Machine Use, Protection, and Decontamination During the COVID-19 Pandemic.
  • For laryngoscopy and intubation:
    • To prepare for emergency intubations, ensure all emergency kits are equipped with the appropriate PPE.
    • Double glove and shed the outer gloves after intubation and minimize subsequent environmental contamination.
    • When possible, have the most experienced anesthesia professional available intubate the patient.  
    • Unless required, avoid awake fiberoptic intubation. 
    • When possible, avoid manual ventilation and perform rapid sequence induction (RSI). 
      • If manual ventilation is necessary, apply small tidal volumes.
    • After extubation, turn down flows, if possible, to avoid contaminating the environment. 
    • After doffing PPE, immediately perform hand hygiene and refrain from touching your hair and face.
  • For airway suctioning, use a closed suction system if available.  
  • To minimize surface contamination, use disposable covers (e.g., plastic surface sheets, ultrasound probe sheath covers).
  • Recover the patient in the operating room or transfer the patient to an airborne infection isolation room.
  • Once the patient leaves the OR, maximize the time before the next case. This time interval depends on the number of air exchanges per hour in that space.  For further details see CDC - Air Guidelines for Environmental Infection Control in Health-Care Facilities.
  • When using point-of-care ultrasound or other devices:
    • Cover the ultrasound unit and cable with a long sheath.
    • Cover non-essential parts of the ultrasound cart with drapes.

Since we don’t know if a patient is COVID-19 positive, do we treat all patients as positive?

Updated 3/23/20
  • For details, see AANA, ASA, APSF, AAAA Joint Position Statement - The Use of Personal Protective Equipment by Anesthesia Professionals during the COVID-19 Pandemic.
  • Due to close patient contact and the need for airway instrumentation, anesthesia professionals are at increased risk of exposure and infection for all diagnostic, therapeutic, and surgical procedures during this rapidly escalating COVID-19 pandemic in the U.S.
  • AANA, ASA, APSF, AAAA recommend as optimal practice that all anesthesia professionals should utilize PPE appropriate for aerosol-generating procedures for all patients when working near the airway.
  • Issuance of N95 masks or availability of PAPRs for all clinical anesthesia personnel should be a priority.  If a facility has existing or projected shortages of N95 masks or PAPRs, however, temporary mitigation plans based on current CDC recommendations should be enacted. These plans should include facility and case-by-case reviews of the potential of patients and procedures to generate aerosolized particles, as well as assessments of respiratory pathogen characteristics (e.g., routes of transmission, community spread, prevalence of disease in the region, infection attack rate, and severity of illness) and local conditions (e.g., number of disposable N95 mask available, current respirator usage rate, and success of other PPE conservation strategies).
  • If COVID-19 is known or suspected, please refer to How do we care for patients with known COVID-19?
  • For further details, see Interim Guidance for Healthcare Facilities: Preparing for Community Transmission of COVID-19 in the United States.

What should we do about MAC cases?

Updated 3/20/20
  • The AANA and the ASA are in agreement regarding MAC cases: 
    • If dispersion of potentially contaminated exhaled gases from an open airway (e.g., “MAC”) is a risk, consider alternate anesthesia plans. Potential contamination of your workspace and the room should be considered.
    • For further details, see ASA Committee on Occupational Health Clinical COVID-19 FAQs.

How do we manage an “open airway” case?

Updated 3/20/20
  • The AANA and the ASA are in agreement regarding “open airway” cases: 
    • Originally, the Anesthesia Patient Safety Foundation (APSF) recommended elevated precautions for an “open airway” case.  This was in large part due to an increased risk of aerosolization and disease transmission.  The definition of “open airway” included cases such as tracheostomies and upper endoscopies that have a high degree of aerosolizing body fluids. APSF did not intend this definition to include all “MAC” cases.  
    • Newer recommendations focus on the risk of exposure from aerosolization of the disease and emphasize attempting to minimize aerosolization of body fluids when caring for all patients.  In situations with risk of high degree of aerosolization of body fluids, a properly fitted N95 mask, or PAPR provides the best protection from COVID-19 exposure.  Traditional face masks do not provide protection against aerosolized small particles.

