André, Rodrigo Gherson

Auler-Júnior, José Otávio Costa

Carmona, Maria José Carvalho

Kayano, Rafael Priante

Malbouisson, Luiz Marcelo Sá

Melo, Brigite Feiner de

Quintão, Vinícius Caldeira

English

Cadernos Espinosanos (E-Journal)

Transforming operating rooms into intensive care unitsand the versatility of the physician anesthesiologistduring the COVID-19 crisisMaria José Carvalho Carmona0000-0000-0000-0000 ,* Vinı́cius Caldeira Quintão0000-0000-0000-0000 , Brigite Feiner de Melo, Rodrigo GhersonAndré, Rafael Priante Kayano, Luiz Marcelo Sá Malbouisson0000-0000-0000-0000 , José Otávio Costa Auler-Júnior0000-0000-0000-0000Disciplina de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR.Carmona MJC, Quintão VC, Melo BF, André RG, Kayano RP, Malbouisson LM. Transforming operating rooms into intensive care units and the versatility ofthe physician anesthesiologist during the COVID-19 crisis. Clinics. 2020;75:e2023*Corresponding author. E-mail: maria.carmona@fm.usp.brWith the prospect of an increasing number of COVID-19cases and with the city of Sao Paulo being the epicenter of theCOVID-19 pandemic in Brazil, Hospital das Clinicas of theFaculdade de Medicina of the Universidade de Sao Paulo(HCFMUSP) initiated an action plan to designate the largestof its eight institutes to the treatment of the disease. With theprogressive increase in the number of attended cases, at theend of March 2020, the 900 beds of HCFMUSP InstitutoCentral (ICHC) were exclusively allocated to patients withCOVID-19. A further 200 intensive care (ICU) beds wereadded in the following month, including those adaptedinside operating rooms. The final plan accounted for morethan 300 ICU beds and included 34 operating rooms in thefour blocks of the main ICHC surgical theater that wereadapted to attend to one to four patients each. This resultedin a complex of four ICUs with up to 76 beds. The rearrange-ment and specialized review of medical gas, electricity, airconditioning, and data network installations were essentialprocedures to ensure the safe use of these areas for this newpurpose.Following the cancellation, postponement, or transfer ofsurgical schedules at other institutes of the HCFMUSPcomplex and Hospital Universitario, the ICHC team of 117physician anesthesiologists was divided into those remainingat the ICHC or conducting specific procedures at the desti-nation sites, with emphasis on trauma, surgical emergencies,transplants, and high-risk obstetrics. According to the lessonslearned from countries that have already gone through thepeak of the pandemic, such as China and Italy, the 60 physi-cian anesthesiologists who stayed in the ICHC were intenselyretrained regarding the correct use of personal protectiveequipment and techniques of donning and doffing to mini-mize the occupational risk of COVID-19.Physician anesthesiologists have previously been trainedand are specialists in accessing the airway, including dealingwith airway difficulty, and the transportation of critically illpatients. Retraining therefore focused on the safe trachealintubation of COVID-19 patients, with respect to patient carewhile minimizing exposure to droplets and aerosols. In addi-tion, anesthetic care for surgical and obstetric patients withCOVID-19, intra-hospital transport of critically ill patients,and the role of the physician anesthesiologist as an intensi-vist were part of the team’s training.On March 30, 2020, the ICHC Anesthesiology team tookover the role of the Rapid Response Team services andstarted working as hospitalists, replacing the Internal Medi-cine team that previously performed this function. Thisdecision was based on the need to pay particular attentionto airway approaches in COVID-19 patients who requiredtracheal intubation at admission, in wards, and in ICUs.Besides minimizing occupational exposure, technical skillsdecrease the risk of adverse events such as cardiac arrestduring tracheal intubation in hypoxic patients. The respon-sibility of intra-hospital transport of intubated patients usingvasoactive drugs was also assumed by the physician anes-thesiologists’ team. This team also collaborated in the train-ing of non-anesthesiologists in airway management. Theusual number of beds in ICU-Anesthesiology increased from17 to 22 after transformation of post-anesthetic recovery bedsinto ICU beds. Additionally, 24 beds in two new ICUs atICHC, as well as the four ICUs created within the surgicaltheater, are currently the responsibility of the AnesthesiologyDivision. Intensive care specialists who did or did not belongto the Anesthesiology Division were recruited as day-to-daymanagers for each ICU.Although the number of physician anesthesiologists wasadequate for the several activities undertaken during the dayshifts, the reallocation of working hours rendered the num-ber of physicians insufficient for night and weekend shifts.This scenario led to extra-institutional professional recruit-ment, allowing physician anesthesiologists from privatehospitals in Sao Paulo city to fill the vacant positions. Theseprofessionals