新冠肺炎疫情防控专家答疑平台系列（双语版）【上】

xiaozhuohc

新冠肺炎疫情防控专家答疑平台系列（双语版）

【上】

中华医学会麻醉学分会

答疑专家：卞金俊，陈向东，程宝莉，戴茹萍，董海龙，邓小明，方向明、郭向阳，黄文起、李茜，李师阳，李天佐，林云，刘艳红，路志红，罗爱林，梅伟，米卫东，彭宇明，宋丹丹，苏殿三，谢克亮，徐懋王东信，王国林，王天龙，王云，王钟兴，吴安石，夏中元，朱涛，赵磊，张林忠，左明章

编辑：王晟 龚亚红

总负责：黄宇光

新冠肺炎疫情防控专家答疑平台第一期——医护人员防护篇

（专家意见仅供参考）

COVID-19 prevention and control experts Q&A platform (1)—protection of medical staff(Expert’s opinion is for reference only)

1、医护人员如何在围手术期防止交叉感染？

How to prevent cross-contamination for medical staff during peri-operative period?

郭向阳，徐懋Guo Xiangyang, Xu Mao

医护人员的防护对于疫情控制非常重要，须注意医护人员自身防护和避免由医务人员导致的交叉感染。临床实践中首先须加强新冠肺炎病例的排查工作，努力做到分区、分类、科学防控，由此术前访视和评估极其重要，需要鉴别患者是否存在NCP的可能，由此采用相应的防护措施。其次，医护人员也是易感人群，尤其是插管、拔管等高暴露操作时候，这就要求根据此次发布的相关疫情防护指南和标准，采用相应的防护标准和物品。科室须建立相关规范，加强相关理论和操作的培训和考核，做到应知应会。 另外，采取针对性防护措施，以及设备、物品和环境的感控，加强自我监测等都是必要的措施。

The protection of medical staff is crucial for the infection prevention and control. We should not only pay attention to self-protection, but also avoid cross infection caused by medical staff. First of all, in clinical practice, it is necessary to strengthen the screening of new cases of COVID-19, and strive to achieve zoning, classification, scientific prevention and control. Therefore, preoperative visit and evaluation are extremely important, and it is necessary to clarify the possibility of COVID-19 in patients, and adopt corresponding protective measures. Secondly, medical staff are susceptible, especially during high exposure risk procedures such as intubation and extubation and other high-risk operations, which requires the adoption of corresponding protection standards and articles according to relevant guidelines and standards issued this time. All the department must establish relevant standards, strengthen the training and assessment of relevant knowledge and operations, and implement to each person. In addition, the adoption of specific precautions, as well as the control of contaminated equipment, facilities and the environment, strengthen self-monitoring and other measures are necessary.

2、麻醉医生如何做好三级防护；三级防护的有哪些操作细节？如果没有三级防护设施可以拒绝进行气管插管及吸痰高危操作吗？

How to make level-3 protection for anesthesiologists? What are the operational details of level 3 protection? Can I refuse high-risk operations, such as endotracheal intubation and aspiration, without level-3 protective facility?

郭向阳，徐懋Guo Xiangyang, Xu Mao

应按照国家颁布的防护标准及操作规范对科室麻醉医生进行统一培训指导并进行考核，确保在实际工作中，麻醉医护人员按照三级防护标准进行穿戴防护。防护细节参照已颁布防护标准，其中最重要的就是注意避免穿戴不规范或在脱防护设备过程中的污染，需要严格按照规范逐步进行。没有三级防护设施条件下，应该积极应对，可以采取措施降低相关风险等级，比如给予肌松剂后进行插管和吸痰操作，减少喷溅和产生气溶胶的可能性，由此降低暴露风险。

It is necessary to conduct unified training and guidance for anesthesiologists in the department according to the protection standards and operational specifications issued by the state, so as to ensure that anesthesiologists wear protection in accordance with the level-3 protection standards in clinical practice. The protection details should refer to the issued protection standards, the most important of which is to pay attention to avoid the contamination in the process of wearing or taking off the protection equipment, which should be carried out step by step in strict accordance with the standards. In the absence of level-3 protection facilities, we should take active measures to reduce the risk level of relevant risk, such as intubation and aspiration after the administration of muscle relaxants to reduce the possibility of spillage and aerosol generation, thereby reducing the risk of exposure.

3、新冠肺炎疫情期间，麻醉科医护人员的哪些工作场景交叉感染的概率比较高，主要高危因素有哪些？

During the outbreak of COVID-19, which scenarioshave a high probability of cross-contamination for the staff of the department of anesthesiology, and what are the main risk factors?

郭向阳，徐懋Guo Xiangyang, Xu Mao

麻醉临床实践中，气管插管、气管切开、心肺复苏、插管前手动通气、拔管、吸痰和内镜检查等，有血液、体液、分泌物等喷溅或可能产生气溶胶，都是暴露高风险，属于高风险操作。

In the clinical practice of anesthesia, endotracheal intubation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation, extubation, aspiration, endoscopy, splashing of blood, body fluids, secretions, etc., or the possible aerosol production, all of which are high-risk exposures and belong to high-risk procedures.

4、三级防护和二级防护具体区别在哪里？三级防护必须要有正压通气吗？

What are the specific differences between level-2 protection and level-3 protection? Is positive pressure ventilation necessary for level-3 protection?

郭向阳，徐懋Guo Xiangyang, Xu Mao

三级防护一般是在对确诊或疑似患者有创操作如给呼吸道传染病病人进行气管插管、切开吸痰时等可能喷溅或产生气溶胶时采取的严密防护，要求在二级防护基础上，加戴面罩或全面型呼吸防护器。正压通气有助于减少医务人员的感染，有条件单位使用正压通气可以加强防护，没有相关设备的单位，可以通过降低暴露风险等级等方法进行防护，采用近期全国和省市地方发布的防护标准和指南穿戴防护服、医用防护面罩和防护面屏/护目镜等方法进行防护。

　  Level-3 protection generally refers to the strict protection that can be taken when performing invasive procedures to confirmed or suspected patients, such as endotracheal intubation and aspiration for patients with respiratory infectious diseases, which may spray or produce aerosols. It is required to wear a mask or a comprehensive respiratory protective device on the basis of level 2 protection. Positive pressure ventilation will help reduce the infection of medical staff. If the positive pressure ventilations are available, it can strengthen protection. When there is no related equipment unit, medical staff can reduce exposure risk by reducing the level of exposure risk and other methods, and then wear protective gowns, surgical protective masks and protective face shield/goggles according to recent national and provincial protection standards and guidelines.

5、麻醉医护工作者在对新冠患者气管插管操作时如何做好防护工作？

How to protect anesthesiologists themselves when intubating patients with COVID-19?

王国林，谢克亮Wang Guolin, Xie Keliang

采取三级医疗防护措施，首选穿戴正压呼吸头套，如果没有则必须戴N95口罩、护目镜和面屏，按照感控要求穿戴好防护服，气管插管操作前加戴一层橡胶手套。患者清醒状态下经面罩高流量给氧，尽量避免加压辅助通气。应适度镇静及充分肌松，待患者意识消失后开始低潮气量高频通气，确保患者自主呼吸完全消失，待患者胸廓起伏达到最低点时迅速完成气管插管。尽可能改善患者的氧供，减少氧债发生。对存在口腔分泌物患者，若无呼吸道梗阻情况，建议完成气管插管后再行气道吸引。气管插管后，严禁穿着个人防护设备离开污染区，应妥善处理消毒。

It is necessary to adopt the three-level medical protection measures. Positive-pressure breathing hood is preferred, if not, N95 masks, goggles and face shields must be worn. Anesthesiologists should wear protective clothing according to infecting control requirement, and wear another layer of rubber surgical gloves before tracheal intubation. When the patient is awake, we should choose high-flow oxygen through a mask and try to avoid pressurized assisted ventilation. Patients should be given moderate sedation and sufficient muscle relaxation. After their consciousness disappears, low-tidal volume high-frequency ventilation should be given. It should be ensured that the patient's spontaneous breathing completely disappears, and the tracheal intubation is quickly completed when the thorax reaches the lowest point. We should try to improve the patient’s oxygen supply and reduce the occurrence of oxygen debt. For patients with oral secretions, if there is no airway obstruction, it is recommended to perform the tracheal intubation before airway aspiration. After tracheal intubation, it is strictly forbidden to leave the contaminated area when wearing personal protective equipment, and it would be properly handled and disinfected.

6、麻醉科工作环境中，气溶胶传播如何防护？

How to prevent the aerosol transmission in the Department of Anesthesiology?

