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 Table of Contents  
Year : 2021  |  Volume : 23  |  Issue : 1  |  Page : 82-87

Management protocols for functioning of operation theatre complex during COVID-19 pandemic – Perspective of a zonal hospital

1 Department of Anesthesiology and Critical Care, INHS Sanjivani, Kochi, Kerala, India
2 Department of Anaesthesiology and Critical Care, INHS Sanjivani, Kochi, Kerala, India

Date of Submission14-Aug-2020
Date of Decision18-Sep-2020
Date of Acceptance25-Oct-2020
Date of Web Publication15-Jul-2021

Correspondence Address:
Surg Capt Vidhu Bhatnagar
Department of Anaesthesiology and Critical Care, INHS Sanjivani, Naval Base, Kochi - 682 004, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_114_20

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Chinese Centre for Disease Control and Prevention announced a novel coronavirus as causative pathogen of COVID-19 on 08th January 2020, after the epidemic broke in Wuhan, China. The coronavirus infection has been incontrollable since then and was given the status of pandemic by the World Health organization in March 2020. World has come to a standstill with the advent of COVID-19 pandemic and multiple changes have made way in the normal functioning of life as well as health-care system. Despite lockdown and restrictions on movement and travel, the virus has managed to seep into multiple countries and presently India is witnessing more than 50,000 new cases daily. Health-care system all over world is exhausted and struggling to handle this contagious virus. This article is an attempt to summarize essential knowledge of COVID-19, review current understanding of COVID-19, and provide recommended management protocols for functioning of operation theater complex which have been formulated and are being followed in our Armed Forces Zonal Hospital in Southern India since Mar 2020.

Keywords: Disinfection, pandemic, personal protective equipment, prevention, sterilization, virus

How to cite this article:
Bhatnagar V, Honwad M S, Dutta S, Sharma K. Management protocols for functioning of operation theatre complex during COVID-19 pandemic – Perspective of a zonal hospital. J Mar Med Soc 2021;23:82-7

How to cite this URL:
Bhatnagar V, Honwad M S, Dutta S, Sharma K. Management protocols for functioning of operation theatre complex during COVID-19 pandemic – Perspective of a zonal hospital. J Mar Med Soc [serial online] 2021 [cited 2021 Oct 23];23:82-7. Available from: https://www.marinemedicalsociety.in/text.asp?2021/23/1/82/321595

  Introduction Top

As year 2020 arrived it brought a huge sea of change with itself which unfolded slowly in the initial months. Chinese Centre for Disease Control and Prevention announced a novel coronavirus as causative pathogen of COVID-19 on eighth January 2020.[1] The coronavirus disease epidemic was initially detected in Wuhan, China, from where it spread to various parts of the world including India, creating a major havoc.[2] The outbreak was declared by the World Health Organization (WHO) as a Public Health Emergency of International Concern (PHEIC) on 30 Jan 2020 due to its spread to 18 countries by then.[3] Human-to-human transmission was also reported. The novel virus, which was initially called as 2019-nCoV was later named as SARS-CoV-2 virus after the virus which caused the SARS outbreak (SARS-CoVs), by International Committee on Taxonomy of Viruses. On March 11, 2020, the PHEIC was declared as pandemic.[4],[5]

Despite lockdown and restrictions on movement and travel, the virus has found its way in our daily living and it seems that the new normal would have to be specified. This article is an attempt to provide recommended management protocols for functioning of operation theater (OT) complex which have been formulated and are being followed in our Armed Forces Zonal Hospital in Southern India Since March 2020.

Problems envisaged while operating upon patients in COVID-19 times

  1. High aerosol generating procedures being carried out in OT
  2. Thorough disinfection and sterilization of OT environment to decrease/minimize cross infection to HCWs and to other patients
  3. Dedicated medical equipment for the patients/usage of disposable expendables wherever possible to minimize the cross infection
  4. Thorough disinfection and sterilization of medical equipment used or patient care
  5. Prevention of needle stick injuries
  6. Expert BWM
  7. Usage of correct Protective personal equipment
  8. Management of linen used for patient care.

Armed with the above knowledge about the SARS-CoV-2, and to cater for all the problems foreseen,[6],[7] a protocol for management and functioning of OT Complex at the Zonal Hospital was prepared. All India Institute of Medical Sciences protocol for COVID, which is considered as a validated document was also referred to while creating these protocols for OT functioning.

