Hello, everyone. I'm Wang Qiang from the First Affiliated Hospital of Xi 'an Jiaotong University. It's my honor to share with you this topic titled, Recommended Practice Procedures of Endotracheal Intubation and Infection Prevention for Patient with Covid-19. This topic will be presented via the following aspects. Since covid-19 has spread rapidly throughout the globe, most clinical manifestations observed have revealed mild to severe respiratory symptoms. Endotracheal intubation is necessary for emergency treatment along with administration of general anesthesia for patients infected with covid-19. However, it also puts anesthesiologists a high risk of nosocomial infections as a result of direct contact with the patient's airway. The indications that endotracheal intubation will be needed are patients under emergency treatment such as severe hypoxemia requiring invasive ventilation and emergency resuscitation, and the patients who need surgery under general anesthesia. Emergency endotracheal intubation. When receiving calls from the isolated ward, we should obtain all pertinent patient information and instruct the supervising physician to make related preparations. Unexperienced anesthesiologist with an assistant prepares and carries emergency intubation supplies and aesthetics to the ward and performs the intubation. Before entering the ward, they should carry out tertiary protections with correct medical protective supplies both in the clean area and semi contaminated area, according to the relevant guidelines. When arriving at the isolated ward, they must check patient information, assess the patient's general condition and perform rapid assessment of the airways. Then the anesthesiologist should optimize the physical position of the patient, such as removing the headboard and keeping them in a supine position. If patients are assessed to have non difficult airways, oral tracheal intubation will be performed by visual laryngoscope. Firstly, they supply sufficient pre-oxygenation according to the following procedures; make patients wear surgical masks, connect the face mask with a respirator balloon with the artificial filter, supply sufficient oxygen with BiPAP or respirator mask. Then they successively give rapid induction anesthetics as following, intravenous injection of two to five milligrams of midazolam combined with etomidate or propofol for deep sedation. After unconsciousness is achieved, inject one milligram per kilogram of rocuronium for enough muscle relaxation, and then inject about two micrograms of sufentanil. Finally after the muscle relaxant is fully effective, quickly insert the endotracheal tube into the trachea using visual laryngoscope, connect the ventilator with filter under just ventilator parameters. Check end expiratory carbon dioxide waveform to confirm the tube into the trachea. According to tertiary protection guidelines, it's not convenient to perform auscultation and should make a comprehensive judgment of the endotracheal tube depth by the distance of tracheal tube from glottis to incisor, bilateral chest undulation, ventilator waveform, ultrasonography, fiber bronchoscope, etc. If intubation fails, they will immediately provide pressurized oxygen with a ventilator mask. When oxygenation is improved, they should optimize the airway management strategy according to the principles of difficult airway intubation. After endotracheal intubation, they then adjust respiratory parameters following the low protective ventilation strategy. Low tidal volume, four to eight milligrams per kilogram, plateau pressures less than or equal to 30 MMH2O, inspired oxygen fraction less than 60 percent, PEEP, five to eight CMH2O and three to five times per hour of recruitment maneuver. Then dispose off intubation items and medical protective gears according to the rules. Endotracheal intubation under general anesthesia. The minus five PA of negative pressure of air conditioning purification system in operating room should be prepared first. Two anesthesiologists wearing tertiary protective equipment take sufficient anesthetics on supplies into the operating room. All members and supplies follow the one-way flow principle. The anesthetic machine is connected with three breath filters. The anesthesiologist evaluates the patient by phone, video, etc. For patients with difficult airways, anesthesiologists prepare related apparatus supplies, a multi-disciplinary personnel according to the principles of anticipated difficult airway intubation. After all, the preparations are complete, anesthesiologists enter the operation room, check the patient again, evaluate the patient's cardiopulmonary function, etc. The patient wears a mask and inhales high flow pure oxygen. Rapid induction is performed by anesthetic titration in the same manner as the above emergency endotracheal intubation guidelines. Then anesthesiologists perform tracheal intubation fixation and depth judgment. According to the principles of unanticipated, difficult airway intubation. If intubation fails, anesthesiologist should call for help and apply a second-generation laryngeal mask. If both fail, immediately establish invasive ventilation through the cricothyroid membrane, monitor vital signs closely, individualize fluid replacement and maintain stable circulation. Apply long protect ventilation strategy, review blood gas levels, adjust oxygenation index and internal environment. Sufficient analgesia and the inhibition of choking are indispensable for extubation. Respiratory secretion is cleared under deep anesthesia. When breathing is fully restored, while sedation is not restored, extubation is performed with a filter at the end. If the patient safety cannot be ensured, the patients with mild symptoms are extubated only once fully awake and the severe cases are taken to the ICU with an endotracheal tube. After the surgery call the operating room front desk staff to open the specified transit boot. Transfer personnel replace secondary protection, cover the patient's entire body with a single surgical procedure. Heavy intubation period, disinfection is equally important. Disposable items such as external tubing of the anesthesia machine, laryngoscopes, anesthesia masks etc, are sealed with double-layered medical garbage bags and marked with the COVID-19 logo and are specially disposed off by professional persons. The surface of the equipment should be wiped and disaffected with 1,000 milligram per liter chlorine disinfectant twice. If it is not resistant to corrosion, use 75 percent ethanol for disinfection. For visible pollution cleanup visible debris using disposable absorbent material. Cover with 2,000 milligrams per liter chlorine containing disinfectant cloths for 30 minute then wipe. The anesthesia machine should be sterilized by connecting the loop of this compound alcohol sterilizer or dissembling the inner tubing. For sterilization of the operation room. Spray with peroxyacetic acid, hydrogen peroxide, and keep the operation room closed for two hours. Turn on laminar flow and ventilation, and keep the operation room closed for at least two hours. In summary, when performing emergency intubation in the outside of operating room, carry sufficient emergency intubation items and drugs, apply tertiary protected gears, evaluate the patient's airway difficulties fully. Lastly, choose the optimal intubation scheme to avoid being caught off guard. When implementing general anesthesia intubation, setup specified transit route, use a negative pressure operating room, pay attention to difficult airway management and critically ill patients respiratory and circulation management. Use sufficient analgesia and inhibition of choking for extubation. Ensure secondary protective gears are used during transfer. During the epidemic, I hope every doctor can protect himself and help more patients. Thank you.