王国林，谢克亮Wang Guolin, Xie Keliang

针对新型冠状病毒肺炎的气溶胶传播途径，麻醉医生应加强防护。气溶胶多是患者在咳嗽和打喷嚏时产生，麻醉医生应重点防护气管插管、拔管或吸痰过程中可能产生的气溶胶。由于气溶胶颗粒比较大，麻醉医生可采用一次性插管工具、戴手套、N95口罩、护目镜和医用面屏防护。气管插管给予患者充分吸氧，增加氧储备，在肌松药作用达高峰后行气管插管（如果是困难气道则按照困难气道处理流程进行）。推荐使用可视喉镜插管，避免长时间面对患者口咽部以减少气溶胶接触时间。吸痰采用密闭式吸痰装置进行，这样能减少气溶胶对室内环境的污染。拔除气管插管前的吸痰：主张在患者较深麻醉自主呼吸未没有完全恢复前完成吸痰，主张在手术室完成拔管（危重症需送ICU者例外）。

Anesthesiologists should strengthen protection against aerosol transmission of COVID-19. Aerosols are mostly produced by COVID-19 patients when they cough and sneeze, so the anesthesiologists should focus on protecting against aerosols that may be produced during tracheal intubation, extubation or suction. Due to the large molecular size of aerosol particles, anesthesiologists can use disposable intubation tools, surgical gloves, N95 masks, goggles and medical masks. Patients should be given sufficient oxygen before tracheal intubation to increase oxygen reservation, and tracheal intubation should be performed after the muscle relaxant reaches its peak. If it is a difficult airway, we should follow the difficult airway treatment process. Visual laryngoscope intubation is recommended to avoid prolonged facing the patient's oropharynx to reduce the time of contact with aerosols. Sputum suction is performed with a closed suction device, which can reduce the aerosol pollution in the indoor environment. Sputum suction before tracheal intubation: It is advisable to complete sputum suction before the spontaneous breathing is fully recovered when the patient is under deep anesthesia, and it is advisable to complete extubation in the operating room (except those who need to send ICU in critical illness).

7、疑似和确诊病人行急诊手术如何进行个人防护？

How to perform personal protection for emergency operation in suspected or confirmed patients?

王国林，谢克亮Wang Guolin, Xie Keliang

对于疑似和确诊患者，如必须实施急诊手术时，一定要采取最高级别的防护。医务人员按三级医疗防护措施，必须戴N95口罩、护目镜和防护面屏，最好在负压手术室进行手术。麻醉诱导预充氧阶段，可考虑使用2块湿纱布将患者的口鼻盖住后行面罩通气。进行气管插管操作时，一次性使用足量肌松药及起效时间，并且在患者完全肌肉松弛状态下进行，尤其要警惕气管插管和拔管时患者呛咳。手术间门口标示为“感染手术”，避免无关人员进出。

For suspected or confirmed patients, the highest level of protection must be taken if emergency surgery is necessary. Medical personnel must wear N95 masks, goggles, and protective masks according to the three-level medical protection measures. It is best to perform surgery in a negative pressure operating room. In the pre-oxygenation phase of anesthesia induction, 2 pieces of wet gauze can be considered to cover the mouth and nose of patients, followed by mask ventilation. When performing endotracheal intubation, a sufficient amount of muscle relaxant should be used at one time, and the patient's muscles need to be completely relaxed before procedure. In particular, it is alert to patients who cough during intubation and extubation. The doorway of the operating room is marked as "infection surgery" to prevent unrelated peoples from entering or leaving.

8、术前没有进行相关新冠病毒筛查的病人急诊手术如何防护？

How to prevent emergency surgery for patients without COVID-19 screening?

王国林，谢克亮Wang Guolin, Xie Keliang

任何急诊手术风险均远高于择期手术，需要再次确认患者是否有流行病史，有无发热、咳嗽、乏力等症状。对每一例患者都不能放松警惕，建议佩戴N95口罩或双层外科口罩、穿手术衣或隔离衣、戴手套。所有急诊全麻患者，插管、拔管时均使用护目镜或防护面屏，尤其要警惕拔除气管导管时患者呛咳气道分泌物或飞沫的污染。对疑似患者手术，需采取最高级别的防护，医务人员按三级医疗防护措施。

The risk of any emergency surgery is much higher than that of elective surgery. It is necessary to reconfirm whether the patient has an epidemiological history, fever, cough, fatigue, etc. We can’t relax our vigilance for each patient. It is recommended to wear N95 masks or double surgical masks, surgical gowns or isolation gowns, and surgical gloves. When intubating and extubating for all emergency general anesthesia patients, it is necessary to use goggles or protective masks, especially to be vigilant against contamination of airway secretion and droplets in patients when removing the tracheal tube. For patients with suspected COVID-19, the highest level of protection is required, and medical staffs should follow three-level of medical protection measures.

9、是否非全麻的选择更安全？非全麻是否需要防护？

Are alternatives to general anesthesia safer than general anesthesia? Does regional anesthesia require protection?

罗爱林，梅伟Luo Ailin, Mei Wei

从以下三个方面考虑，非全麻的选择更安全：1.医护人员的安全。借鉴SARS的防控经验，气道相关操作导致医护人员感染的风险高；2.病人的安全。麻醉医师在三级防护下进行气道管理难度增加，困难气道风险增加。且机械通气可能造成新冠肺炎患者肺部并发症；3.医疗环境的安全。全麻相关医疗废物，如气管导管，带来潜在的病毒传播风险更高。全麻中使用的麻醉机等设备也存在被污染的风险。故如条件允许，建议在非全麻的麻醉方式下完成手术。

基于新冠肺炎的传播途径、强传染性及存在无症状携带者等事实，接触确诊、疑似患者或确诊患者密切接触者，及其周围环境都存在感染风险。在此类患者的手术中，医护人员采取何种级别防护与麻醉方式的选择没有直接关系。具备条件的医疗机构，此类患者的手术建议在负压手术间进行。所有参与手术的医护人员（包括麻醉医师）须采取三级防护措施。

   According to the following three aspects, the choice of non-general anesthesia is safer: 1. The safety of medical staff. Based on the experience of prevention and control for SARS, the risk of infection caused by airway related operations is high; 2. Patient safety. It is more difficult for anesthesiologists to manage airway under level III protection precaution, and the risk of difficult airway is increased. Mechanical ventilation may cause increased risks of pulmonary complications in COVID-19 patients; 3., the safety of medical environment. General anesthesia related medical wastes, such as tracheal tubes, pose a higher risk of virus transmission. There is also a risk of contamination of anesthesia machines and other equipment used in general anesthesia. Therefore, if possible, we recommended to complete the operation under regional anesthesia.

Based on the fact that the high risk of transmission and present of asymptomatic carriers of COVID-19, there is a risk of infection in contact with the confirmed or suspected patients, or in contact with people has close contacts of the confirmed patients and their surrounding environment. During the operation of this kind of patients, the protection level taken by medical staff has no direct relationship with the choice of anesthesia. For qualified medical institutions, the operation of such patients is recommended to be performed in the negative pressure operating room. All medical staff (including anesthesiologists) involved in the operation shall take level III protection precaution.　

10、新冠肺炎疫情下气管插管的适应证有哪些？有哪些注意事项？

The indication of intubation during the outbreak of COVID-19 and points of attentions

左明章，宋丹丹 Zuo Mingzhang, Song Dandan

在当前新冠肺炎疫情下，有三类患者进行插管时需要特别关注：（1）重症和危重症新冠肺炎患者，患者在接受标准氧疗后呼吸窘迫和（或）低氧血症无法缓解时，给予高流量鼻导管氧疗或无创通气，短时间内病情无改善甚至恶化，应当及时进行气管插管；（2）疑似和确诊患者行急诊全麻手术；（3）限期全麻手术。注意事项：（1）对限期手术患者在术前访视患者时，询问接触史和相关症状，再次筛查。如是疑似病例，根据相关流程汇报；（2）对疑似和确诊患者，做好三级防护；（3）气管插管前进行评估，包括气道评估；（4）准备好困难气道管理车和相关设备。

During the outbreak of COVID-19,three groups of the patients need to be intubated should be focused on：

(1)、for severe and critical COVID-19 patients: if respiratory distress and/or hypoxemia are not relieved after standard oxygen therapy, HFNC or non-invasive ventilation strategy can not improve condition of the patient or even deteriorate, tracheal intubation will be performed immediately.

(2) general anesthesia for the emergency operation patients with confirmed or suspected 2019-nCoV infection

(3)general anesthesia for confine operation

Points of attention:

(1)、for the patients undergoing confine operation, contact history and associated symptoms should be enquired in detail during preoperative interview. If the patient is suspected 2019-nCoV infection, immediately report should be performed according to established process.

(2)、Level-3 protective strategy is mandatory in case of patients with confirmed or suspected 2019-nCoV infection;

(3)、Adequate assessment before intubation is performed, especially for airway assessment;

(4)、difficult airway vehicle and necessary equipments should be well prepared.