Are there specific recommendations for caring for obstetric patients?

What is AANA’s position when CRNAs are asked to assume critical care responsibilities during the COVID-19 pandemic?

Updated 4/2/20

CRNAs are being asked to assume ICU APRN roles at our hospital. What are some resources to support us in this role?

Updated 3/24/20

PPE

Are there specific recommendations for EGD procedures, and other cases with a high risk of aerosolization?

Updated 3/20/20
  • When deciding whether to cancel a case or use higher-level PPE, consider your local COVID-19 risk profile related to community spread. 
  • In addition, when making these decisions, consult with local infection control experts.  This will inform your own risk assessment considering the patient, skill sets of the endoscopists, and local resources.
  • For cases with a high risk of aerosolization, ETTs provide the most secure airway. Airway masks with apertures for gastroscopes such as a POM (Procedural Oxygen Mask by Curaplex) or similar masks may limit dispersion as an alternative when N95 supplies are low.  
  • Best practices may be in flux because of shortages of N95 masks and other PPE for patients with known COVID-19, as well as for those who are undiagnosed or asymptomatic.

My hospital thinks the AANA guidance is too strict or is inconsistent with CDC guidance. How should I discuss AANA guidance with my facility or department?

Updated 3/25/20
  • AANA guidance focuses on patient and anesthesia professional health and safety and is based on current CDC and APSF recommendations for protecting healthcare providers if patients have known or suspected COVID- 19 infection.  
  • During the SARS outbreak in the 2000’s, CDC learned that SARS infected healthcare providers caring for SARS patients even though these providers followed contact and droplet precautions. Droplet particles from coughing, sneezing, or airway procedures (e.g., laryngoscopy, intubation, suctioning, bronchoscopy) could aerosolize into finer particles suspended in air currents and penetrate ordinary surgical masks. 
  • The AANA recommends taking steps to reduce the risk of droplet particle aerosolization, including:
    1. Having the most experienced anesthesia professional available intubate the patient, if possible.
    2. Wearing PPE including:
      • Fit-tested N95 mask or a powered air purifying respirator (PAPR).*
      • Face shield or goggle.
      • Gown, impervious if possible.
      • Gloves.
        • Double glove and shed the outer gloves after intubation and minimize subsequent environmental contamination.
    3. Avoid awake fiberoptic intubation unless necessary.
    4. Consider RSI.  Apply small tidal volumes if manual ventilation is necessary. 
    5.  The AANA opposes healthcare facility policies that limit healthcare providers from self-supplying the PPE they need to be safe.  See position statement.

* For further details, see the AANA, ASA, APSF, AAAA Joint Position Statement - The Use of Personal Protective Equipment by Anesthesia Professionals during the COVID-19 Pandemic.

When should we use a N95 mask?

Updated 3/23/20
  • When the CRNA will be at an increased exposure risk, such as open-airway procedures, the N95 mask provides the best protection from the spread of COVID-19.  During these procedures, it is prudent to consider all patients to be carriers of COVID-19, as patients may be asymptomatic at the time of their procedure. 
  • Issuance of N95 masks or availability of PAPRs for all clinical anesthesia personnel should be a priority.
  • If appropriate resources are not available, the safety of the provider and the patient should be the most important factors in when to use masks and when to cancel elective procedures.
  • Further detail, see the   AANA, ASA, APSF, AAAA Joint Position Statement - The Use of Personal Protective Equipment by Anesthesia Professionals during the COVID-19 Pandemic.

Can we re-use PPE, including the N95 masks?

Equipment

After treating a patient with known or suspected COVID-19, how do we clean the anesthesia machine?

