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May 7, 2020

Surgery in a Time of Uncertainty: A Need for Universal Respiratory Precautions in the Operating Room

Author Affiliations
  • 1Deputy Editor, JAMA
  • 2Department of Surgery, University of California, Los Angeles
JAMA. 2020;323(22):2254-2255. doi:10.1001/jama.2020.7903

Much has been learned about coronavirus disease 2019 (COVID-19) in the past 4 months, but still much remains unknown. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is well characterized but how widely it has spread throughout the population is not known, nor is it known why some individuals who are infected with the virus do not develop symptoms, whereas other individuals develop serious COVID-19 disease with a high mortality rate. COVID-19 has had a devastating effect on the world, bringing normal activities and the economy to a near halt.

Routinely scheduled surgery was abruptly stopped virtually everywhere in the US with the arrival of SARS-CoV-2. Important questions remain about how and when routine surgical procedures should be resumed and how that can be done safely. Protecting operating room (OR) staff from contracting SARS-CoV-2 is of paramount importance and many questions remain about how to best achieve that goal. This Viewpoint discusses expanding the use of standard precautions that assume any body fluid might be infectious and includes the use of gloves, masks, and gowns that are currently used to protect staff against blood-borne infections by implementing a policy of universal respiratory precautions in the OR environment to protect staff against possible COVID-19 infection.1 Universal OR respiratory protection would include respirators used along with conventional face masks and eye protection worn by health care personnel during all patient interactions.

Patients Having Elective Surgery

Implementing a policy of universal respiratory precautions reinforces and highlights the need to identify individuals with acute COVID-19 infection, as well as those who may have been previously infected, who will undergo surgery and requires an adequate supply of personal protective equipment (PPE). Preoperative testing for SARS-CoV-2 infections should be performed. If patients have evidence of COVID-19 infection, surgery should be deferred if possible because the risk of poor patient outcomes and the risk of spread to health care workers is substantial. Patients who are not tested or test negative for acute infection should be assumed to potentially be infected with SARS-CoV-2. Tests for acute infection are variable, with sensitivity as low as 60% when nasal or 31% when pharyngeal swabs are used.2 In addition, some asymptomatic patients can shed SARS-CoV-2 and can potentially transmit the disease to others.3 Given the uncertainties of testing, the high prevalence of the disease in some regions, and that asymptomatic patients may be shedding virus, it should be assumed that the virus is present in every patient entering the OR. Until more is known, to reduce the risk of exposure for health care personnel, universal OR respiratory precautions would provide a better, more effective approach than current standard practices.

In addition to detecting potential acute disease, there is now emphasis on antibody testing to determine if individuals have had COVID-19 and recovered. Although these tests may detect an antibody response to a possible virus infection, it is not known yet if the measured antibodies can effectively prevent infection. Thus, even if patients or health care personnel have serology tests suggestive that they have recovered from COVID-19, there is no assurance that they cannot become reinfected with SARS-CoV-2. Until the value of serology tests is established, all health care personnel should follow recommendations for the use of appropriate PPE to avoid COVID-19 infection irrespective of serology results.

Rationale for Universal Respiratory Precautions

COVID-19 is primarily a respiratory disease. Transmission through droplets and aerosolization seem most prevalent; therefore, strategies should address these 2 modes of transmission. Respiratory droplets can be projected in turbulent clouds that may travel distances as far as 25 feet from a patient and the turbulent cloud may ensure a moist environment facilitating survival of the virus particles for unknown periods.4 Consistent with this observation is the finding of SARS-CoV-2 on PPE and air ducts of rooms housing patients with COVID-19 and possible transmission via an air-conditioning system.5,6 OR personnel should assume that the chance of SARS-CoV-2 acquisition is highest during close contact with the patient and during procedures that generate fine aerosols.7 However, because SARS-CoV-2 can be found in body fluids,2 OR personnel should take care to avoid exposure to the virus from aerosolization that occurs during surgery from electrocautery and venting of insufflation gases. Adherence to universal OR respiratory precautions should effectively minimize the risk for OR personnel becoming exposed to SARS-CoV-2 from patients.

Implementing Universal OR Respiratory Precautions

The future course of COVID-19 is unknown. Currently, some regions have very little disease and adopting additional protective mechanisms against COVID-19 beyond what is currently used might not be necessary. However, COVID-19 spreads through a community for weeks before patients develop symptoms. Even if there is little disease now, there is no assurance this will be the case in the future. Conceivably, OR personnel could be unwittingly exposed to COVID-19 when asymptomatic patients are shedding virus before a community learns that COVID-19 is present.

The additional use of PPE, specifically N95 respirators, could limit implementation of universal OR respiratory precautions. These respirators should become more widely available as production and supplies increase, and a recent report indicates that N95 respirators can be reprocessed.8,9


Scheduled surgery has stopped in much of the US because of COVID-19. Because some patients whose surgical procedures are delayed may develop urgent clinical problems or progressive disease, finding a way to resume surgery is a high priority. Potential exposure of OR personnel to SARS-CoV-2 is one reason surgery has been shut down. Adopting universal OR respiratory precautions should reduce the risk for OR staff to develop COVID-19 and might facilitate an earlier resumption of elective surgery.

OR staff performing invasive procedures are often asked to potentially risk exposure to numerous communicable diseases. To date, most of these have been blood-borne related and the staff members are protected by adopting the appropriate standard precautions against these pathogens. In this unprecedented time of the COVID-19 pandemic, understanding of disease characteristics and transmission dynamics of SARS-CoV-2 is just beginning. Facilities should consider adoption of a universal precaution protocol for respiratory infections in the OR because it offers a path to mitigate the risk of exposure to SARS-CoV-2 and protect the most important resource in health care: physicians, surgeons, nurses, and other health care personnel.