新冠肺炎疫情防控专家答疑平台第二期——气道与呼吸管理篇

（专家意见仅供参考）

COVID-19 prevention and control experts Q&A platform (2)—Airway and respiratory management (Expert’s opinion is for reference only)

1、对于确诊或者疑似新冠肺炎患者如何选择麻醉方案，既减少院内感染发生、又维持诱导期间循环呼吸平稳？

How do we optimize the anesthetic scheme for patients with confirmed or suspected 2019-nCoV infection, to reduce the incidence of nosocomial infection andmaintain circulation and respiration stable during induction?

左明章，宋丹丹Mingzhang Zuo, Dandan Song

（1）、评估及治疗：禁食禁饮、容量、氧合、心功能、困难气道。呕吐和腹泻患者,需补充血容量;部分患者进展快且检查滞后,若心功不全或休克，应用血管活性药维持血压。
（2）、插管工具: 选择可更换叶片的视频喉镜(采用一次性透明保护套保护镜柄和显示屏)、可视光棒和喉罩;需作气管切开和ECMO准备。
（3）、麻醉诱导和插管:
1)诱导前在麻醉面罩与呼吸回路之间、麻醉机的吸入及呼出端各加装一个呼吸滤器;
2)纯氧吸入和正压通气，改善氧合;注意调整氧流量避免环境污染;
3)选用丙泊酚或依托咪酯、罗库溴铵和阿片药;充分肌松，避免呛咳，一次插管成功;
4)如通气困难或插管失败，立即置入喉罩通气;必要时应选择环甲膜穿刺或气切。
5)非一次性气管插管用具使用后应严格消毒。

(1)、Assessment and treatment: Fasting and drink-deprivation; Evaluation ofblood volume ,oxygenation, cardiac function and difficult airway . Patients with vomiting and diarrhea need to expand blood volume. Some patients get worse rapidly and the results of examination lag behind.If the patient has cardiac insufficiency or shock, vasoactive drugs should be used to maintain blood pressure.

(2) 、Intubation tools: videolaryngoscope with replaceable blade(using disposable transparent protective sleeve to protect laryngoscope handle and display screen), lightwand and laryngeal mask; Tracheotomy and ECMO preparation are necessary.

(3)、Anesthesia induction and intubation :

1）Install breathing filters between anesthesia mask and respiratory circuit , inhalation and exhalation end of anesthesia machine before induction ;

2）Pure oxygen inhalation and positive pressure ventilation to improve oxygenation; Pay attention to adjust oxygen flow to avoid environmental pollution;

3) Select propofol or etomidate, rocuronium and opioids; require sufficient muscle relaxation to avoid coughing and optimize first attempt success of intubation;

4) If ventilation is difficult or intubation fails, the laryngeal mask should be placed immediately for ventilation. Do cricothyroid membrane puncture or tracheotomy if necessary.

5) Non-disposable endotracheal intubation appliance should be strictly disinfected after use.

2、外出插管一般用什么药？疑似或者确诊病人插管时选择何种药物？如何进行防护？

Which drugs are normally used for the intubation out of the operating rooms? Which kinds of drugs are more appropriate for the intubation of the patients confirmed or suspected with 2019-nCoV? How does the anesthesiologist conduct the self-protection during the procedure of intubation?

夏中元，戴茹萍Xia Zhongyuan, Dai Ruping

(1)、采用快速诱导技术:丙泊酚或依托咪酯、罗库溴铵、瑞芬太尼;药品在清洁区准备好。充分肌松，避免呛咳，争取一次插管成功。插管工具每个病区自备!
  (2)、防护:首先核实诊断情况:①已排除病例做好标准防护;②疑似和确诊病例实施三级防护:标准防护基础上，于清洁区穿戴防护口罩、帽、护目镜、双层乳胶手套、防护面屏、隔离衣、鞋套;确诊病例应佩戴正压防护面罩即新风系统;③确保一名麻醉医师在隔离病房外辅助，缩短时间;④插管完成后:按规定流程处理各类物品、废物、设备;⑤隔离病房区域依次脱掉外层防护;缓冲区依次脱掉内层防护用具;进入清洁区及时沐浴更衣。注意每个环节做好手卫生。

(1) 、Recommend to use rapid-sequence induction and intubation strategy. All the anesthetics including propofol/etomidate, rocuronium and remifentanil are prepared in the clean area. Assure fully neuromuscular relaxation to avoid bucking or coughing before intubation, and try to complete the intubation successfully with the first attempt. Furthermore, the wards also need to prepare the necessary equipment and instruments for the intubation.

(2)、 Self-protection of the anesthesiologist: First of all, the anesthesiologist should confirm the clinical diagnosis of the cases and follow the following protocols.

1）Standard protection should be applied for the uninfected cases;

2）Implement the third level of protection for  the suspected or confirmed cases: in addition to the standard protection, it should use the personal protective equipment (PPE), which includes fit-tested N95 respirators, disposable hat, eye protection, latex examination gloves, full face shield, protective coverall gown and shoe covers. For the confirmed cases, powered air purifying respirators are necessary for healthcare personnels to increase the personal protective level；

3）Ensure there is another anesthesiologist to help outside the isolated ward to shorten the incubation time;

4）Procedures after intubation: treat the goods, wastes and equipment followed by the specified protocol; ⑤ The outer protective equipment is removed in the isolated ward, and the inner equipment is removed in the buffer area. Should bath and change clothes before entering the cleaning area. Notably, hand hygiene should be performed every step in the all aseptic tasks.

3、对于非疑似的择期手术全麻，是否按照常规诱导就可以？

For the general anesthesia of elective surgery in the non-suspected cases, is it safe to conduct the routine anesthesia induction？

夏中元，戴茹萍 Xia Zhongyuan, Dai Ruping

对于非疑似的择期手术全麻，疫情期间因部分患者处于潜伏期,可能无任何临床表现,但具备传染性,因而应该做好标准防护:措施: (1)患者戴医用外科口罩;(2)麻醉医师穿工作服(洗手衣)，戴一次性手术帽、外科口罩，手卫生，戴乳胶手套;(3)在面罩通气、气管插管及拔管时宜戴护目镜或防护面屏;(4)强调:充分评估患者情况困难气道可能、心肺功能，推荐采用快速诱导技术，充分肌松，避免插管过程中患者出现呛咳。　

Standard protections should be conducted when performing general anesthesia for the non-suspected cases, because some patients are contagious in the incubation period without clinical manifestations during the epidemic period. (1) Patients should wear disposable surgical face masks; (2) Anesthesiologists use PPE and always perform the hand hygiene; (3) Take care of eye protection in the process of airway manipulations, such as facemask ventilation, endotracheal intubation and extubation; (4) Notes: recommend to use rapid sequence intubation after comprehensive assessment of patients’ physiological characteristics and health condition, including the potential difficult airway, cardiopulmonary function, etc. Ensure the complete neuromuscular blockade to avoid bucking before intubation.

4、对于急诊病人全麻诱导应如何掌握和实施？

How to practice the induction of general anesthesia for the emergency patients?

夏中元，戴茹萍Xia Zhongyuan, Dai Ruping

所有急诊患者除常规检查外，需加做胸部CT和咽试纸核酸检测。
（1）、对于已排除新型冠状病毒感染的急诊患者，标准防护措施，根据患者情况选择诱导方式。
（2）、对于待排除新型冠状病毒感染的患者：如非紧急手术，可暂缓，等待专家组会诊。对于需抢救生命的病例，按照确诊病例准备使用负压手术间，在准备间备齐药品及各类麻醉工具控制手术间人数，医护人员按照三级防护。
（3）、对于确诊或疑似的患者，对于需抢救生命及剖宫产病例，使用负压手术间，控制手术间人数，按照三级防护。

In addition to routine examination, it’s important for every emergency patient to confirm the result of chest computed tomography (CT) and sequencing or real-time reverse transcription-polymerase chain reaction (RT-PCR) assay of nasal and pharyngeal swab specimens.

(1)、For uninfected patients, apply the standard protections, and take consideration of patient's health condition before choosing the type of anesthesia.

(2)、For patients who have not yet been excluded the possibility of infection: postpone non-emergency surgery temporarily and wait for consultation of the expert group meeting. For those requiring the emergency life support, they should be regarded as the confirmed cases and the surgery should be undergone in the negative pressure operation rooms. Drugs and equipment are prepared in the clean area. Strictly control the number of persons involved in the operation, and the healthcare staffs should implement the third level of protections.

(3)、For patients with confirmed or suspected injection, rescue or cesarean section should be undertaken in the negative pressure environments, the number of persons should be controlled and the third level of protection shall be applied for healthcare staffs.

