COVID-19 and Anesthesia Machines and Equipment Maintenance

1. How do we clean and sterilize laryngoscope/Glidescope^TM blades?

• We do not have guidance on individual laryngoscope processing or high-level disinfection processes for patients with respiratory pathogens. To our knowledge, none of the four major U.S. manufacturers of disposable videolaryngoscope blades (covers) recommend cleaning or sterilizing their disposables for reuse. However, a number of U.S. medical centers are using various techniques to process and reuse these covers.
• ASA and APSF recommend the use of videolaryngoscopes during more difficult intubation (Mallampati Type 3 and above) instead of typical laryngoscopes in an effort to limit exposure for of operating room and anesthesia personnel to aerosol. Admittedly, there are no data to confirm that video laryngoscopes reduce aerosol generation or the incidence of disease transmission.
• Below are several examples of techniques used by medical centers to process blades for re-use. Neither ASA nor APSF endorse any specific company or technique. These examples are provided only for information:
  • Some medical centers use techniques commonly used to clean endoscopes. This equipment type can be thought of as a super medical dishwasher. A number of centers use this technique and have not reported damage to any of their disposable blades.
  • Some medical centers use vaporized hydrogen peroxide. This is a low temperature sterilization process. A number of centers that have used this process also have not reported damage to any of the disposable blades.
  • Some medical centers use manual cleaning and autoclaves and have not reported damage to their disposable blades.
• To conserve videolaryngoscopy equipment, remember that routine direct laryngoscopy can be used with patients with Mallampati Class 1 and 2 airways. Regardless, please refer to CDC and FDA regulations regarding the reuse of single-use medical devices.
• We also recommend that you contact the manufacturer for cleaning guidance in the face of shortages. You may also wish to review recommendations on Infection Prevention in the Operating Room Anesthesia Work Area from the Society for Healthcare Epidemiology of America (SHEA) for consideration.

2. What type of breathing circuit filters should be used to prevent passage of the COVID-19 virus into the anesthesia machine? Could breathing circuit filters become a vector for subsequent patients?

• With regard to this question, please refer to the APSF FAQs on Anesthesia Machine Use, Protection, and Decontamination during the COVID-19 Pandemic.

3. Does the anesthesia machine need to be decontaminated after use on a COVID-19 patient? We have breathing circuit filters in the circuit and the gas sampling line is also filtered.

• Please refer to ASA “Recommendations when caring for a patient with known or suspected COVID-19 infection” that states, “After the case, clean and disinfect high-touch surfaces on the anesthesia machine and anesthesia work area with an EPA-approved hospital disinfectant.” The internal components of the anesthesia machine and breathing system do not need “terminal cleaning” if breathing system filters have been used as directed. Please seek additional guidance from anesthesia machine manufacturers as well as from the APSF on decontamination.

4. Where can I find information on converting anesthesia machines to ICU ventilators?

• If the pandemic overcomes the capacity of the hospital ICUs to provide ventilators, unused operating room anesthesia machines can be purposed for use in the ICUs. Please refer to ASA and APSF guidance for further information. Anesthesia machine manufacturers have also provided their recommendations on repurposing the anesthesia machine for ICU use.

5. Where in the anesthesia circuit should we place the breathing circuit filter to protect the gas sampling tubing?

• The gas sampling line should be protected by placing a breathing circuit filter at patient end after the Y-piece and then sampling from the side of the filter opposite to the patient (from the machine side of the filter). If there is a sampling port on the patient side, it must be capped. Ensure that the gas sampling line is protected from gases expired from the patient by placing it on the machine side of the filter.
• If a filter cannot be placed between the breathing circuit and the patient’s airway and if the gas sampling system does not have an effective viral filter prior to exhausting sampled gases back into ambient air or into the internal conduits of the anesthesia machine, then place a 0.2 micron filter at the entry to the water trap. This is the same filter that is typically placed in an epidural tray for filtering epidural injections.
• Both GE and Draeger provide water trap filters that are at least 99.999% effective and are suitable for protecting the gas sampling system. Wipe surface of the drug filter if not changed between patients. Change the filter and water trap after use on a COVID-19 patient.
• Some capnometers and gas analyzers, especially those used in non-operating room settings, transfer the output gas back into the room. Multi-gas analyzers, typically used with or integrated into anesthesia machines, transfer the output gas back into the anesthesia machine or into the scavenging system. It is especially important to filter the analyzer gas if the effluent is discharged either into the room or back into the breathing system.

6. For the pediatric patient how do you protect the sampling line due to the fact the breathing circuit filter adds dead space and is too heavy for ETT?

• A filter placed between the breathing circuit and the patient’s airway adds to respiratory dead space; smaller patients may not tolerate the additional dead space volume. If a filter cannot be placed between the breathing circuit and the patient’s airway, then place a viral filter at the end of the expiratory limb at the connection to the anesthesia machine. If the gas sampling system does not have an effective viral filter prior to exhausting sampled gases back into ambient air, then place a 0.2 micron filter at the entry to the water trap. This is the same filter that is typically placed in an epidural tray for filtering epidural injections. Wipe surface of the drug filter if not changed between patients. Change the filter and water trap after use on a COVID-19 patient.
• Both GE and Draeger provide water trap filters that are at least 99.999% effective and are suitable for protecting the gas sampling systemNew 
• The dead space of a viral circuit filter is generally a concern for patients whose tidal volume is less than 300 mL (i.e. patients weighing under 50 kg). The internal volume of the circuit filter, listed in the manufacturer’s specifications, indicates the additional dead space for a given filter. A rule of thumb is to consider three times the internal volume of the device as the minimum tidal volume.
• We recommend you review the APSF website for more information on this topic.