Updated 3/20/20
  • Cleaning procedures are the same for all patients if a high quality heat moisture exchange filter (HMEF) is placed between the circuit and the airway. Discard disposable items – breathing circuit, reservoir bag, gas sampling tubing, mask and wipe all exposed surfaces. Manufacturers’ cleaning recommendations are useful for individual devices.
  • If appropriate breathing circuit filters were used as directed, internal components of the anesthesia machine do not need special cleaning.  
  • For further details, see APSF FAQ on Anesthesia Machine Use, Protection, and Decontamination During the COVID-19 Pandemic

Should we repurpose our anesthesia machines as ventilators for ICU patients?

General

How does COVID-19 affect practicing pregnant CRNAs?

Updated 3/20/20

Where can we report drug shortages?

Updated 4/3/20

What are the current recommendations for canceling or rescheduling elective surgeries?

Updated 4/10/20

Where can a retired CRNA find volunteering opportunities?

Updated 3/26/20
  • The AANA recommends reaching out to organizations directly regarding opportunities to volunteer your services. We also suggest using Google or other search engines for state or city-specific information, utilizing searches such as “covid healthcare volunteer opportunities Illinois.”

    In addition, executive orders from state governors may include specific provisions concerning retired healthcare providers, including expedited reactivation of licensure for recently retired healthcare providers and opportunities for volunteering.  Please check your state board of nursing website for postings with more information; website and contact information for all boards is at https://www.ncsbn.org/contact-bon.htm.

    Please also check COVID-19 State Government Affair Resources, which provides information on state emergency declarations, legislation, and regulations that may affect state licensure requirements for volunteers.  For example, state government action may authorize use of out-of-state nursing licensees and/or facilitate use of in-state inactive licensees and retired healthcare providers.

    Some state boards of nursing are also auto-renewing active licenses that are about to expire.  Information regarding your current licensure status is available on most board of nursing websites (see link above), and also at nursys.com.  Please utilize internet resources as much as possible, as board of nursing telephone and staff resources are likely to be inundated with calls and questions.

About These FAQs

The AANA has received many questions and inquiries regarding clinical responses, implications, and precautionary measures to take during the COVID-19 pandemic. We understand these are trying times and CRNAs are rightly concerned about putting their patients, colleagues, family members, and selves at risk.

The international and national guidance is changing frequently, sometimes daily, so please follow this page. We are trying to provide updated information as quickly as possible.

Because this is a pandemic and there may be shortages of personal protective equipment (PPE), facility capacity, and staff, it may not be possible to follow anesthesia best practices. Instead, facilities, with anesthesia team input, may need to develop policies, procedures, and practices based on a risk assessment weighing several factors, including the extent of community COVID-19 transmission, patient population, extent of supplies on hand, reliability of supply chain, available staff, and intensive care capacity.

The responses provided to these FAQs are for information only and are not medical or legal advice. They are not official AANA policy (unless indicated) or peer-reviewed clinical practice guidelines, and they do not supersede laws, regulations, or government directives or dictate the decisions of the individual CRNA or facility. Please consult with appropriate healthcare and legal counsel to guide determinations to apply in the specific practice setting.


COVID-19 Resources

PPE, N95 Masks, and Respirators

Anesthesia-Related Information

COVID-19 CDC Guidance

Equipment

Infection Control

Information from CMS

Policy Templates

Other Organizations COVID-19 Resource Pages

Disclaimer

The resources on this page may incorporate or summarize views, guidelines, or recommendations of third parties. Such material is assembled and presented in good faith, but does not necessarily reflect the views of the AANA. Links to third-party websites are inserted for informational purposes and do not constitute endorsement of the material on those sites, or of any associated organization.  The resources on this page are for information only and are not medical or legal advice. They are not official AANA policy (unless indicated) and they do not supersede laws, regulations, or government directives or dictate the decisions of the individual CRNA or facility.


Additional COVID-19 Resources