5、有的“指导建议”推荐在麻醉诱导预充氧阶段，使用两块湿纱布将患者的口鼻盖住然后进行面罩通气，患者是否会感到不适，具体如何操作？

Some "guidelines" recommend that use two pieces of wet gauze to cover the patient's mouth and nose and thenventilate with mask for preoxygenationduring the anaesthesiainduction. Will the patient feel uncomfortable and how to do this?

左明章，宋丹丹Mingzhang Zuo, Dandan Song

"新冠肺炎患者如果在ICU或在重症病房需要治疗插管，对于给予高流量氧疗的患者，可以扣上面罩，面罩与简易呼吸器安装一个高效防水过滤器；对于使用无创通气的患者，在面罩或鼻罩与呼吸路之间加装一个高效防水过滤器，提高氧浓度；如果急诊麻醉手术，在诱导时，先在患者口鼻处盖上两层湿纱布再面罩通气，防止患者诱导期出现呛咳喷溅，减少呼吸道飞沫传播。注意不能影响患者的通气，也不能让纱布掉入患者的口腔中。

具体操作：预充氧阶段，使用两块纱布（大小可覆盖患者的口鼻）蘸适量温生理盐水盖住患者口鼻，面罩通气前覆盖即可，然后马上诱导给药，低潮气量通气，注意观察呼吸阻力，如果影响通气，待肌松药起效后可以去除。"

"疑似或者确诊病例需要急诊全麻手术，手术室内困难气道的处理遵循《2017CSA困难气道管理指南》，前提是必须做好三级防护，全面准备，选用最熟悉的工具，最有把握的方法，尽快完成插管，减少呛咳。

If the patients infected with COVID-19 need to be intubated in the intensive care unit, a high-efficiency waterproof filter can be installed between the mask and simple respirator for patients given high-flow oxygen therapy; for patients using non-invasive ventilation, we can install a high-efficiency waterproof filter between the mask or nose mask and the respiratory circuit, therefore oxygen concentration can be increased. In case of emergency operation, we can cover the patient's mouth and nose with two pieces of wet gauze and then ventilate with mask before anesthesia induction in order to prevent cough and splash then reduce the spread of respiratory droplets during the induction period. Be careful not to affect the patient's ventilation, or allow the gauze to fall into the patient's mouth.

Steps: during the preoxygenation stage, use two gauze (the size of which can cover the patient's mouth and nose) which are dipped into appropriate amount of warm normal saline to cover the patient's mouth and nose before mask ventilation, and then induce immediately with low-tide ventilation. Pay attention to the respiratory resistance, if that affects ventilation ,it can be removed after the muscle relaxant has taken effect.

If suspected or confirmed cases require emergency surgery in general anesthesia,the treatment of difficult airways in the operating room follows the《2017 CSA Guidelines for the Management of Difficult Airways》.The premise is that three levels of protection must be made and prepare for everything, choose the most familiar tool and the most confident method to complete intubation as soon as possible to reduce cough.

6、疑似或者确诊病人存在困难气道应该采用何种方式插管？

Which methods of intubation should be used for the suspected or confirmed patients with difficult airways?

左明章，宋丹丹Mingzhang Zuo, Dandan Song

新冠肺炎重症和危重症患者在ICU或在重症病房需要治疗插管：

（1）、如果是已预料到的困难气道，建议镇静镇痛、表面麻醉，保留自主呼吸下用可视软镜引导经鼻气管插管；医护人员三级防护，强调团队合作，尽量减少患者的咳嗽反射。如果无面罩通气困难，也可以先用插管型喉罩，再给肌松药，再进行气管插管。

（2）、如果是已预料到困难气道，预计现有气道管理设备包括可视软镜插管困难，直接行气管切开或直接使用ECMO，再在麻醉诱导下，行气管插管或气管切开。

注意：

1）、明确气管插管的必要性，警惕无法面罩通气的患者；

2）、尽可能使用带有一次性喉镜片的可视喉镜，并用保护套保护显示器及镜柄；

3）、医疗废弃物处理，喉镜柄、显示器等非一次性用品的消毒管理制度。

Serious and critical patients infected with COVID-19 require intubation in the ICU:

(1)、If the difficult airway has been anticipated, recommend that nasotracheal intubation should be guided by video flexible intubating scope with sedation, analgesia and surface anesthesia under spontaneous breathing; implement the  three-level protection, emphasize teamwork, and try to reduce the cough reflex of patients. If it is not difficult to ventilate with mask, intubatinglaryngeal mask can be used first, then muscle relaxant can be given, and finally tracheal intubation can be carried out.

(2)、If a difficult airway has been expected and intubation with the existing airway management equipment including video flexible intubating scope is difficult, we can choose tracheotomy directly or apply ECMO then dotracheal intubation or tracheotomy after anesthesiainduction.

Notes:

1)、 Be clear about the necessity of intubation, and be alert to patients who cannot ventilate with the mask;

2)、Use visual laryngoscopes with disposable laryngoscope bladesas far as possible, and protect the display screen and laryngoscope handle with a protective cover;

3)、Make management system for medical waste and non-disposable supplies such as laryngoscope handles and display screen.

7、人工鼻能过滤病毒吗？

Can Heat and moisture exchanger（HME）filter out viruses？

吴安石，张林忠Wu Anshi, Zhang Linzhong

人工鼻，学名叫热湿交换器(heat and moisture exchanger，HME)，是一种被动的湿化装置，其原理是利用病人呼出气体中的温度和湿度对吸入气体进行加温加湿，而单纯人工鼻，没有过滤功能，是不能阻断新冠病毒的。
细菌过滤器一般采用高效过滤介质，可有效截留管路中的杂质、细菌和其他病原体，一般可滤除空气中0.5μm以上的微粒，其滤除率达到90%以上，因此可有效滤除各种致病菌。
    人工鼻与细菌过滤器并不相等，人工鼻主要是保温湿化气道，而细菌过滤器则主要是过滤空气或病人呼出气中的病原菌。一般病毒直径在纳米级，如冠状病毒直径大约在50-140nm，而细菌直径在微米级，一般球菌的直径约1μm，中等大小的杆菌长2～3μm，直径0.2～0.3μm，大的杆菌如炭疽杆菌长3～10μm。因此，病毒大小远小于细菌，呼吸机细菌过滤器应该不能直接过滤掉病毒（与过滤膜可滤除微粒直径有关）。但是，病毒很难独立存在于空气中，必须要借助于呼吸道飞沫或飞沫核作为载体。飞沫核是飞沫在空气中失去水分后由剩下的蛋白质和病原体所组成，直径一般5μm左右，按照细菌过滤器可滤除微粒的直径，飞沫核是可以被过滤掉的，因此细菌过滤器应该是可以防止病毒传染的。
    “术中推荐使用人工鼻，有证据表明人工鼻的使用可以有效地预防麻醉机免受细菌和病毒的污染”（《新型冠状病毒肺炎患者围术期感染控制的指导建议》）。注意要使用有滤过膜的人工鼻，包括单纯过滤器【静电式过滤器（electrostatic filter）机械式过滤器（mechanical filter）】和复合式人工鼻（即HME+Fliter，FHME）。
具体请咨询人工鼻厂家，确定类型和细菌或病毒过滤效应。

Heat and moisture exchanger（HME），also called ‘Artificial nose’, is a kind of humidifying device，which uses the temperature and humidity of the patient's exhaled gas to warm and humidify the inhaled gas. However, the artificial nose alone, with no filtering function, cannot block the new coronavirus (COVID-19).

Bacterial filters generally use high-efficiency filter media, which can effectively trap impurities, bacteria and other pathogens in the pipeline. It can filter out the particles with diameter more than 0.5μm in the gas, which filtration effciency is more than 90%. Therefore, Bacterial filters can effectively filter out the most of pathogenic bacteria.

The ‘artificial nose’ is not the same as bacterial filter. The former is mainly used to heat and humidify the airway, while the latter is mainly used to filter the pathogens in the air or the patient's exhaled gas. Generally, the diameter of viruses is at the nanometer level, for example, the diameter of coronaviruses is about 50-140nm. While the diameter of bacteria is at the micrometer level. Therefore, the size of the virus is much smaller than the bacteria, and the ventilator bacterial filter should not be able to filter the virus out directly (related to the diameter of the filter membrane to remove particles).However, Viruses cannot survive for long on their own in the air. They are usually carried by respiratory droplets or droplets nuclei. The droplet nuclei is composed of the remaining proteins and pathogens after the droplets lose moisture in the air，and The diameter is generally about 1 to 5μm. According to the diameter of the particle that can be filtered by the bacterial filter, the droplet nuclei can be filtered out. So the bacterial filter is supposed to prevent virus infection.

