Anesthesiologists face the Ebola epidemic: Time to 'educate, train and prepare'

"Given the current spread of the disease, anesthesia personnel worldwide may be called upon to provide perioperative care for EVD patients undergoing emergency surgery or for airway management," according to the article by Dr Andres Missair of University of Miami (Fla.) and colleagues. "Anesthesia departments should educate, train, and prepare their providers immediately for such encounters and assure that the required equipment is readily available."

What's the Evidence on Anesthetic Management of Ebola Infection?

Dr Missair and colleagues reviewed the scientific literature to gather evidence regarding management of patients with known or suspected Ebola virus infection. Because of their role in performing invasive procedures -- including airway intubation, bronchoscopy, and venous catheter placement, among others -- anesthesiologists have the potential for high-risk exposure and direct contact with EVD patients.

Because of the unprecedented nature of the world Ebola epidemic, so far there is little direct evidence on the anesthetic management of EVD. However, data from animal studies of Ebola, as well as studies of patients with infectious diseases such as tuberculosis, provide a sound basis for initial recommendations.

"Any health care activity with an EVD patient carries risk except contact with that person before they developed symptoms," Dr Missair and coauthors write. Patient assessment for possible exposure to Ebola is critical -- but it can be difficult to recognize Ebola infection in its early stages. Any patient who has traveled to affected regions of Western Africa and has fever or any additional symptoms should be isolated and investigated.

The use of personal protective equipment (PPE) is paramount to preventing Ebola transmission. Without PPE, any procedure involving contaminated body fluids or potential for "sharps" injury (needles, scalpels, etc) puts health care providers at high risk of exposure.

Dr Missair and colleagues emphasize that guidelines for PPE must be strictly adhered to at all times -- even in emergencies. Their review includes recommendations for disposing of EVD-contaminated equipment and steps to follow in case of high-risk exposures -- that is, direct contact with body fluids of an infected person.

Most Ebola Patients Won't Have Surgery -- But Other Procedures Carry Risks

Supportive care is the mainstay of treatment for EVD; surgery would typically not be recommended in an infected patient. "The risks of viral transmission to multiple staff and intraoperative patient death may outweigh any benefits of performing the surgery," Dr Missair and coauthors write.

But other types of invasive procedures may be needed and should be anticipated. Reported EVD cases in the United States include patients undergoing airway intubation, and one who received hemodialysis. Dr Missair and colleagues outline steps that may help to reduce transmission risk in patients undergoing intubation and mechanical ventilation. Alternatives to general anesthesia, such as peripheral nerve blocks, may help to reduce the risks of transmission.

Limited evidence suggests that Ebola virus can persist for several days on contaminated surfaces, although it is highly sensitive to light and drying. Dr Missair and coauthors discuss the implications for cleaning of patient care equipment is discussed; when possible, dedicated equipment should be used only for EVD patient care. Mechanical ventilators pose more complex challenges for use and sterilization.

Evidence suggests that Ebola virus is most often transmitted by direct contact, but there is concern that transmission could occur through inhaled aerosol particles -- which may be generated by many different medical procedures. The authors discuss enhanced precautions, including additional forms of PPE, to reduce the risk of viral transmission during such procedures.

With the documented occurrence of Ebola virus infection in health care professionals caring for patients with EVD, it's essential to establish effective guidelines to enhance preparedness and safety. Dr Missair and colleagues conclude, "Although there is a significant lack of scientific data, our search of the current literature identified some strategies that may be helpful to protect anesthesia staff from acquiring the virus while enabling them to provide appropriate medical care to their patients."