Anesthesia Care of the Patient with Mpox (Monkeypox)

Certified Registered Nurse Anesthetists (CRNAs) may care for patients infected with the Mpox virus, previously referred to as Monkeypox.1

Anesthesia professionals are at an elevated risk of Mpox exposure due to the potential for respiratory droplet transmission and should take adequate precautions.2

To support the safety of patients and anesthesia professionals, the AANA Infection Control Advisory Panel offers the following evidence-based perioperative infection control considerations. These considerations can be used to develop facility policies and procedures, which should be in alignment with current local trends, recommendations from public health officials, and reliable published resources.1

Mpox Transmission

+ Human transmission is possible via respiratory droplets but is not considered to be “airborne.” Mpox virus may be found in saliva or respiratory secretions. Masks are recommended for close, face-to-face contact, such as intubation and extubation. Infected patients should be cared for in an airborne infection isolation room (AIIR).3

+ Human transmission is also possible by contact with bodily fluids.2 Direct contact with Mpox rash, scabs, and touching objects/fabrics (e.g., clothing, bedding, towels) and surfaces that have been used by someone with Mpox may also transmit the virus.4

+ Facilities should establish policies and procedures regarding appropriate patient masking.

Mpox Signs and Symptoms; Pre-operative Testing

+ The infection usually begins with common flu-like symptoms which include, fever, headache, muscle and back aches, fatigue, and swollen lymph nodes. Patients are contagious at the start of the first symptom. Within 1-3 days, a skin rash will appear which will spread across the body. This rash will progress through various stages, starting as flat red spots and progressing to pustules and scabs. This rash will typically last 2-4 weeks.5

+ A person with Mpox can spread it to others from the time symptoms start until the rash has fully healed and a fresh layer of skin has formed.4

+ Pre-operative testing is recommended if a patient has a rash consistent with Mpox.6

Postponement of Elective Surgery

+ Elective surgeries should be postponed for patients who have suspected or confirmed Mpox until the patient has been determined to be noninfectious.

+ If surgery cannot be postponed, the surgery should be scheduled when a minimum number of perioperative personnel are present at the end of the day when possible.7

First Point of Contact, Pre-anesthetic Assessment

+ Preventing respiratory droplet exposure during airway examination and manipulation is extremely important.

+ If possible, consider conducting a portion of the preoperative assessment remotely through videoconferencing.2 If videoconferencing is not possible, CRNAs should observe universal precautions, and droplet precautions during the in-person assessment and evaluation, with mask, gloves, hair, and eye protection during exams, and careful doffing of personal protective equipment (PPE) afterward.

Bag-Mask Ventilation and Airway Procedures Are the Time of Greatest Risk of Exposure

+ Universal use of circuit microbial filters, eye protection and N95 masks should be mandatory during these situations.

+ Video-laryngoscopy may help avoid the need for close proximity of the CRNA’s face to the patient during tracheal intubation.2

+ Patients should receive airway care in an AIIR negative pressure room when possible.

Increase Hand Hygiene Frequency

+ Perform hand hygiene at least 8 times per hour during anesthesia care.8

+ In critical care environments, perform hand hygiene at least 4 times per hour 8

Personal Protective Equipment (PPE)

+ When caring for Mpox-positive patients, all health care providers in the operating room should wear appropriate PPE, including5:

• N95 mask

• Disposable gloves

• Eye protection (e.g., goggles/face shield that covers the front and sides of the face)

• Isolation gown

During Surgery

+ The clinical team should be dedicated to the infected patient and should not go from one operating room to another to prevent particle transmission.5

+ If anyone must leave the operating room, all PPE must be removed in the appropriate order (e.g., gloves, and gown, hands washing, eye protection, hands washing) followed by hand scrubbing.

+ New PPE should be worn before entering the operating room again.5

Vascular Care Recommendations

+ Disinfect injection ports using 70-90% isopropyl alcohol prior to access by scrubbing 5-30 seconds to create friction, followed by drying.

+ Avoid using open lumens (uncovered stopcocks) as they are at an increased risk of contamination.

+ Clean all medication vials with an alcohol wipe after the dust cover is removed from the vial and before access to prevent contamination and infection.

+ Keep injection ports, syringe tips, and IV tubing off the floor.8

Infection Control and Strict Disinfection Procedures

+ Proper disinfection of anesthetic equipment must be ensured.

+ If possible, disposable equipment such as bed linen and drapes should be utilized 2

Increased Risk for MRSA Infection

+ The risk of MRSA (Methicillin Resistant Staphylococcus Aureus) infection increases with activities or places that involve crowding, skin-to-skin contact, and shared equipment or supplies.

+ Non-intact skin, such as abrasions or incisions are often the sites of a MRSA infection. Thus, patients with active Mpox may be at increased risk for MRSA colonization due to iatrogenic exposure during care measures, and the presence of open skin lesions. Prescribe post-discharge decolonization for the patient colonized with MRSA as the result of health care exposure.8

Additional Resources

+ Clinical providers can consult with the CDC Monkeypox Response Clinical Escalations Team, eocevent482@cdc.gov or CDC EOC at (770) 488-7100

+ For additional background materials please visit the following webpages:

• CDC Mpox Information for Healthcare Professionals

• American Nurses Association: Monkeypox

• AANA Infection Prevention and Control Guidelines

+ The Infection Control Advisory Panel can be reached at practice@aana.com

Sources:

1. World Health Organization. WHO recommends new name for monkeypox disease. Accessed Nov. 29, 2022. https://www.who.int/news/item/28-11-2022-who-recommends-new-name-for-monkeypox-disease

2. Chowdhury SR, Datta PK, Maitra S. Monkeypox and its pandemic potential: what the anaesthetist should know. Br J Anaesth. Sep 2022;129(3):e49-e52. doi:10.1016/j.bja.2022.06.007

3. Centers for Disease Control and Prevention. CDC Monkeypox Response: Transmission. CDC. Accessed Oct. 19, 2022. https://www.cdc.gov/media/releases/2022/0509-monkeypox-transmission.html

4. Centers for Disease Control and Prevention. Monkeypox: How it Spreads. Accessed Nov. 14, 2022. https://www.cdc.gov/poxvirus/monkeypox/if-sick/transmission.html

5. Aurélie Gouel-Cheron EK, Christophe Riouxd, Solen Kerneise PM. Monkeypox-infected patients in the perioperative context: Recommendations from an expert centre. Anaesthesia Critical Care & Pain Medicine. 2022;41(5):3. doi:https://doi.org/10.1016/j.accpm.2022.101122

6. Centers for Disease Control and Prevention. Monkeypox Testing Basics. Accessed Oct. 19, 2022. https://www.cdc.gov/poxvirus/monkeypox/testing/testing-basics.html#:~:text=Currently%2C%20 testing%20is%20only%20recommended,to%20be%20tested%20for%20monkeypox

7. Association of periOperative Registered Nurses. What precautions are needed for a surgical patient with suspected or confirmed monkeypox infection? Accessed Oct. 19, 2022. https://www.aorn.org/aboutaorn/aorn-newsroom/transmission-precautions-for-monkeypox-infection

8. Charnin JE HM, Bartz R, et al. A Best Practice for Anesthesia Work Area Infection Control Measures: What Are You Waiting For? Accessed Oct. 19, 2022. https://www.apsf.org/wp-content/uploads/ newsletters/2022/3703/APSF3703-2022-10-a10-BestPracticeArea.pdf