"The use of artificial nose is recommended intraoperatively. And there is evidence that the use of artificial nose can effectively prevent the anesthesia machine from contamination by bacteria and viruses." ( Guidelines for perioperative infection control of patients with novel coronavirus pneumonia)

Pay attention to use the artificial nose with filtering membrane (composite artificial nose, HME + filter, FHME), and bacteria filters (electrostatic filter or mechanical filter). For details, consult the artificial nose or filter manufacturer to determine the type and filtering effect on bacteria or virus.

8、针对无法排除新冠可能（非疑似、非确诊）如何正确使用滤器？全麻时的三个滤器是怎样连接的？链接位置？3个过滤器，死腔会不会太大了？

How to use the filters correctly for the cases that cannot rule out the possibility of COVID-19 infection(non suspected or non confirmed) ? How are the three filters connected during general anesthesia? Where is the location to attach? Is the dead space too large due to the use of filters?

吴安石，张林忠Wu Anshi, Zhang Linzhong

尚未完全排除新冠肺炎的患者，手术时建议使用1个人工鼻（具有过滤功能型）和2个过滤器。复合式人工鼻（FHME）应该置于呼吸环路Y型接口的患者端，而细菌过滤器可以连接在呼吸环路的麻醉机端（进气口和出气口各连接1个）。为安全起见，每台手术结束均应更换新的呼吸管路和人工鼻，术中一旦出现气道分泌物或血液污染，及时更换，避免失效和/或通气阻力增加。

应谨慎使用人工鼻的情况包括：分泌物多或粘稠，呼气的潮气量不足，小潮气量通气策略管理的患者（如ARDS）。1个人工鼻的机械死腔大约在10-50ml。麻醉机出气端和进气端都有单向阀,对于成人使用人工鼻和细菌过滤器不会明显额外增加死腔。

Patients with COVID-19 pneumonia have not been completely excluded, it is recommended that 1 ‘artificial noses’ (with filtering function) and 2 filters should be used during surgery. The one ‘artificial noses’ (with filtering function) should be placed at the patient interface of Y-piece and two bacteria filters should be connected to the air inlet and the air outlet respectively between the disposable breathing loop and the anesthesia machine. For safety, after each operation, a new disposable breathing loop, artificial nose and bacteria filters should be replaced. Once there are the airway secretions or blood contamination during the operation, replace them in time to avoid the failure of filtration function or increased ventilation resistance.

Artificial noses should be used with caution as follows: thick and copious secretions in the airway, insufficient expiratory tidal volume and patients receiving low tidal volume ventilation management (such as ARDS). The mechanical dead space of one artificial nose is about 10-50ml. There are one-way valves for air outlet and air inlet of anesthesia machine. Thus no significant additional dead space increase for adult using artificial nose and filters.

9、确诊或疑似新型冠状病毒感染的肺炎患者全麻插管手术后复苏注意事项及处理措施有哪些？防疫防控重点需要注意哪些？疑似病人手术全麻拔管需要注意什么？如何在吸痰中保护自己？拔管过程中应如何做好个人防护？

What are the points for attention and measures during postoperative resuscitation period for the suspected or confirmed cases after general anesthesia ?How about the key points of protective measures? What we need to notice to extubate for suspected cases? How to protect ourselves during aspiration？How to do personal protection during extubation?

陈向东，林云 Chen Xiangdong，Lin yun

（1）、疑似病例按确诊病例处理。
术后复苏，所有医护及相关人员均按三级防护做好自我保护（防护服，隔离衣，医用N95口罩+外科口罩，防护目镜，防护面罩），复苏吸痰拔管，操作的麻醉医生应戴正压头盔自我保护。所有一次性个人防护用品必须在使用后仔细弃置，避免再利用。如果资源有限无法获得一次性个人防护用品，则使用可再利用的装备（如布料的隔离衣或防护服），每次用完后正确消毒。在摘脱及抛弃任何个人防护用品后，总是立即执行手卫生措施。

（2）、重症患者，术毕带管送ICU隔离病区，转运须走专用污染通道，维持肌松和麻醉深度，防止患者呛咳，维持生命体征平稳。交接后原路返回，尽量勿带回物品，不得不带回的任何物品必须按规定放于指定区域，严格消毒

（3）、轻症患者，术后复苏在手术间进行。

为减少患者复苏时呛咳，插管时气管导管可涂抹利多卡因乳膏，术中做好镇痛，使用舒芬或羟考酮等。为减轻复苏拔管时的应激反应，若无禁忌，插管前可予小剂量地塞米松/甲强龙。

吸痰，拔管操作医生戴正压头盔防护，要尽可能的远距离操作，操作尽量轻柔，减少患者呛咳，操作前给予患者口鼻处以必要的遮挡。勿断开气管导管与麻醉机螺纹管开放吸痰，应使用一次性密闭式吸痰管，通过专用接头密闭吸痰，尽量减少吸痰次数。

确认符合拔管指征，再行拔管，拔管后立即用纱布或外科口罩覆盖患者口鼻，注意患者通气，必要时面罩给氧。拔管后所有和病人接触或可能接触的一次性物品立即迅速丢弃至指定位置或用黄色医疗废物垃圾袋包裹。 待患者生命体征平稳，通过专用污染通道送隔离病房，交接后原路返回，带回的任何物品按规定放于指定区域，严格消毒处理。所有手术间病人手术或当日手术结束后必须进行终末消毒，包括麻醉机常规使用麻醉消毒机消毒、手术间进行终末消毒。

（1）、 Suspected cases shall be treated as confirmed cases.

For the postoperative resuscitation, all medical and related personnel should protect themselves according to the three-level protection (protective clothing, isolation gown, N95 medical mask + surgical mask, protective goggles, protective face mask). For suction and extubation, the anesthesiologist should wear positive pressure helmet for self-protection. All used disposable personal protective equipment must be carefully discarded to avoid reuse. If disposable personal protective equipment is not available due to limited resources, we could use reusable equipment (such as a cloth isolation gown or protective clothing) and disinfect it properly after each use. Always implement hand hygiene measures immediately after removing and discarding any personal protective equipment.

(2）、For severely patients, they should be transferred to the isolation area of ICU after operation, through the special pollution channel during transportation. Maintain the depth of muscle relaxation and anesthesia, prevent patients from choking cough, and keep the vital signs stable. After the handover, we should return to the original road. Try not to bring back any items. Any items you have to bring back must be placed in the designated area according to regulations and strictly disinfected.

(3)、For mild patients, postoperative resuscitation should be performed in the operating room.

To reduce the incidence of choking and coughing during resuscitation, lidocaine cream can be applied to the tracheal tube during tracheal intubation, and sufentanil or oxycodone can be used to improve analgesia. In order to reduce the stress response during resuscitation and extubation, if there is no contraindication, a small dose of dexamethasone / prednisolone can be given before intubation.

The doctor should wear a positive pressure helmet for sputum suction and extubation operation. It should be operated as far as possible to prevent droplet transmission, and as gentle as possible to reduce the patient's cough. Before the operation, the patient's mouth and nose should be covered with necessary shelter. Do not disconnect the tracheal tube and the sputum tube of the anesthesia machine to open sputum suction. Use a disposable closed sputum suction tube and seal the sputum through a special connector to minimize the number of suctions.

Make sure the indication of extubation is met, and then extubate. Immediately after extubation, cover the patient's mouth and nose with gauze or surgical mask. Pay attention to the patient's ventilation, and give oxygen to the mask if necessary. Immediately after extubation, all disposable items that have come into contact with or may come into contact with the patient are quickly discarded to the designated location or wrapped in yellow medical waste garbage bags. After the patient's vital signs are stable, they will be sent to the isolation ward through a dedicated pollution channel, and the doctors should return by the original way after the transfer. Any items brought back will be placed in the designated area according to regulations and strictly disinfected. All patients in the operating room must be sterilized at the end of the operation or that day, including routine anesthesia disinfection using anesthesia machines, and terminal disinfection in operating rooms.

10、有没有指标什么情况下上呼吸机，无创和有创指标又是怎样？

Indications for using ventilators, under what circumstances to choose non-invasive or invasive mechanical ventilation?

王东信，彭宇明 Wang Dongxin,Peng Yuming

存在低氧血症者应立即进行氧疗，氧合维持目标：非怀孕成年患者SpO2≥90%，怀孕患者SpO2≥92-95%。
    轻症患者初始给予普通鼻导管吸氧，以5L/min开始。
    重症患者如呼吸窘迫加重或者标准氧疗无效时，可给予高流量鼻导管吸氧，以20L/min起始，逐步上调至50-60L/min，同时依据氧合目标调整FiO2。在患者可以耐受的条件下使用无创通气。《北京协和医院关于 “新型冠状病毒感染的肺炎”诊疗建议方案（2.0，2020-1-29）》不建议无创通气先于高流量鼻导管吸氧使用。
    当患者进行标准高流量鼻导管吸氧或无创通气后，若短时间（1-2h）病情无改善甚至恶化，SpO2<90%，建议及时进行气管插管、有创机械通气。

Patients with hypoxemia should receive oxygen therapy immediately. The target of oxygen saturation should be maintained above 90% in non-pregnant adults and 92% to 95% in pregnant patients, respectively.

