What are the guidelines for N95 respirator use during emergency and elective cesarean sections?

Posted on April 8, 2020 by Madalon Burnett

Summary

OR teams caring for patients undergoing emergency and elective c-sections with confirmed or suspected COVID-19 should wear N95 respirators in case of the need to convert to general anesthesia.  

I.   CONFIRMED OR SUSPECTED CASE OF COVID-19

  • March 13 2020: the Society of Obstetricians and Gynecologists of Canada (SOGC) recommends the following for patients with confirmed or suspected COVID-19 (1):
    • Testing should be performed as per local guidelines and recommendations (See http://www.bccdc.ca/health-professionals/clinical-resources/covid-19-care/lab-testing for current recommendations on testing in British Columbia).
    • Cesarean delivery should be reserved for obstetrical indications. 
    • Given that intubation is considered an aerosol-generating procedure, the surgical team should wear N95 respirators for cesarean delivery in case there is a need to convert from neuraxial to general anesthesia.

 

  • For aerosol generating procedures in suspected and confirmed cases of COVID-19, the WHO recommends respirators, eye protection, gloves and gowns, and aprons if the gowns are not fluid resistant (2). 

 

What is a suspected case?

  • The public health agency of Canada defines a suspect case as having 2 or more of: [fever, cough, sore throat, runny nose, headache] AND meets exposure criteria, which currently includes anyone who has spent time in Canada (3). 

 

  • As the percentage of the population with asymptomatic COVID-19 increases, we may reach a point at which we treat all aerosol generating procedures as though the patient has COVID-19 – this threshold is decided by  provincial health authorities (4). No BC guidelines could be found suggesting whether we have reached this threshold. The Royal College of Physicians and Surgeons of Canada has requested the government to provide more comprehensive guidelines to support physicians making decisions about PPE to address this problem (5). To help the provider decide in the meantime, in Canada right now, 73% of COVID-19 cases are community based transmission (6).

II.   PATIENTS UNDER INVESTIGATION FOR COVID-19

  • Health Canada recommends “an N95 respirator (plus eye protection) should be used when performing aerosol-generating medical procedures (AGMPs) on a person under investigation (PUI) for COVID-19” (7).

III.   PATIENTS WHO HAVE SCREENED NEGATIVE FOR COVID-19

  • No specific guidelines for negative screened individuals and the use of N95 masks during aerosol generating procedures could be found. The WHO states that most COVID-19 transmission is transmitted by symptomatic, laboratory positive individuals, but there is an asymptomatic transmission period (8). Preliminary data suggests that there could be a 30% false negative rate in COVID-19 nasal PCR swab testing (9). The SOGC does not recommend using droplet precautions in cases of negative tested COVID-19 swabs for routine care (10). 

IV.   PPE PRACTICES FOR ELECTIVE VS EMERGENT CESAREAN SECTIONS

  • April 1 2020: Alberta Health Services suggests (4): 
    • Elective: All members of the OR team should wear PPE including an N95 mask due to the possibility of an unanticipated AGMP occurring during the case, even for elective C-sections under spinal anesthetic.
    • Emergent: For a STAT GA C-section the entire OR team should be in PPE with N95 masks prior to RSI as the patient is prepped and draped prior to induction. For the laboring patient requesting an epidural, contact/droplet precautions should be donned.

Questions? Comments? Does this need to be updated? Do you have valuable points to add ? Please email ask.reakt@ubc.ca.

References

  1. “Updated SOGC Committee Opinion –  COVID-19 in Pregnancy.” Sogc.Org, 2020, www.sogc.org/en/content/featured-news/Updated-SOGC-Committee-Opinion__COVID-19-in-Pregnancy.aspx. Accessed 8 Apr. 2020.
  2. Rational use of personal protective equipment (PPE) for coronavirus disease (COVID-19) [Internet]. Available from: https://apps.who.int/iris/bitstream/handle/10665/331498/WHO-2019-nCoV-IPCPPE_use-2020.2-eng.pdf
  3. Public Health Agency of Canada. Interim national case definition: Coronavirus disease (COVID-19) – Canada.ca [Internet]. Canada.ca. 2020 [cited 2020 Apr 8]. Available from: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/national-case-definition.html
  4. FAQs for PPE in OR and Surgical Services [Internet]. [cited 2020 Apr 8]. Available from: https://www.albertahealthservices.ca/assets/info/ppih/if-ppih-surgical-services-ppe-faq.pdf
  5. Royal College supports call for guidelines for PPE use and to mobilize Canadian production – Royal College Newsroom [Internet]. Royal College Newsroom. 2020 [cited 2020 Apr 8]. Available from: https://newsroom.royalcollege.ca/royal-college-supports-call-for-guidelines-for-ppe-use-and-to-mobilize-canadian-production/
  6. ‌‌Public Health Agency of Canada. Epidemiological summary of COVID-19 cases in Canada – Canada.ca [Internet]. Canada.ca. 2020 [cited 2020 Apr 8]. Available from: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/epidemiological-summary-covid-19-cases.html#a5
  7. Public Health Agency of Canada. Coronavirus disease (COVID-19): For health professionals – Canada.ca [Internet]. Canada.ca. 2020 [cited 2020 Apr 9]. Available from: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals.html#i
  8. Advice on the use of masks in the community, during home care and in healthcare settings in the context of the novel coronavirus (COVID-19) outbreak [Internet]. Who.int. 2018 [cited 2020 Apr 9]. Available from: https://www.who.int/publications-detail/advice-on-the-use-of-masks-in-the-community-during-home-care-and-in-healthcare-settings-in-the-context-of-the-novel-coronavirus-(2019-ncov)-outbreak
  9. Yang Y, Yang M, Shen C, Wang F, Yuan J, Li J, et al. Evaluating the accuracy of different respiratory specimens in the laboratory diagnosis and monitoring the viral shedding of 2019-nCoV infections. 2020 Feb 12 [cited 2020 Apr 8]; Available from: https://www.medrxiv.org/content/10.1101/2020.02.11.20021493v2.full.pdf
  10. ‌SOGC Recommendations: COVID-19 and Pregnancy [Internet]. 2020 [cited 2020 Apr 9]. Available from: https://sogc.org/common/Uploaded%20files/COVID-19_algorithm_VP_March%2017_EN2_rev.pdf

Disclaimer

The above is intended to serve as a rapidly-created, accessible source of information curated by medical students and healthcare professionals. It is for educational purposes only and is not a complete reference resource. It is not professional medical advice, and is not a substitute for the discretion, judgment, and duties of healthcare professionals. You are solely responsible for evaluating the information above.