were also enrolled in at least three more ICUs,with up to 12 beds each. The direct or indirect participationof physician anesthesiologists in ICUs containing at least150 beds optimized the service capacity for severe cases ofCOVID-19 in the city of Sao Paulo.With the increase in demand for mechanical ventilatorsand the market shortage of specific equipment for severeDOI: 10.6061/clinics/2020/e2023Copyright & 2020 CLINICS – This is an Open Access article distributed under theterms of the Creative Commons License (http://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in anymedium or format, provided the original work is properly cited.No potential conflict of interest was reported.1COMMENTScases, the use of anesthesia machines as mechanical ventila-tors is necessary in ICUs. This has been successfully appliedin other countries (1). The ICHC has a technologically modernset of anesthesia equipment, which provides adequateresources for prolonged respiratory assistance and weaningfrom mechanical ventilation. Together with the biomedicalengineering team, several tests were carried out to adapt theanesthesia machines available in the surgical theater for use inICUs. Other anesthesia machines that were placed at diagno-stic and therapeutic sites or that were made available fromother institutes of the HCFMUSP complex were also testedand adapted. When used in intensive care, the frequency ofthe need to exchange the soda lime, which is used to absorbcarbon dioxide and reduce the consumption of gases andinhalation anesthetics, is reduced with the use of increased gasflow (2). The use of anesthesia machines as ICU ventilatorsalso makes it possible to sedate patients using inhalation anes-thetics. However, this procedure presents technical limitationswhen using the mechanical ventilators commonly used inICUs (3).Besides the implementation of new practices on the basisof the best evidence available in the literature, these medicalcare activities provide opportunities for specific clinical researchin anesthesiology or in partnership with other disciplines.Furthermore, the clinical demand in these unprecedentedtimes can encourage technological innovation and university-industry partnerships, especially with the Escola Politecnica ofthe Universidade de Sao Paulo and private companies. Byfollowing the appropriate protocols, this could promote thedevelopment of new materials and equipment that couldimprove the economic-industrial complex of healthcare inBrazil.The significant participation of physician anesthesiologistsduring the COVID-19 crisis at HCFMUSP has corrobora-ted the versatility of these specialists, as has already beendemonstrated in other countries (1). Physician anesthesiolo-gists, who are skilled team members, are collaborating in theinformal training of newly hired nursing teams to care forcritically ill patients and are showing physiotherapists howto use anesthesia machines as mechanical ventilators inICUs. The environment is also one of great mutual learning.For instance, the experience of physician anesthesiologistsand nurses in several types of surgery in the pronationposition contributes to minimizing the risks related to theintubation and extubation of patients in ICUs. Anotherimportant benefit of this teamwork is the psychologicalsupport offered by the Psychology Division and the Psy-chiatric team of the Instituto de Psiquiatria of HCFMUSP(IPq) to physicians, residents, and other health professionalsinvolved in the treatment of COVID-19 patients, includingphysician anesthesiologist staff and residents. As a fortunateconsequence of this intense training and awareness program,very few anesthesiologists are getting infected within thehospital environment.Changes and adaptations, in consideration of both patientsand health care teams, are continuously being implemented.The anesthesiology field has incorporated various modelsfrom aviation checklists throughout the years, and in times ofcrisis, adopting strict protocols can contribute to improvedresults.’ REFERENCES1. Peters AW, Chawla KS, Turnbull ZA. Transforming ORs Into ICUs.N Engl J Med. 2020;382(19):e52. https://doi.org/10.1056/NEJMc20108532. Torres MLA, Canhisares FAT, Quintão VC. [Management of CO(2)absorbent while using the anesthesia machine as a mechanical ventilatoron patients with COVID-19]. Rev Bras Anesthesiol. 2020. https://doi.org/10.1016/j.bjan.2020.04.0013. Hanidziar D, Bittner EA. Sedation of mechanically ventilated COVID-19patients: challenges and special considerations. Anesth Analg. 2020.https://10.1213/ANE.00000000000048872Turning OR into COVID-19 ICU: Anesthesiology roleCarmona MJC et al.CLINICS 2020;75:e2023

Transforming operating rooms into intensive care units and the versatility of the physician anesthesiologist during the COVID-19 crisis

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Transforming operating rooms into intensive care units and the versatility of the physician anesthesiologist during the COVID-19 crisis

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