Mild patients are initially administered with oxygen therapy through ordinary nasal cannula, starting with 5L/min.

If respiratory distress is aggravated or standard oxygen therapy is ineffective, severe patients will be administrated with oxygen therapy by high-flow nasal cannula, starting with 20L/min and gradually increasing to 50-60L/min. Meanwhile, FiO2 can be adjusted according to the target of oxygen saturation. Non-invasive mechanical ventilation will be used if patients can tolerate. It is not recommended that non-invasive ventilation is used before high-flow nasal-cannula oxygen therapy based on the guideline of “The proposal for the diagnosis and treatment of COVID-19 in Peking Union Medical College Hospital (Version 2.0, 20200129)”.

If the clinical symptoms does not improve but become worse in 1-2 hours or SpO2 < 90% even undergoing high-flow nasal cannula oxygen or non-invasive ventilation, endotracheal intubation and invasive mechanical ventilation need to be applied in time.

新冠肺炎疫情防控专家答疑平台第三期——临床与医疗流程篇

（专家意见仅供参考）

COVID-19 prevention and control experts Q&A platform (1)—clinical and medical standard operating procedure (Expert’s opinion is for reference only)

1、新型冠状病毒的肆虐给医院目前的择期手术和急诊手术的数量、病种构成等带来了怎样的影响？

How does the outbreak of the novel coronavirus affect the number of elective and emergency operations and the composition of

它防护措施不变。2.无法自然生产的择期剖腹产，此类患者往往术前缺乏胸部影像学证据，如果合并肺部症状和发热，会给麻醉管理带来挑战。

The performance of elective operations in hospital has been seriously impacted by the epidemic. There are many possible reasons for the suspension of elective operations, for example, both doctors and patients are afraid of being infected by the novel coronavirus. Besides, there is a steep decline in the amount of blood donation, which leads to the shortage of blood in the hospital. In current situation, anesthesiologists are facing two main types of operations. One is emergency operation, the others is elective caesarean section. Patients of emergency operations are all critically ill. For COVID-19，they may be confirmed COVID-19 patients, suspected patients, completely excluded patients, or have to be identified but cannot be diagnosed as soon as possible. Except for completely excluded patients, the Grade III level of protection should be executed during all emergency operations at this period. Protective suit can be replaced by disposable gown if the patient is being excluded as COVID-19 pneumonia immediately before operation. As for elective caesarean section, radiological examination results are always not acquired, which may bring great challenge to anesthesia management if complicating with lung symptoms and fever.

2、新冠肺炎疫情下，疑难病例成功实施的要点有哪些？

What is the key point of performing anesthesia on serious cases during the new coronavirus epidemic？

王天龙，赵磊Wang Tianlong, Zhao Lei

要点包括：

(1)、派高年主治医师以上职称管理疑难病例，避免主管医生兼台；

(2)、术前访视充分，做出详尽麻醉计划和物品准备；

(3)、术中麻醉过程中，严密监护及管理，尽量避免主管麻醉医生离开术间；

(4)、对于并存新冠肺炎患者，采取简单有效麻醉方式，避免使用过度复杂麻醉方式，缩短术间工作时间。选择对呼吸、循环、肝肾功能影响轻微的麻醉药物，实施保护性通气策略，避免容量过负荷增加心肺负担，充分抗应激，维护内环境和体温正常；

(5)、采用伤口局麻药浸润镇痛+NSAIDS+κ受体激动剂，不鼓励给与镇痛泵，避免过度术后随访相关人员接触风险；

(6)、每个病人最好在术间完成麻醉后苏醒，建议关闭PACU，以降低人员聚集风险。

The key points are as follows:

(1)、Experienced attending doctors or senior doctors are supposed to perform anesthesia on difficult cases, and two rooms anesthesia care by one attending should be prohibited.

(2)、Detailed anesthesia plan and preparation should be based on sufficient and accurate preoperative interview.

(3)、The chief anesthesiologist should be in charge of the anesthesia and monitoring vital signs attentively, avoiding leaving the operation room.

(4)、For patients with COVID-19, in order to shorten surgery duration, simple and effective anesthesia procedures are better than excessively complex ones. Anesthetics with less influences on respiratory, circulatory and hepatorenal functions are preferred. Protective pulmonary ventilation strategies, avoiding fluid overload which may aggravate the burden on cardiopulmonary functions, effective anti-stress measures, maintaining internal environmental stability and maintaining body temperature are required.

(5)、To decrease the exposure risk of related staff during postoperative follow-up, we encourage local anesthetic wound infiltration analgesia combining with intravenous NSAIDs and κ-receptor agonist instead of postoperative patients-controlled analgesia.

(6)、To assure each patient complete recovery from emergency period in the operation room, not in PACU. PACU should be shut down temporarily avoiding more staff infectious risk.

3、我们特别关心特殊患者老年人的麻醉管理，老年人基础疾病较多，一旦合并新型冠状病毒肺炎感染，预后较差；对于这类特殊人群，麻醉科医生应当特别关注哪些方面？

We are especially concerned about anesthesia on geriatric patients. Considering that the elderly have many co-existed diseases, once combined with new coronavirus pneumonia infection, the prognosis is usually poor. In this case, what should anesthesiologists particularly focus on?

王天龙，赵磊Wang Tianlong, Zhao Lei

对于并发新冠肺炎且需要外科手术的老年患者，麻醉科医生需要关注一下几个问题： （1）、术前电话随访患者、家属和主管医生，了解患者既往慢性病史和当前肺部状况，制定详细管理计划；

（2）、麻醉诱导前，经静脉给与甲强龙1-2mg/kg，降低气道高反应性，给与小剂量戊乙奎醚0.008mg/kg,降低气道分泌物并改善肺顺应性；

（3）、已经并发新冠肺炎的老年患者，在麻醉前已经处于高度应激状态（缺氧，呼吸困难，精神高度紧张），因此在麻醉过程中，需要给与充分抗应激管理（瑞芬太尼，右美托咪定，必要时给与β-受体阻滞剂控制因术前应激导致的窦性心动过速）；

（4）、实施有创动脉血压和功能性血流动力学监测（唯捷流，MOSTCARE, LIDOCOrapid等），并实施目标导向液体管理联合缩血管药物实施限制性液体管理策略，保护肺功能；（5）、给与积极抗炎管理，给与乌司它丁5000单位/kg，可能有助于防范炎症风暴和多器官功能衰竭的突然发生；

（6）、实施肺保护性通气管理策略；

（7）、优化心肌氧供需平衡，维持心率在基线心率的80%-120%；

（8）、 通过不间断血气分析调整肺通气参数，并维持全身氧供需平衡；

（9）、避免低体温。

As for geriatrics with COVID-19, there are several issues that anesthesiologists need to pay attention to.

(1)、Visiting patients, family members and doctors by phone and video before surgery to obtain the patient's previous chronic medical history and current pulmonary function status, and develop a detailed management plan.

(2)、The methylprednisolone of 1~2mg/kg before anesthesia induction can decrease high reactivity of airway. A low dose penehyclidine of 0.008mg/kg can minimize airway secretion and improve lung compliance.

(3)、If the aged patient has been suffering from the novel coronavirus pneumonia, sufficient anti-stress treatments (e.g. remifentanil, dexmedetomidine, and β-receptor inhibitor which can treat sinus tachycardia caused by preoperative stress) should be given during the operation because the body is already severely stressed (anoxic, dyspnea, extremely nervous).

(4)、Invasive arterial blood pressure and functional hemodynamic monitoring should be implemented (Vigileo, MOSTCARE, LIDOCOrapid, etc.). Fluid infusion should be restricted through goal-directed fluid management combined with preventive vasoconstrictor.

(5)、The ulinastatin infusion of 5,000 U/kg can prevent excessive inflammatory response, and restrain inflammatory storms and multiple organ failures.

(6)、Protective pulmonary ventilation strategies are indicated.

(7)、Keeping balance of myocardial oxygen supply and demand. Heart rate should be maintained between 80%~120% of baseline heart rate.

(8)、Adjusting ventilator parameters underfrequent blood gas analysis, which can also help maintain the balance of systemic oxygen supply and demand.

(9)、Hypothermia should be avoided as much as possible.