  Recommended Preventive Measures to Break the Chain Top

OT complex being a unique environment which could have extended exposure to elevated aerosol concentrations in closed spaces and thus has high propensity for infection spread. This could be due to large number of droplets and aerosols generated following airway handling or various surgeries.[8] Therefore, standard protective measures utilized in routine clinical work may not be effective enough to prevent the spread of COVID-19, more so, when patients are either in the incubation period or are unaware about their infection, or choose to conceal their infection. Though the recommendation is to stop cold, elective surgeries, however, all emergency patients need to be taken inside OT complex for perioperative period. The following measures were stringently followed to counteract the problems expected and to prevent possibility of cross infection and to curb infection spread.

  Social Distancing/Entry Protocol and Screening Top

All personnel working inside the OT complex were sensitized regarding social distancing. All unauthorized entry to OT complex was restricted. As early as mid-Mar 2020, all patients were screened with help of a COVID questionnaire which was prepared and validated by Anesthesiologists. COVID questionnaire consists of 14 questions which include questions like contact history, history of travel, history of any fever/respiratory symptoms etc., were asked. After Jul 2020, all patients coming to OT were screened with Trunat investigation in addition to the COVID questionnaire, because community transmission of coronavirus was considered to be prevalent in Kerala.

  Hand Hygiene Top

Hand Hygiene is already a part of OT complex regimen; however, it was more strictly enforced. Hand washing with soap and water prior to any patient contact and after every patient/fomite contact was enforced strictly. Use of disinfectants such as alcohol-based hand rubs/chlorhexidine based hand-rubs were enforced stringently after contact with fomites.

Dedicated operation theater earmarked for suspects and cases

  1. Emergency OT (OT 4), the standalone OT, has been dedicated for emergency surgery for COVID-19 patients. OT 4 has high efficiency particulate air (HEPA) filters, it is not connected to central air-conditioning and has a separate air conditioner. Moreover, it is closest to the entrance of OT complex so as to avoid contamination of OT complex
  2. Surgeons lounge is designated for donning and the Toilet next to Surgeons lounge is designated for Doffing
  3. Only patients are allowed inside the OT and no next of kin allowed in OT complex. Patient needs to be wearing a three-ply surgical mask before entering OT as well as wearing disposable OT dress/gown, gloves and shoe covers at all times while his/her stay in OT complex
  4. Patient are transported on designated stretcher inside the isolation cubicle so as to minimize the environmental disinfection
  5. Patient are directly taken into OT 4 and not to wait inside pre op room; likewise, patient are directly shifted to COVID ward or ICU after completion of surgery and not taken into post anesthesia care unit (PACU) since both Pre op and PACU are situated inside the main OT complex. A two bedded isolation ICU/PACU/step down care unit is designated in the isolation room of ICU for all those patients who require intensive postoperative monitoring
  6. Checking of all documentation, consent, identity etc., is performed outside OT complex, in the corridor
  7. Clear marking is displayed on door of OT 4 if a COVID-19 patient is being operated inside. Minimal personnel to be inside taking all universal precautions to decrease the risk of cross infection
  8. Only equipment which is essential is kept in this OT. All equipment is covered with transparent plastic covers which can be disinfected and disposed off
  9. All surgical instruments are cleaned in the wash area after the surgery is over and not taken out till the time OT is not fumigated
  10. As soon as surgery is over and patient is transported out of the OT, it is fumigated and then carbolized using Sterisol (1:4)/virkon/hypochlorite solution/70% ethyl alcohol
  11. No successive patient is taken in this OT till the time OT cleaning and disinfection is not complete
  12. After the community transmission of coronavirus was evident in Kerala (number of cases did not have any contact history) from July 2020, onward, a Trunat investigation of the patient coming to OT was made mandatory so as to know the COVID status. However, the questionnaire and consent forms were continued. A machine for conducting Trunat was procured by the zonal hospital with help of Command Head Quarters. The Trunat system earlier was employed for testing infectious disorders like Tuberculosis, H1N1 infection and now has been deployed for diagnosing COVID-19 after customized cartridges were made available. The turnaround time is much less as compared to RT PCR (60–120 min). A viral lysis buffer is provided which deactivates the virus thereby decreasing the biosafety hazard posed by this investigation and disposal of cartridges. The Pathologist and his team in the hospital underwent training for handling of Trunat machine.