7. Where can I purchase breathing circuit filters? Does ASA or APSF have any specific product recommendations?

• Hospitals have supply chain managers who generally have established relationships with the contracted suppliers because breathing circuit filters are commonly used on ICU ventilators and anesthesia machines. Anesthesia supply businesses are a second option. When buying breathing circuit filters, obtain those with the highest VRE. Purchase some with smaller internal volume if your practice includes pediatrics. We cannot recommend specific products to purchase.

8. We are using breathing circuit filters that filter 99.9999%. We also have HMEF filters that filter even more. Which filters should I use?

• The presence or respiratory pathogens in your area and levels of current filtration supplies will help you determine how to best allocate scarce resources. Reserving the higher filtration breathing circuit filters for the patients with the highest viral titers seems appropriate. Note that a filter may have different filtering capabilities for different pathogens. Please also consult with your local infectious disease physicians and infection control staff. We also recommend you review the APSF website for a discussion on anesthesia machines.

9. Should we use breathing circuit filters for all general anesthetics since we may not conclusively know which patients are COVID-19+ or otherwise contagious?

• Breathing circuit filters are commonly used with circle systems in the operating room. This is a best practice that should be adopted as standard policy in all practice locations. The filters are VFE rated, and we recommend, at a minimum, filters with a VFE of 99.99% that are already commonly being used.

10. Should I be concerned that my anesthesia machine is a vector for transmission?

• Please review the APSF website for a discussion on anesthesia machines.

11. What is the position of the ASA on placing multiple patients on a single mechanical ventilator?

• ASA, the Society of Critical Care Medicine (SCCM), American Association for Respiratory Care (AARC), Anesthesia Patient Safety Foundation (APSF), American Association of Critical‐Care Nurses (AACN) and American College of Chest Physicians (CHEST) issued a consensus statement on the concept of placing multiple patients on a single mechanical ventilator on March 26, 2020.

12. For vaccinated, asymptomatic and negative COVID-19 patients, do we need to protect the CO₂ sampling line with a second HEPA filter for each general anesthesia case?

• Guidance on the approach to filtering airway gases is available on the APSF website. Current guidance recommends using an HME filter at the airway and sampling gas from the machine (filtered) side of the HMEF. The viral filtration effectiveness varies with HMEFs and filtering performance at the airway as susceptible to moisture or soiling, especially for electrostatic filters. Sampled gas typically enters a water trap and many of these traps have an internal filter effective for filtering viruses. Some traps do not and the viral filtration effectiveness is not documented for many. The level of additional protection recommended for the sampling line, in addition to the HMEF, depends upon where the exhaust gas from the gas analyzer is routed. If the analyzer is separate from the anesthesia machine, a second filter is not required if the exhaust port for sampled gas is connected directly to a scavenging system or central suction. It is not recommended for exhaust gas to enter the room directly since inhalation anesthetics will also contaminate the room. If scavenging cannot be accomplished, additional filtering is prudent to protect against viral infection. 
• If the analyzer is built into the anesthesia machine, it is important to understand if the exhaust gas from the analyzer goes to the scavenger, back into the circuit or into the room. If exhaust gas is routed into the breathing circuit and the effectiveness of the water trap filter for virus is unknown, additional filtering is prudent to prevent contaminating the inside of the anesthesia machine. It is not recommended for exhaust gas to enter the room directly since inhalation anesthetics will also contaminate the room.  If scavenging cannot be accomplished, additional filtering is prudent to protect against viral infection. 

13. What processes should I use to return an anesthesia machine that was purposed for ICU back to an operating room setting? If a machine is not used for a month or so, do we need to do any special testing prior to routine anesthesia service?

• Complete guidance on how to return an anesthesia machine to service in the operating room after use for long term ventilation of patients with COVID 9 related respiratory failure can be found in the APSF/ASA Guidance on Purposing Anesthesia Machines as ICU Ventilators.
• The current recommended steps are:
  • Remove and discard all disposables - circuit, filters, CO₂ absorbent, mask, sampling line and associated water trap. 
  • Following manufacturer instructions, sterilize the internal breathing system and ventilator components. 
  • Wipe external surfaces with appropriate anti-viral cleaning solution 
  • Replace the disposables with new clean/sterile replacements 
  • Place a viral filter on the inspiratory limb for two to four weeks. This filter could be left in place between patients to conserve supply. 
• If the machine has not been used for more than a month, no special testing should be required other than the usual preventive maintenance and pre-use test procedures. It is not likely that viable virus would remain after that period of time.
• Please review the APSF website for a discussion on anesthesia machines.

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Disclaimer

Viewers of this material should review these FAQs with appropriate medical and legal counsel and make their own determinations as to relevance to their particular practice setting and compliance with state and federal laws and regulations. The ASA has used its best efforts to provide accurate information. However, this material is provided only for informational purposes and does not constitute medical or legal advice. This response also should not be construed as representing ASA policy (unless otherwise stated), making clinical recommendations, dictating payment policy, or substituting for the judgment of a physician and consultation with independent legal counsel.