Professional Documents
Culture Documents
ISSN No:-2456-2165
Debesh Chandra Talukder, Sk. Nurul Fattah Rumi, Nazmul Islam Munna,
Associate Professor, Department of Professor & Head , Department of Professor & Line Director, Medical
ENT & Head Neck Surgery, ENT & Head Neck Surgery, education Department, Directorate
Dhaka Medical College Hospital Dhaka Medical College Hospital General of Health Service
Md. Abu Yusuf Fakir, A F Mohiuddin Khan, Brig. Gen. Dr. Md. Nasir Uddin,
Professor & Additional Director Professor & Head (Retd.), MBBS, Director, Dhaka Medical
General, Directorate General of Department of ENT & College Hospital
Health Service Head Neck Surgery,
Dhaka Medical College Hospital
Abbreviations:-
HCP: Health care professional, PVP-I: Povidone
Iodine
WHO declared COVID-19 outbreak as pandemic in In our setting, placement of a transparent, sterile
March, 2020, which was started from Wuhan of china. polythene which acts as an interface between patient and
During this pandemic, (every person or patient has chance surgeons and all other HCPs is the change maker.
of being infected with corona virus,) nobody is immune of Meanwhile, rational use of Povidone Iodine mouthwash for
being infected with coronavirus or being asymptomatic gargling and nasal application either by spray or nasal
career of this 1. irrigation or drop will reduce viral load from nose and
mouth, as well as covering the face with a mask or face
Tracheostomy is an ancient lifesaving surgical shield of the patient to reduce the chance of transmissibility
procedure in which the trachea is surgically opened in its of COVID-19 patient. Thus, transmission of COVID-19
anterior wall and a stoma is created and maintained to will be reduced. This technique was innovated by the
facilitate ventilation 2, 3, 4. In our country or South East corresponding author and applied in Dhaka Medical
Asia region, carcinoma larynx or other head neck cancer is College Hospital in two (2) cases.
the most common indication of tracheostomy still now 5,6.
In a resource constraint country- like Bangladesh, patient A. Povidone Iodine :
presents to the hospitals at advanced stage usually with In 1955 Povidone-iodine (iodine with water-soluble
stridor. Upper airway obstruction due to trauma to larynx polymer polyvinylpyrrolidone, PVP-I) was invented 9. The
(by road traffic accident, cut throat injury, hanging) or active moiety, non PVP‐bound (free) iodine is released into
foreign body, laryngeal papilloma, prolonged mechanical solution from the PVP‐I complex. PVP delivers the free
ventilation are some other common indications of iodine to target cell membranes. Free iodine that mediates
tracheostomy 5,6. In our context, emergency tracheostomy the basic mechanism of action (oxidation of amino acids
is not uncommon/ quite common, especially in our centre, and nucleic acids in biological structures), which is difficult
at Dhaka Medical College Hospital 7. to counteract. This basic mechanism of action leads to
strong microbicidal activity expressed by multiple modes of
Tracheostomy is an aerosol generating procedure. If a action that include the disruption of microbial metabolic
patient of COVID-19, either confirmed, suspected or pathways, as well as destabilisation of the structural
asymptomatic career, requires tracheostomy for any of components of cell membranes, causing irreversible
those indications, it’s a critical and alarming issue for the damage to the pathogen. Consumed free iodine is then
health care professionals, including doctor, nurse, other replaced by PVP‐bound iodine. The concentration of free
HCPs for the highly contagious nature of this virus 8. iodine is the determining factor of the microbicidal action
of PVP‐I. In a study investigating the virucidal activity of
In current situation prior to any (routine) surgery different disinfectants, Electron micrographic study
report of RT-PCR test for coronavirus is mandatory. In a revealed that, exposure of iodine led to destruction of
developing country- like Bangladesh, patient presents to the nucleoproteins of viral particle – which is the main
hospitals at advanced stage usually with stridor. Most of the mechanism of action 10,11. However, disruption of surface
time, surgeon has no (waiting) time for tracheostomy, so proteins essential for the spread of enveloped viruses has
confirmation of COVID-19 by RT-PCR test can’t be done also been noted 10,12. Furthermore, Iodine is a scavanger
instantly. Prior to surgery it’s recommended to do a CT of free radical oxygen species, co ntributing to anti-
scan of chest 8, if not possible at least Chest X-ray to find inflammatory properties 10, 13. This interaction ultimately
clue regarding COVID-19. But sometimes situation is results in microbial death.
unfavourable for doing any of them. Few minutes or even
seconds are demarcating line between life and death. For B. Virucidal activity of PVP-I
this reason health care professionals should take maximum Povidone‐iodine has been reported as having the
protections for their own safety within lots of limitation, highest virucidal activity profile among several antiseptics
seeming every patient as a COVID-19 patient. such as CHG, benzalkonium chloride (BAC), BEC and
alkyldiaminoethyl‐glycine hydrochloride (AEG) 10, 14.
Though the government, local authorities, personally
all HCPs are trying to provide or collect adequate personal PVP-I has been shown to be active in vitro against the
protective equipment (PPE) or other measures, throughout coronaviruses that have caused epidemics in the last two
the world there is deficiency of it. In a resource constraint decades, namely SARS-CoV causing the severe acute
country, like us, we need to have cheap, affordable, easily respiratory syndrome (SARS) epidemic of 2002–3 and
available measures for protection. MERS-CoV the agent responsible for causing the Middle
East respiratory syndrome (MERS) epidemic of 2012–13.