Dedicated team

  1. All OT personnel practice Hand hygiene diligently at regular intervals. PPE is worn as per hospital guidelines for use of PPE in OT complex [Table 1]. The guidelines are inspired by OT protection guidelines from the Indian Society of Neuroanaesthesiology and Critical Care[9]
  2. The team dedicated for performing surgical procedure on COVID-19 patient is nominated. None of the personnel from this team take part in any other surgical procedure taking place on COVID negative patients. The team comprises one surgeon, one anesthesiologist, and three OR technicians. One OR technician assist in the induction of anesthesia technique, second one assists the surgeon and the third one is the circulating technician inside OT
  3. In case if the patient becomes critically unstable or goes into arrest all OR technicians will assist the anesthesiologist; surgery may have to halt till patient stabilizes
  4. Expertise of OT matrons will be utilized on case to case basis, since only one OT Matron is posted and available
  5. All the personnel should be well versed with donning and doffing procedure as well as strict asepsis. Any personnel working in the designated OT for COVID-19 patients, need to be in PPE. Personnel not in PPE not to enter the OT at any point of time
  6. Movement inside OT is restricted if a COVID confirmed case is being operated in OT 4. Personnel not involved in the case need to be inside the main OT complex and not in near vicinity of OT 4
  7. Hand hygiene is practiced diligently before donning and after doffing
  8. Donning and doffing is carried out only in the designated area. Extreme precautions are exercised while doffing so as to decrease the chances of contamination and cross infection
  9. Donning sequence
  10. Table 1: Hospital guidelines for use of personal protective equipment in operation theatre complex

    Click here to view

    1. Hand hygiene
    2. wear head gear, hand hygiene for asepsis
    3. wear sterile inner gloves, hand hygiene for asepsis
    4. PPE overall suit, hand hygiene with alcohol rub
    5. wear sterile shoe covers, hand hygiene with alcohol rub
    6. wear N95 mask, hand hygiene with alcohol rub
    7. wear sterile goggles, hand hygiene with alcohol rub
    8. wear visor/face shield, hand hygiene
    9. pull over the hood, hand hygiene with alcohol rub
    10. wear sterile surgical gown, hand hygiene with alcohol rub
    11. wear sterile outer gloves

  11. Doffing Sequence:

    1. Remove outer pair of gloves inside OT and discard in red bin, hand hygiene with alcohol rub
    2. remove surgical gown after peeling it away from body and discard in yellow bin, hand hygiene with alcohol rub
    3. step out in designated doffing area, pull down the hood and doff the overall suit and discard in yellow bin, hand hygiene with alcohol rub
    4. remove visor and discard in the plastic bucket containing hypochlorite solution, hand hygiene with alcohol rub
    5. remove goggles and discard in the plastic bucket containing hypochlorite solution, hand hygiene with alcohol rub
    6. remove N 95 mask and discard it in yellow waste bin, hand hygiene with alcohol rub
    7. remove head gear and discard it in yellow waste bin
    8. clean hand with soap and water till elbows.

  12. Any PPE that becomes heavily soiled needs to be replaced immediately with fresh PPE.

Anesthesia technique

  1. Avoid general anesthesia (GA) if possible.[10] Regional anesthesia after taking all strict asepsis precautions to be preferred
  2. In cases where GA is essential, GA with endotracheal intubation to be followed using Rapid sequence technique. No spontaneous or assisted ventilation with Face mask or supraglottic airways to be chosen as anesthesia technique. Protocol was created for safe intubation and extubation.[10]
  3. Intubation Protocol:

    1. Preoxygenation with 100% oxygen
    2. Rapid sequence intubation using intravenous propofol/thiopentone and scoline. Intubation cubicle and extra oral vacuum suction to be used for intubating patients. Extra oral vacuum suction unit also to be placed at the open end of the intubation cubicle to decrease the chances of aerosol contamination [Figure 1]
    3. Not to ventilate the patient with bag. After endotracheal intubation, the cuff needs to be inflated before ventilating the patient. Confirm ETT placement with help of capnography and not auscultation
    4. Minimum personnel in OT at the time of Intubation
    5. A high efficiency hydrophobic filter interposed in between face mask and breathing circuit to be used [Figure 2]. Another HME, bacterial and viral filter to be placed in the expiratory limb of the closed circuit in the anesthesia workstation
    6. Use of video laryngoscope and fiberoptic bronchoscope assisted intubation to be used where indicated
    7. The soiled laryngoscope blade and facemask to be kept in closed containers and disinfected as soon as possible
    8. Hand hygiene with alcohol rub practiced by all personnel before and after each patient contact.
Figure 1: Intubation using intubation cubicle and extra oral vacuum suction unit

