key: cord-0787973-a8xt4jlw authors: Thampi, Swapna; Yap, Andrea; Fan, Lijia; Ong, Jacqueline title: Special considerations for the management of COVID‐19 pediatric patients in the operating room and pediatric intensive care unit in a tertiary hospital in Singapore date: 2020-04-22 journal: Paediatr Anaesth DOI: 10.1111/pan.13863 sha: 5e166133aac7ac40613daf311411358f911a2e14 doc_id: 787973 cord_uid: a8xt4jlw COVID‐19 was first identified in Wuhan, China and is caused by the novel coronavirus SARS‐CoV 2. It has now spread rapidly to over 190 countries and territories around the world and has been declared a global pandemic by the World Health Organization. The virus is spread through droplet transmission and currently has a mortality rate of over 4% globally. The pediatric population has been found to be less susceptible to the disease with the majority of children having milder symptoms and only one pediatric death being reported globally so far. Despite this, strategies need to be put in place to prevent further spread of the virus. We present a summary of the general measures implemented at a large adult and pediatric tertiary hospital in Singapore (National University Hospital) as well as the specific strategies in place for the operating room and pediatric intensive care unit. In December 2019, a cluster of viral pneumonia cases of unknown etiology was reported in Wuhan, China. 1 Sequence analysis identified the virus to be related to the SARS-CoV clade and was later named COVID-19. 2 Since the virus subtype was discovered in January 2020, it has spread quickly to over 190 countries and territories around the world. 3 The newest strain of coronavirus has been found to cause a range of respiratory symptoms from a cough or fever, to acute respiratory distress. 1, 4 The virus is spread through droplet transmission from close contact with infected individuals (symptomatic or asymptomatic) and by touching contaminated surfaces. 5 It has a higher rate of transmission than other members of the coronavirus family such as Middle East Respiratory Syndrome and Severe Acute Respiratory Distress Syndrome, but a significantly lower mortality rate 3, 6, 7 On March 11, 2020, COVID-19 was declared a global pandemic by the World Health Organization and many countries are now in a state of emergency. The mortality rate for COVID-19 at the time of writing is 4.36% and varies in each country. 3 The pediatric population has been found to be less susceptible to the disease with children having milder symptoms and only one death reported globally so far. 5, [8] [9] [10] The first COVID-19 case in Singapore was confirmed on January 23, 2020. Initial cases were imported cases from Wuhan followed later by local transmission from 3 distinct clusters. 11 Preparedness Clinics to allow for the assessment, investigation, and treatment of patients with a fever or respiratory symptoms in the community. All patients with mild symptoms were given a medical certificate for 5 days and advised to stay at home. Any patient with symptoms of pneumonia or respiratory distress was sent to hospital by a dedicated ambulance. The public were provided with surgical masks (four per household) and encouraged to wear masks only if they felt unwell, and to maintain social distancing. A dedicated team was created and a smartphone app developed to assist with contact tracing. Anyone who had close contact with a confirmed COVID-19positive individual was tested and isolated for 14 days if they were asymptomatic. Any person that tests positive is admitted to hospital. Every department in the hospital was required to divide their staff into two teams; each team member was to have minimal to no contact with the other team to ensure social distancing and business continuity in the event of COVID-19 transmission to a healthcare worker. All healthcare workers submitted their temperatures twice a day via the hospital intranet (prior to starting work and before leaving). Staff were allowed to go home but were told not to return to work if they became unwell (temperature > 37.5°C or if they developed a cough, shortness of breath or other symptoms of flu). Staff with the abovementioned symptoms were given 5 days of medical leave and must stay at home. They were only allowed to return to work if they were afebrile and if their respiratory symptoms were resolving. If the symptoms persisted or worsened, the healthcare worker would be swabbed for COVID-19 and the medical leave extended. In addition, any healthcare worker returning from overseas had to observe a strict 2-week leave of absence at home before commencing work. To prevent the spread of COVID-19 to healthcare workers, additional infection control measures were implemented. Mask fitting exercises and personal protective equipment (PPE) training was provided to all healthcare personnel. Our PPE includes an N95 mask, eye protection with goggles or an eye shield, gown, and gloves. For healthcare workers who have failed their mask fitting, a powered air-purifying respirator (PAPR) can be used instead of an N95 mask. A PAPR consists of a head hood, a motor-driven fan, a filter, and a battery. It can also be donned over an N95 mask for aerosol generating procedures in known COVID-19 patients. PAPR training was also provided to the healthcare personnel. Specific guidelines for the use of PPE and/or PAPR are outlined in The OR workflow for a suspected or confirmed COVID-19 pediatric patient is the same as for an adult patient in our hospital. 14 All OR personnel are required to wear full PPE for confirmed or suspected COVID-19 patients ( Table 1) Table 2 . pediatric illnesses, such as bronchiolitis or bronchitis, would be treated as a suspected case. These children would be admitted to a negative pressure room, and as a result, PICU beds are often used for isolation purposes. All suspected cases will undergo 2 nasopharyngeal swabs for COVID-19 during their admission in PICU, each separated by a 24-hour interval. They are only de-isolated when both of their swab results are negative. This is in line with the observation that initial SARS-CoV-2 testing by RT-PCR can be falsely negative in the early phase of illness. 14 While the confirmed COVID-19 rate is low, the burden of care lies in the management of suspected cases in the initial 48-hour period prior to the swab results. All our negative pressure rooms have a dedicated anteroom, and the patient is given one-to-one nursing. Each child can only be accompanied by one caregiver who is provided with a surgical facemask and advised to stay in the room with the child at all times. Most of our negative pressure rooms have en suite bathrooms to minimize the movement of both parent and child on the ward. Healthcare workers are required to don PPE before entering the patient's room for physical examinations and other clinical work. The use of PAPR in addition to PPE is recommended for all trained personnel performing aerosol generating procedures such as suctioning, tracheal intubation, and bronchoscopy. Nebulization should be avoided due to the risk of aerosolization of infected droplets. 15 Instead, metered dose inhalers are preferred, especially because both modes of delivery for beta-agonist have similar efficacy. 16, 17 Depending on the severity of the respiratory illness, early intubation is recommended in our center, due to risk of aerosolization of respiratory droplets with other forms of non-invasive ventilation. This is done to protect healthcare workers, as well as avoiding emer- The pediatric code blue workflow has also been revisited in light of We would like to acknowledge our colleagues in the Department of Anesthesia and Pediatric Intensive Care. The authors report no conflict of interest. Swapna Thampi https://orcid.org/0000-0003-0186-7952 Outbreak of acute respiratory syndrome associated with a novel coronavirus, Wuhan, China first update 22 WHO. 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