4、我们特别关心特殊患者孕产妇的麻醉管理，孕产妇行剖宫产手术过程中，可能感染新生儿，对于这类特殊人群，麻醉科医生应当特别关注哪些方面？确诊或疑似的产妇剖宫产麻醉方式的选择及防护措施，新生儿如何做好防护？

What are the special considerations for the anesthesia management of parturients with diagnosed or suspected COVID-19? How to choose the anesthetic method and to do the infection control during management of the parturients? Neonates maybe at high risk of being infected during cesarean section. How could we protect the neonates?

李师阳 Li Shiyang

（1）、应当特别关注麻醉前评估与准备，制定麻醉计划及应急方案，并反复进行模拟演练。

1）、评估除了常规麻醉评估之外，要重点评估待产妇新冠肺炎进展状态及胎儿情况；

2）、准备工作应重点对麻醉医生进行新冠肺炎防控知识培训及情景模拟演练。确保熟练整个围麻醉期的所有流程。
⑴ 、Special attention should be paid to the pre-anesthesia evaluation and preparation, the anesthesia plan, the emergency plan, and repetitive simulation training.

1）、Evaluation should be focused on the severity and development of the infection, and the fetal status.

2）、Preparation should be focused on the training of infection control for all the anesthesia staff and scenario simulation training. All the anesthesia staff should be familiar with all the peri-anesthesia protocols of infection control and self-protection.

⑵、麻醉方式首选椎管内麻醉，次选全身麻醉。应当在负压手术间进行麻醉，麻醉医生的防护参照新冠肺炎防控指南。椎管内麻醉应给待产妇应给戴医用防护口罩，用氧气面罩在口罩外高流量吸氧，注意保持口罩密闭性。全身麻醉应在呼吸回路的患者端装上有过滤效应的人工鼻。
⑵、Intrathecal anesthesia remains the first-choice in parturients without contraindication. Surgery should be done in negative-pressure operating room. The self-protection of the anesthetists should follow the guideline of COVID-19 infection control. Parturients should wear surgical mask during intrathecal anesthesia. High-flow oxygen could be given through oxygen mask over the surgical mask. For general anesthesia, filter should be attached between the endotracheal tube and the breathing circuit.

⑶、新生儿出来一般情况稳定后，应尽快转送至新生儿隔离病房。

(3)、The neonate should be transferred to the neonate isolation ward once the condition permitted.

5、对于儿科手术，麻醉科医生应当特别关注哪些方面？

Which aspects should anesthesiologists pay particular attention to when it comes to pediatric surgery?

苏殿三Su Diansan

首先应该区分是湖北还是非湖北地区。
湖北地区：
    择期手术一般都已经暂停，目前只有急诊手术。对于急诊手术的麻醉，都应该按照疑似或者确诊病人来进行。麻醉方法和一般的急诊应该没有大的区别，关键是麻醉医生的防护要到位，要达到标准的三级防护，至少是加强的二级防护。
非湖北地区：
    择期手术：术前一般已经严格筛选，可以排除新冠病毒感染，因此按照常规麻醉即可，麻醉医生也只需要一般防护即可
    急诊手术：
根据是否有流行病学史，临床征象3项（发热/呼吸道症状，肺CT，白细胞低/淋巴细胞低）
• 有流行病学史无临床表现应该二级预防
• 有流行病学史且临床征象中的一项应该二级预防
• 有流行病学史且临床征象中的两项应该三级预防（疑似病人）
• 无流行病学史无临床表现应该一般预防
• 无流行病学史临床征象中的一项（可以用病毒以外的原因解释）一级预防
• 无流行病学史临床征象中的两项，二级预防
• 无流行病学史临床征象中的三项，三级预防（疑似病人）
• 流行病学史和临床征象不详的非常紧急的病人，应该三级防护
对于手术中插管和拔管等操作和成人的注意事项相似。请参见刚刚在《麻醉安全与质控》杂志发表的麻醉科防控新型冠状病毒肺炎工作建议（第1版）。

First of all, we should distinguish anesthesia between Hubei and non-Hubei regions.

Hubei area:

Currently, elective surgery has generally been suspended and only emergency surgery is available. All patients received emergency surgery should be regarded as suspected or confirmed patients. Comparing with normal emergency operation, there is no big difference of anesthesia method except the protection of the anesthesiologist must be in place and tertiary protection or at least enhanced secondary protection must be achieved.

Non-Hubei area:

Patients of elective surgery who have received strict screening before surgery can exclude COVID-19

infection. Therefore, anesthesiologists just need general protection as other conventional anesthesia.

Other patients of emergency surgery should be evaluated through epidemiological history and three

clinical symptoms (fever/respiratory symptoms, lung CT, decrease of white blood cells/decrease of lymphocytes). Hence the protection of anesthesiologist should base on the following situations:

• Epidemiological history without clinical symptoms: secondary prevention

• Epidemiological history and one of the clinical symptoms: secondary prevention

• Epidemiological history and two of the clinical symptoms: tertiary prevention (suspected patient)

• No epidemiological history and no clinical symptoms: conventional prevention

• One of the clinical symptoms without epidemiological history (explainable for reasons other than viruses): Primary prevention

• Two of the clinical symptoms without epidemiological history: secondary prevention

• Three clinical symptoms without epidemiological history: tertiary prevention (suspected patient)

• Critical but epidemiological history and clinical symptoms unknown: tertiary protection

The considerations of intubation and extubation during a surgery are similar to those for adults. Please

refer to the recommendations for the prevention and control of NCP in the Department of Anesthesia (First Edition) published in the Journal of Anesthesia Safety and Quality Control.

6、对于非常时期的平诊急诊，需要手术病人完成哪些术前检查？术前病人有发热，是否应该都必须有CT结果？

For emergency and selective surgery in this extraordinary period, what preoperative examinations should be completed before surgery? And is it necessary of CT results for the preoperative patients with fever?

黄文起、王钟兴Huang Wenqi, Wang Zhongxing

手术患者需要完善以下检查结果

（1）血常规检查（粒细胞及淋巴细胞计数）
（2）胸片或CT检查正常（胸片疑似患者以CT检查结果为准，急救患者除外）；
（3）咽拭子或血液核酸检测筛查结果（急救手术除外）；
（4）常规心脏、肝肾、凝血系统功能评估。

术前病人有发热，询问其流行病学史，并应该有CT结果，急救病人除外。有流行病学史患者，急诊手术又不可推迟，如果没有CT结果，应立即行咽拭子或血液核酸检测筛查并追踪结果，核酸检测的完整程序需要4小时，然后按照疑似病例进行防护。

The following examinations should be completed before an operation:

（1） Blood routine examination (counts of granulocytes and lymphocytes).

（2） Chest radiograph or CT examination (CT examination results shall prevail when Chest radiograph shows suspected, except for critical emergency patients).

（3） Throat swab or blood nucleic acid detection (except for critical emergency surgery).

（4） Routine assessment of cardiac function, hepatic and renal function and coagulation system.

For the patient with fever, epidemiological history and CT examination result are necessary, except for

emergency patients. Considering emergency surgery cannot be postponed, patients who have epidemiological history should take the throat swab or blood nucleic acid detection immediately if there are no CT examination results. Because the full process of nucleic acid detection takes four hours, anesthesia and protection should be performed as the suspected case.

7、开展择期手术后，怎么防控隐匿性感染患者（无症状感染者）的感染问题？

Once carrying out elective surgery, how to prevent and control the infection of occult patients (Asymptomatic infectors)?

黄文起、王钟兴Huang Wenqi, Wang Zhongxing

隐匿患者（无症状感染者）至今未有官方定义，处于非新冠肺炎患者及疑似新冠肺炎患者之间。由于其并无临床症状、核酸结果阴性，而流行病学史也无法准确判断，湖北省以外的省市非常难发现隐秘患者，故建议按加强一级防护进行。
(1)、患者转运：一人一车，用防渗透铺单保护转运车床，使用后及时消毒。在转运途中，病情允许时患者应佩戴一次性外科口罩，采用一次性手术大单覆盖全身，并由专人提前疏通转运通道，减少无关人员暴露。巡回护士、麻醉医师、转运人员在一级防护外加一件隔离衣、护目镜进行防护。麻醉复苏应在原手术间进行，转运中应尽量减少对环境的污染，按医院指定路线接送患者，减少在公共区域停留。

(2)、手术人员：按加强一级防护，外加一件隔离衣、护目镜进行防护；规范流程脱卸防护用品，参加的医务人员自行进行健康监测。
(3)、废物处理：手术间及转运车清洁前应对保洁人员进行相关知识培训并做好人员防护，完成后在《特殊感染手术术后登记本》登记。
(4)、详细完成交接班记录。

Occult patients (Asymptomatic infectors) who between non-NCP and suspected NCP are still not officially defined. In those patients, no clinical symptoms, negative nucleic acid detection results and vague epidemiological history make it difficult to find them out in the outside Hubei province, so increase one level protection during every anesthesia should be recommended.