Click here to view
Figure 2: A high efficiency hydrophobic filter interposed in between face mask and breathing circuit for intubation

Click here to view

Extubation protocol

  1. A high efficiency hydrophobic filter interposed in between face mask and breathing circuit is supplemented with another high efficiency hydrophobic filter [Figure 3]. Extra oral suction to be placed to minimize aerosols while extubation
  2. All attempts are made to have a smooth extubation and avoid bucking/coughing on circuit. Extubation is performed using the intubation cubicle and vacuum suction unit also to be placed at the open end of the intubation cubicle to decrease the aerosol contamination
  3. Protocol for disconnection of endotracheal tube for transport and suctioning if required:
  4. Figure 3: A high efficiency hydrophobic filter interposed in between face mask and breathing circuit supplemented with another high efficiency hydrophobic filter for extubation

    Click here to view

    • When initiating transport leave the HME filter in place on endotracheal tube and connect to transport ventilator or Bains circuit
    • In-line closed suction should be used for suctioning for ETT suctioning. Oral suctioning to be performed in presence of intubation cubicle and vacuum suction unit
    • Clamp the endotracheal tube whenever disconnected from ventilator.

  5. As soon as extubation is over and patient is awake enough, oxygen with nasal cannula to be supplemented and a surgical three-ply face mask to be placed on patient's face, covering his/her nose and mouth
  6. Patient to be transported in the isolation pod on designated stretcher [Figure 4]
  7. Disposable breathing circuits to be thrown after each use, HME filter mounted to ETT to be discarded after each use and the facemasks and other equipment to be cleaned and disinfected using soap and water and 70% ethyl alcohol.

  Environmental Disinfection Top

Environmental disinfection and infection prevention methods[11]


  1. Cleaning of the equipment is carried out only by PPE clad personnel. Fumigation of OT using Sterisol solution, is also carried out by PPE clad ORTs
  2. Meticulous cleaning of patient-care items with water and detergent, or with water and enzymatic cleaners before high-level disinfection or sterilization procedures
  3. Removal of visible organic residue (e.g., residue of blood and tissue) and inorganic salts with cleaning
  4. Cleaning of medical devices as soon as practical after use (e.g., at the point of use) because soiled materials become dried onto the instruments
  5. Manual cleaning (using friction) or mechanical cleaning (with ultrasonic cleaners, washer-disinfector, washer-sterilizers) performed
  6. The detergents or enzymatic cleaners selected are compatible with the metals and other materials used in medical instruments. Rinse step is ensured to be adequate for removing cleaning residues to levels that will not interfere with subsequent disinfection/sterilization processes
  7. Inspection of equipment surfaces for breaks in integrity that would impair either cleaning or disinfection/sterilization carried out. Equipment that no longer functions as intended or cannot be properly cleaned, and disinfected or sterilized is discarded.

Indications for sterilization, high-level disinfection, and low-level disinfection[11]

  1. Before use on each patient, critical medical or surgical devices and instruments that enter normally any sterile tissue or the vascular system needs to be sterilized
  2. High-level disinfection for semicritical patient care equipment (e.g., gastrointestinal endoscopes, endotracheal tubes, anesthesia breathing circuits, and respiratory therapy equipment) that touches either mucous membranes or nonintact skin carried out with help of plasma sterilizer
  3. Low-level disinfection for noncritical patient-care surfaces (e.g., bedrails, over-the-bed table) and equipment (e.g., blood pressure cuff) that touch intact skin carried out with Sterisol (1:8 dilution)
  4. Preexisting ultraviolet lights, in every OT are switched on every night from 08.00 pm to morning 06.00 am, for viricidal action
  5. The equipment used for sterilization in our Central Sterile Stores Department is Horizontal Steam sterilizer and Plasma sterilizer
  6. BWM is followed as per Hospital's guidelines on BWM, revised for COVID-19 scenario. The BMW is segregated at source into recyclable; infected plastics/tubings/gloves; soiled dressing material/gauze, glass sharps and metal sharps and sent to Hospital BMW Management area where again it is checked and disposed off as per BMW management guidelines. Since BMW is a huge topic in itself, hence it is not discussed in detail here.