Here, some simple, but novel and very effective SARS-CoV-2 is highly homologous with SARS-CoV, and
measures will be discussed for protection of all HCPs in as such it is considered a close relative of SARS-CoV1015.
this highly aerosol generating procedure. Polythene and In his study Egger et al suggests that, upto 0.23%
Povidone Iodine are the change maker in this novel concentration of PVP-I is virucidal 12, 13. Kariwa showed
technique of tracheostomy, mentioned in this article. that treatment in vitro of SARS-CoV with various
preparations of PVP-I for 2 minutes was enough to reduce
viral activity to undetectable levels14. The lowest
Proposed Steps of Tracheostomy (under local Hands of surgeons, tracheostomy tube and all
anaesthesia) in COVID-19 pandemic necessary instruments kept inside the polythene sheet.
Consent- written informed consent is mandatory with Trachea is to open with a vertical incision to make a
double risk bond fenestra, in between 2nd and 3rd or 3rd and 4th rings,
which can be converted into a circular or quadrangular
Preparation of patient opening. Sparing 1st tracheal ring is mandatory to
Prior to surgery, patient is to gargle with 10-15 ml prevent subglottic stenosis.
PVP-I 1% (undiluted) or 20-30 ml 0.5% (diluted with Tracheostomy tube is to insert and is to secure by tapes
same amount of water) mouthwash solution or suture.
Nasal irrigation with PVP-I (0.5%) is to be given, in Gauze dressing is to place between skin and flange of
case of difficulty or inconvenience of patient PVP-I the tube around the stoma 17,18.
nasal spray or drop should be applied.
Patients’ nose and mouth is to cover with face shield or D. Preparation of application of Povidone Iodine or PVP-I
face mask (optional). prior to surgery:
For gargling and mouthwash :
Preparation of members of surgical team For fully conscious patient-
Sterile surgical gown should be put over impermeable PVP-I 1% solution (undiluted) 10 ml for 30 sec to 1
gown or protective apron. minute or 0.5% solution (diluted by mixing same amount
FFP3 or FFP2 or N95 mask or PAPR on face of water, i.e. 10 ml PVP-I with 10 ml water ) 20 ml for 1-2
Eye protective goggles minutes.
Hood cap is preferable than simple cap forehead
protection. For patient with altered consciousness –
Head light or top light both can be used. If head light is A sponge swab or similar is soaked in 2-5 ml of 1%
used, it should be protected with head cap. PVP-I and this is carefully wiped around all oral mucosal
surface
Double gloves is preferable.
All health care professionals are proposed to use PVP-I
For nasal application:
for gargling and applying in nose in same manner as
Nasal spray: 2 puff in each nostril with a standard
proposed for patient for protection as adjunct to PPE
atomizing devise with 0.5% solution of PVP-I or
before or after tracheostomy.
Nasal irrigation: Irrigate or wash through both nostril
with 50 to 200 ml of 0.5% PVP-I solution or
Microscope drape is an alternative, but not available Povidone Iodine is safe for gargling as mouthwash,
everywhere and relatively expensive 22. for inhalation or instillation as nasal spray, drop or vapour.
PVP-I Nasal Spray directly attacks viruses by trapping and
F. Special considerations: disabling them in the nasal cavity. The disabled viruses are
Number of health care professionals in the OT should then expelled with the product after blowing the nose 29,
be minimum. 30, 8.
Experienced and skilled surgical team is must.
If facility and time allows tracheostomy should be done By destroying/eliminating the culprit virus from its
under general anaesthesia in a negative pressure room. route of entry, risk of transmission of COVID-19 from
Before opening of the trachea patient to health care professionals will be reduced in
Intratracheal injection of 3-5 ml Lignocaine is significant amount as well as viral load of COVID-19
recommended to reduce the cough reflex. infected patients will be minimized. So Patient as well as
ventilation should be stopped (if under general health care professionals should use Povidone Iodine
anaesthesia) accordingly.
After opening of the trachea
electrocauterization by monopolar diathermy should be Wearing face shield or face mask or respirator by the
avoided, otherwise minimized. patient, the chance of viral transmission from him/her is
following insertion of a cannula or endotracheal tube reduced. Sometimes patients with upper airway obstruction
the ventilation circuit is to be connected with that can’t tolerate more obstruction caused by face mask or
particular one to resume ventilation of the patient (if respirator. For this reason this option is not mandatory
under general anaesthesia or in ICU) 8. always.
However, modern healthcare would not be possible As tracheostomy is an aerosol generating procedure,
without the use of plastic materials. and novel coronavirus is highly contagious, so higher level
of protection is required. A simple and cheap polythene
Polythene is popular for its greater flexibility, comfort sheet as barrier drape as well as rational and novel use of
and mobility. Polythene, with its exceptional barrier Povidone Iodine can significantly reduce the chance of
properties, light weight, low cost, durability, corona virus transmission among the health care
biocompatibility and transparency, is ideal for medical professionals working in the operation theatre.
applications.
Conflict of interest
Today’s most innovative medical procedures are All authors declared, there is no conflict of interest.
dependent on plastics 6.
Contributions:
It can be sterilized by Glutaraldehyde, Formaldehyde Corresponding author is Arefin MK. He generated the
or Ethylene Oxide easily 31. idea of the technique, which was appreciated and accepted
by all the authors. Arefin MK prepared the manuscript and
In this article, we added Polythene barrier and submitted. All other authors read, revised and participated
Povidone Iodine for protection for transmission of novel in coordination of this article.
corona virus in addition with existing technique of