Statement on COVID -19 Testing Before Elective Head and Neck Surgery

Many states are preparing for the resumption of oncology-related and elective surgeries. Health care facilities are planning detailed stepwise approaches to ramping up their surgical schedules.
Our statements apply to all head and neck surgeries and procedures supported by anesthesiologists in all anesthetizing locations.

SHANA supports the recommendations of Society For Ambulatory Anesthesia (SAMBA) for screening for symptoms of COVID -19 and nucleic acid amplification testing, including PCR testing for all patients scheduled for elective surgery as feasible. However, additional considerations may be entertained in certain circumstances as outlined by the statement of the American Society of Anesthesiologists (ASA), Anesthesia Patient Safety Foundation (APSF), regarding communities that have low disease prevalence according to the best judgement of the caring head and neck anesthesiologist.

We further recommend and clarify:

1. Emergent head and neck surgical procedures must proceed regardless of COVID-19 status i.e. must be performed without delay. These may include airway compromise, infections, free flap complications and/or bleeding. In this case, we recommend the use of full PPE, consideration for use of videolaryngoscopy in the first intubation attempt, and rapid sequence induction (avoiding bag-mask ventilation) to rapidly secure the airway. A filter should be placed on the endotracheal tube before positive pressure ventilation is applied. Full PPE entails a fit-tested N-95 mask or a NIOSH branded respirator or a PAPR, eye protection (goggles or face shield), body covering such as a non-permeable full-body jumpsuit or non-permeable operating room gown, and gloves (considering double layers).

2. Surgical procedures of the head and neck are typically considered aerosol generating procedures (AGP) , this is commonly encountered during  tracheal intubation, tracheal extubation, head and neck and airway surgical procedures, bronchoscopy and pulmonary interventions, upper and lower GI endoscopy.

3. Every attempt should be made to screen all patients for symptoms of COVID-19 disease and test for SARS-CoV-2 infection by PCR testing. Symptoms include fever, cough, dyspnea, malaise, myalgias, and atypical symptoms such as nausea, vomiting, diarrhea, and loss of smell and taste.

4. Patients should be screened and tested as close to procedures as possible. We recommend testing 24-48 hours before a planned elective procedure (but not greater than 72 hours). Given this requirement, efforts should be made to make testing available over the weekend in preparation for surgery scheduled for Monday as possible.

5. Following testing and symptom screening, all patients must self-isolate before their scheduled procedure.

6. Elective surgical procedures must be canceled and rescheduled for any patient testing positive for SARS-CoV-2 and/or the presence of symptoms of COVID-19 disease.

7. Planned elective surgery can proceed for patients with a negative test for the SARS-CoV-2 virus who remain free of COVID-19 associated symptoms (please note; existing tests for SARS-CoV-2 have up to a 30% false-negative result rate, but specificity is improved in the absence of symptoms associated with the COVID-19 disease).

In conclusion, SHANA supports COVID-19 symptom screening and SARS-CoV-2 testing all patients before elective head and neck surgeries as feasible. Emergency cases must proceed regardless of the determination of COVID status requiring the use of full PPE for all cases for the duration of operative care (tracheal intubation to extubation/transfer). Elective cases should proceed with negative test and symptoms  and cancelled for positive test and/or symptoms.