American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Surgical Protocol for Possible or Confirmed Ebola Cases

Disclaimer:  Experience with Ebola and measures to prevent infection of health care workers are evolving quickly as new information is gained.  Please check the CDC website frequently to see if there have been any updates in protocols.

Ebola is a highly infectious disease caused by a filovirus (Ebola virus), whose normal host species is unknown.  Infection can be potentially fatal and operating room personnel (nurses, surgeons, technicians, and anesthesia staff) all need to be aware of patients with possible or confirmed Ebola infection.

Ebola virus is usually detectable in the blood at the time of early symptom presentation.  It then increases logarithmically and can reach extremely high levels  (5 -10 billion RNA copies/ml serum). Viral levels are highest when the patient is in the most active phase of the disease.  All body fluids should be considered infectious. Please refer to for information about viral transmission. http://www.cdc.gov/vhf/ebola/transmission/human-transmission.html

Elective surgical procedures should not be performed in cases of suspected or confirmed Ebola (EVD). Emergency operations can be considered in cases as defined by the CDC: Persons Under Investigation, Probable Cases, and early Confirmed Cases. Patients with severe active disease would not likely tolerate an operation due to the severity of their disease. Any decision to operate should weigh all risks and benefits; specifically the risk of death from the current severity of their EVD, risk of death from their surgical disease, and risk of exposure to the OR team against the likelihood of potential benefit of emergency surgery. Choice of operative approach (open or MIS) should take into consideration minimizing potential hazards to all members of the OR team.

Although protocols for Personal Protective Equipment are in place to protect health care workers, there is no guideline for operating room personnel and surgical providers who might need to perform an operation on a patient with confirmed or suspected Ebola infection, this guideline adapts some of the Centers for Disease Control Recommendations and applies them specifically to the OR environment.

PROTOCOL

1. Training

All members of the healthcare team should practice through simulation the donning and doffing PPE prior to caring for a possible Ebola patient.  

2. Patient Transport and Transfer to OR

All healthcare providers should wear:

  • Gloves
  • Level 3 Association for the Advancement of Medical Instrumentation (AAMI) fluid resistant gown
  • Eye protection (goggles or face shield)
  • Facemask
  • Hood
  • Leg/shoe covers

3. Surgical Checklist

Suspected or confirmed Ebola status should be discussed in the pre and post operative briefing and become part of the Safe Surgery Checklist so all personnel are aware of potential risks of exposure.

4. OR Staff Personal Protection Equipment

Due to the significant risk of exposure to blood or bodily fluids all OR room personnel should wear:

Personal Protective Gear

    • AAMI Level 4* Impervious Surgical Gowns
    • Leg coverings that have full plastic film coating over the fabric not just over the foot area.
    • Strong consideration of using a surgical helmet with an integrated AAMI Level 4 gown such as the Stryker Flyte Sterishield system to prevent potential face splashes. If this is not available a long full plastic face shield to come down over the neck.
    • Fluid resistant Surgical Mask, consider N95 masks if aerosols will be generated
    • Double gloves, with the outer layer of gloves should be extra long surgical gloves such as the Ansell Extenda length 15.25 inch long or other similar product to provide better protection of the forearms.
    • Cape style fluid impervious hoods (place hood on prior to gown placement to allow for full neck coverage)

5. Surgical Drapes

AAMI Level 4* drapes should be used.

*Level 4 AAMI rated gowns, drapes, and protective apparel demonstrate the ability to resist liquid and viral penetration in a laboratory test, ASTM F1671 (Standard test method for resistance of materials used in protective clothing to penetration by blood-borne pathogens using Phi-X174 bacteriophage penetration as a test system).

6. Operative Technical Considerations

  • Keep sharps to a minimum
  • Use instruments, rather than fingers, to grasp needles, retract tissue, and load/unload needles and scalpels
  • Give a verbal announcement when passing sharps
  • Avoid hand-to-hand passage of sharp instruments by using a basin or neutral zone that has been agreed upon at the case start
  • Use alternative cutting methods such as blunt electrocautery
  • Substitute endoscopic surgery for open surgery when possible
  • Endoscopic procedures: decompress the abdomen or chest of all insufflation pressure prior to removing ports to avoid spray-back of material from the cavity.
  • Use round-tipped scalpel blades instead of pointed sharp-tipped blades
  • Use electrocautery preferentially to scalpel for incisions
  • No needles or sharps on the Mayo stand
  • No recapping of needles
  • Use blunt tip suture needles when possible
  • Continue “sharps safety” techniques during OR table clean up post procedure

7. Doffing PPE

OR personnel should doff PPE using a trained observer system and consideration of a clean but fully protected “buddy” to assist. Absolutely avoid touching the face, especially the nose, mouth, or lips.

8. Specimen and Waste Management

Extensive guidelines exist on the CDC website

9. OR Staff Exposure (adapted from CDC guidelines)

Persons with percutaneous or mucocutaneous exposures to blood, body fluids, secretions, or excretions from a patient with suspected or confirmed Ebola should:

  • Stop working and immediately wash the affected skin surfaces with soap and water.
  • Mucous membranes (e.g., conjunctiva) should be irrigated with copious amounts of water or eyewash solution
  • Immediately contact Infectious Disease consultant in your hospital for post exposure evaluation.

Guideline Creation Version 1 October 6, 2014
Version 2 October 19, 2014
Updates will be made if and when new data are available.

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References

http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf

http://www.cdc.gov/sharpssafety/resources.html

http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html

http://www.cdc.gov/vhf/ebola/pdf/ppe-poster.pdf

http://www.cdc.gov/vhf/ebola/hcp/index.html

http://www.cdc.gov/vhf/ebola/transmission/human-transmission.html