Education of medical and paramedical personnel

Any new situation or crisis warrants correct information and updating knowledge regarding management of that crisis. This was taken as a gospel truth and junior medical staff and paramedical staff were kept abreast with the latest information on coronavirus through training sessions, educative videos, simulation based learning with simulated patient and small group discussions.[12] Small training capsules on donning and doffing of PPE, cardiopulmonary resuscitation (CPR) in COVID scenario were also conducted for the entire OT staff. Health education to patients was followed with help of educational posters displayed in PAC and patient waiting area. The guidelines on CPR in COVID scenario have been displayed at various sites in OT complex.[13]

  Conclusion Top

Armed with the updated knowledge about the viral transmission, epidemiology and clinical transmission, prevention measures and management strategies, these protocols were designed for a smooth flow of work in the OT complex. Till date we have managed total 198 Surgeries in OT from 01 March to 31 July 2020 and have been able to handle our suspects and positive cases successfully without any cross infection to Health café workers owing to stringent use of the guidelines laid down. This article is an attempt to stress that an informed team working with adequate knowledge as per laid down guidelines can be extremely efficient.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020;382:1199-207.  Back to cited text no. 1
Phelan AL, Katz R, Gostin LO. The novel coronavirus originating in Wuhan, China: challenges for global health governance. JAMA 2020;323:709-10.  Back to cited text no. 2
Mahase E. China coronavirus: WHO declares international emergency as death toll exceeds 200. BMJ 2020;368:m408.  Back to cited text no. 3
Statement on the Second Meeting of the International Health Regulations (2005) Emergency Committee Regarding the Outbreak of Novel Coronavirus (2019-nCoV); 2021. Available from: https://www.who.int/news/item/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov). [Last cited on 2021 Jan 17].  Back to cited text no. 4
Chan JF, To KK, Tse H, Jin DY, Yuen KY. Interspecies transmission and emergence of novel viruses: Lessons from bats and birds. Trends Microbiol 2013;21:544-55.  Back to cited text no. 5
Di Saverio S, Pata F, Gallo G, Carrano F, Scorza A, Sileri P, et al. Coronavirus pandemic and colorectal surgery: Practical advice based on the Italian experience. Colorectal Dis 2020;22:625-34.  Back to cited text no. 6
Guo ZD, Wang ZY, Zhang SF, Li X, Li L, Li C, et al. Aerosol and surface distribution of severe acute respiratory syndrome coronavirus 2 in hospital wards, Wuhan, China, 2020. Emerg Infect Dis 2020;26:1583-91.  Back to cited text no. 7
Vanamoorthy P, Singh GP, Bidkar PU, Mitra R, Sriganesh K, Chavali S, et al. The Neurocritical Care Society of India (NCSI) and the Indian Society of Neuroanaesthesiology and Critical Care (ISNACC) joint position statement and advisory on the practice of neurocritical care during the COVID-19 pandemic. J Neuroanaesthesiol Crit Care 2020;2:49-114.  Back to cited text no. 8
Cheung JC, Ho LT, Cheng JV, Cham EYK, Lam KN. Staff safety during emergency airway management for COVID-19 in Hong Kong. Lancet Respir Med 2020;8:e19.  Back to cited text no. 9
Regulatory Changes Due to Covid 19 (July). Lexplosion; 2021. Available from: https://lexplosion.in/regulatory-changes-due-to-covid-19/regulatory-changes-due-to-covid-19-july/. [Last cited on 2021 Jan 17].  Back to cited text no. 10
Rutala W, Weber D. Disinfection, sterilization, and antisepsis: Principles, practices, current issues, new research, and new technologies. Am J Infect Control 2019;47:A1-2.  Back to cited text no. 11
Garzonis K, Mann E, Wyrzykowska A, Kanellakis P. Improving patient outcomes: effectively training healthcare staff in psychological practice skills: A mixed systematic literature review. Eur J Psychol 2015;11:535-56.  Back to cited text no. 12
Edelson DP, Topjan AA. Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID-19. Circulation 2020;141:e933-43.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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