(1)、Patient transport

The patient must be transported by a dedicated moving-bed covered by an impermeable sheet, then the bed should be sterilized immediately after used. During the transport, the patient should wear a disposable surgical mask if condition permits and be covered with a big disposable surgical drape. It is necessary to clear the transport channel in advance so that the exposure of unrelated personnel could be reduced. Besides the primary protection, the circulating nurse, anesthesiologist and transport personnel should wear one more isolation gown and goggle. Anesthesia resuscitation should be performed in the operation room. Finally, transporting should follow the designated route by hospital so that the pollution could be minimized and staying time in public areas could be reduced.

(2)、Surgical personnel

Besides the enhanced primary protection, the circulating nurse, anesthesiologist and transport personnel should wear one more isolation gown and goggle.Removing protective equipment should be based on the standard procedures. All the participating medical staff must perform health monitoring on their own.

(3)、Waste disposal

The cleaners should be trained in relevant knowledge and protection. After every cleaning, cleaning personnel should record on Special Infection Postoperative Record Book.

(4)、Write the shift record in detail.

8、目前，对于非新冠肺炎患者进行急诊手术，会加强哪些术前评估和防疫操作来避免感染？

At present, for emergency surgery, what kinds of preoperative assessment and

prevention of patients with NCP should be enhanced?

黄文起、王钟兴 Huang Wenqi, Wang Zhongxing

术前需要完善的评估及防控措施如下：

(1)、详细了解明确流行病学史
(2)、血常规检查（主要是粒细胞及淋巴细胞计数）
(3)、胸片或CT检查正常（胸片疑似患者以CT检查结果为准，急救患者除外）；
(4)、咽拭子或血液核酸检测筛查结果（急救手术除外）；
(5)、其他重要脏器系统包括心脏、肝肾、凝血系统功能评估。
(6)、患者入手术室时需带上手术口罩。手术室层流的滤过器的定期清洁和更换，手术室新风送风量增大。重视全身麻醉患者的机控呼吸气道过滤器（人工鼻）、区域阻滞麻醉患者的氧疗通道过滤器标准使用。

Before the surgery, please complete the following points:

(1) 、Inquiring epidemiological history in detail；

(2) 、Blood routine examination (mainly granulocyte and lymphocyte count)；

(3) 、Chest radiograph or CT examination (CT examination results shall prevail

when Chest radiograph shows suspected, except for critical emergency patients)；

(4) 、Throat swab or blood sample nucleic acid detection (except for critical emergency surgery)；

(5) 、Routine assessment of cardiac function, liver and kidney function and coagulation system；

(6) 、The patient entering the operating room should wear a medical protective

mask. It is significant that the filter of laminar flow of operating room must be cleaned and replaced at regular intervals, as well as the increase of air change flow. Filtering artificial nose should be used whether in general anesthesia or regional anesthesia.

9、肿瘤病人大多血常规也异常，如果无法测核酸，按疑似病人处理吗？

Since the blood routine of patients with tumor is abnormal mostly, should we regard those patients as suspected cases if there were no nucleic acid detection results?

黄文起、王钟兴Huang Wenqi, Wang Zhongxing

肿瘤病人的排查处理同样按照国家卫健委新冠肺炎诊疗方案第六版进行，并不因其粒细胞等异常而进行特殊处理，如果无法及时得到核酸检测结果，依旧参照以下流程：有流行病学史中的任何一条，且符合临床表现中任意 2 条；或无明确流行病学史的，符合临床表现中的 3 条，按疑似新冠肺炎病人处理。
   流行病学史
(1)、发病前14天内有武汉市及周边地区，或其他有病例报告社区的旅行史或居住史；
(2)、发病前14天内与新型冠状病毒感染者（核酸检测阳性者）有接触史；

(3)、发病前14天内曾接触过来自武汉市及周边地区，或来自有病例报告社区的发热或有呼吸道症状的患者；
(4)、聚集性发病；
   临床表现
(1)、发热和/或呼吸道症状；
(2)、具有上述肺炎影像学特征；
(3)、发病早期白细胞总数正常或降低，或淋巴细胞计数减少。

　The screening of cancer patients is also in accordance with sixth edition of the new coronary pneumonia diagnosis and treatment of national health commission. If nucleic acid detection result cannot be available in time, the following procedures should be completed as before: A patient who meets the conditions that has one of epidemiological history and any two of clinical symptoms simultaneously, or has no clear epidemiological history but has any three clinical symptoms, should be treated as a suspected patient.

Epidemiological history

(1) 、The patient has a travel or living history of Wuhan and its surrounding areas or other communities with reported cases within 14 days.

(2) 、The patient has a history of contact with an identify patient (positive nucleic acid test) within 14 days.

(3) 、The patient has a history of contact with a patient who comes from Wuhan and its surrounding areas or the community with fever or respiratory symptoms cases within 14 days.

(4) 、Clustering infection.

Clinical symptoms        

(1) 、Fever and/or respiratory symptoms.

(2) 、Imaging features of the above pneumonia.

(3) 、The count of white blood cells in the early stage is normal or decreased and the count of lymphocyte is decreased.

10、如果确诊或者疑似新型冠状病毒肺炎患者进行急诊手术，麻醉科医生术前评估常规内容外，还应重点关注哪些实验室和辅助检查结果，从而快速评估患者的肺部感染状况和全身状况？

For confirmed or suspected patients with NCP of emergency surgery, who need to be quickly evaluated the pulmonary infection and systemic status, what kinds of laboratory and auxiliary examination results should the anesthesiologist focus on besides the routine preoperative examination?

黄文起、王钟兴Huang Wenqi, Wang Zhongxing

需要重点关注的实验室检查和辅助检查如下：

(1)、实验室检查（主要是粒细胞及淋巴细胞计数）
发病早期外周血白细胞总数正常或减低，淋巴细胞计数减少，部分患者可出现肝酶、LDH、肌酶和肌红蛋白增高；部分危重者可见肌钙蛋白增高。多数患者 C 反应蛋白（CRP）和血沉升高，降钙素原正常。严重者 D-二聚体升高、外周血淋巴细胞进行性减少。及时床旁检测 血红蛋白（Hb）水平, 血糖， 动脉或静脉血气分析。
(2)、核酸检测
鼻咽拭子、痰、下呼吸道分泌物、血液、粪便等标本中可检测出新型冠状病毒核酸。核酸检测的完整程序需要4小时。
(3)、胸部影像学
早期呈现多发小斑片影及间质改变，以肺外带明显。进而发展为双肺多发磨玻璃影（GGO）、浸润影，严重者可出现肺实变，胸腔积液少见。
(4)、其他重要脏器系统包括心脏（TNI、proBNP）、肝肾（总胆红素、白蛋白和血肌酐）、凝血系统功能(APTT、PT、INR、FIB)评估。
(5)、呼吸力学及动脉血气分析，包括：呼吸频率、脉搏氧饱和度、氧合指数。

Key points for laboratory examination and assistant examination are listed:

(1)、Laboratory examination (mainly granulocyte and lymphocyte count)

In the early stage, the count of white blood cells is normal or decreased and the count of lymphocyte is decreased. Liver enzyme, LDH, muscle enzyme and myoglobin may be increased in some patients, and some critical patients’ troponin was also increased. In most patients, c-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were increased, while procalcitonin was normal. In the critical cases, D-dimer was increased but peripheral blood lymphocyte was decreased progressively. Timely bedside detections were necessary such as hemoglobin (Hb) levels, blood sugar monitoring, arterial or venous blood gas analysis.

(2)、Nucleic acid detection

Nucleic acid of COVID-19 could be detected in the sample of nasopharyngeal swabs, sputum, secretion of lower respiratory tracts, blood, feces, etc. The whole process of nucleic acid detection would take four hours.

(3)、Chest imaging

There were multiple small patchy shadows and interstitial changes in the early stage, obviously in the lung periphery. With progress of the disease, it would develop into multiple ground-glass opacities (GGO) and infiltrating shadows in bilateral lung. Bilateral pulmonary consolidation was observed in severe patients, while pleural effusion is unusual.

(4)、Evaluation of other important organs and systems, including cardiac system (TNI, pro-BNP), hepatic and renal system (total bilirubin, albumin and serum creatinine) and coagulation system (APTT, PT, INR, FIB).

(5)、Respiratory mechanics and arterial blood gas analysis, including respiratory rate, pulse saturation and oxygenation index.

新冠肺炎疫情防控专家答疑平台.docx (137.1 KB, 下载次数: 0)

2020-3-16 19:38 上传

点击文件名下载附件