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Article Information

Corresponding Author: Edward H. Livingston, MD, JAMA, 330 N Wabash Ave, Chicago, IL 60611 (edward.livingston@jamanetwork.org).

Published Online: May 7, 2020. doi:10.1001/jama.2020.7903

Conflict of Interest Disclosures: None reported.

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2 Comments for this article
Universal Respiratory Precautions in the COVID-19: A Requisite for Patient Protection
Robert Whittington, M.D. | Columbia University Irving Medical Center
I enjoyed reading the JAMA Viewpoint article entitled "Surgery in a Time of Uncertainty- A Need for Universal Respiratory Precautions in the Operating Room” authored by Dr. Edward Livingston. I am an anesthesiologist in NYC, and this article was indeed timely as we are currently developing strategies for the safe, successful resumption of elective surgery. I fully agree with Dr. Livingston's opinion that Universal Precautions must be the standard approach taken, as we resume elective surgery for the reasons highlighted in this article.

I wish to make one additional point. We need to think of the exposure risk
as being bi-directional. There is the possibility that an asymptomatic or mildly symptomatic healthcare worker could transmit COVID-19 to a patient presenting for elective surgery. There have been reports of cases in the NYC area where asymptomatic healthcare personnel were tested and were found to be COVID-19 positive. Also, as we enter the flu season later this year, I can foresee a situation where a mildly symptomatic colleague with COVID-19 mistakes their symptoms for the common cold. Hence, it is imperative that healthcare personnel not only take universal precautions, but that these precautions must include properly fitting PPE, especially N95 masks.

Government regulations regarding “Fit Tests” were recently relaxed in March, as these tests could not be reliably performed during the pandemic for practical reasons. However, now that we are no longer in the midst of a “surge”, we must make sure that this PPE (especially N95 respirator masks) is appropriately safe before proceeding with elective surgery. As hospitals are being inundated with N95 masks from a myriad of manufacturers, it is critical that some system be developed to ensure proper N95 mask fit. Furthermore, we should no longer accept the reuse of N95 masks as standard issue PPE. This is a requisite to ensure the safety of the healthcare personnel as well as our patients. The best way to achieve this level of safety is indeed by adopting Universal Precautions properly. I thank Dr. Livingston for effectively addressing a major concern of many of us practicing in regions of the U.S. that were especially devastated by the COVID-19 pandemic.
Resuming Elective Surgery during COVID-19 pandemic
Raju Vaishya, MS, MCh, FRCS | Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, INDIA
We read with interest the Viewpoint on ‘Surgery in a Time of Uncertainty’ (1), being surgeons ourselves. It is well-known that routine surgery of almost all types has been abandoned across the globe during the pandemic of COVID-19. This has happened mainly because of the assumption that invasive surgery, especially under general anesthesia (with intubation), may potentiate viral transmission from an established or asymptomatic case of COVID-19 to operating room (OR) staff and other healthcare workers, though there is no significant proof of this assumption so far. It has also been advised that all patients undergoing surgery must have a preoperative test for COVID-19, to protect OR staff. However, it has not been emphasized enough to test all OR staff on a regular basis to protect patients and their colleagues, as these staff may also be asymptomatic carriers. Hence, we advocate that all healthcare workers, including the OR staff must have COVID testing on a regular basis to prevent viral transmission, especially from asymptomatic carriers. It becomes more important as it has been reported that almost 50-70% of the population is an asymptomatic carrier (2).

We believe the time has now come to start thinking of resuming routine surgery in a gradual fashion, since many patients requiring surgery are waiting for long enough and are suffering with pain and the progression of their disease and its consequences. Hence, adequate planning and strategies need to be developed to resume surgical work in various specialties safely, with an important aim being to the maintain safety of our patients and the staff. It is therefore vital that the hospitals planning to undertake surgical work must have adequate infrastructure and resources to deal with these critical cases (3). There is a debate on the type of OR ventilation system which may be the best for the current crisis. The use of laminar flow theatres may provide a protective effect for staff and patients with controlled airflow and high air change rates, but some studies suggest the use of negative pressure rooms to reduce risk of contamination of adjacent areas, with microbial loads within the operating room remaining comparable to positive pressure systems (4). We believe that these ventilation system considerations in isolation are not enough to protect staff and patients and the compulsory use of Personal Protective Equipment (PPE) in the OR is absolutely mandatory by all staff, especially during orthopedic and trauma surgery. Here, an increased exposure to aerosols is expected by the use of electrocautery, pulse lavage, orthopedic procedures (e.g. drilling, sawing, reaming etc.) We concur with the author that universal OR respiratory precautions must be adopted to reduce risk to OR staff and help facilitate earlier resumption of elective surgery (1).

We are of the view that an attempt should be made to resume operative work in a gradual fashion, with due safety precautions. During the ongoing crisis surgical procedure requiring minimal invasion and shorter operative times should be preferred over complex and long surgeries and those which are likely to generate a significant amount of aerosols (3).


1. Livingston EH. Surgery in a Time of Uncertainty: A Need for Universal Respiratory Precautions in the Operating Room. JAMA. Published online May 07, 2020. doi:10.1001/jama.2020.7903.
2. Gandhi M, Yokoe DS, Havlir DV. Asymptomatic Transmission, the