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FAQ ON ANESTHESIA MACHINE USE,

PROTECTION, AND DECONTAMINATION
DURING THE COVID-19 PANDEMIC

Contributor: Jeffrey Feldman MD, APSF Chair of Committee on Technology

Disclaimer: We aim to present our recommendations and a forum for questions. Given the novelty
of COVID-19, best-available clinical evidence is supported from anecdotal reports from China,
South Korea, Italy and previous epidemics like SARS and MERS. The APSF does not support or
endorse any specific product, equipment or trademarked technique. We strongly promote
consistency with your governing bodies and organizations such as the CDC, WHO, ASA, AANA,
and AAAA.

What is the best strategy for protecting the anesthesia machine from contamination by a
potentially infected patient?

What type of breathing circuit filter is likely to prevent passage of the SARS COV-2 virus
from the patient to the anesthesia machine?

Do I have to worry about transmitting the SARS COV-2 Virus from the Anesthesia Machine
to a patient?

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 Should the sampled gas be returned to the breathing circuit or scavenger?

Do I need to replace the water trap for sampled gas after each patient?

What is the proper method of cleaning the anesthesia machine between patients, including
patients potentially infected with SARS COV-2?

Do the internal components of the anesthesia machine ever need to be

decontaminated/sterilized?

How can the internal parts of the machine be sterilized?

CAN AN ANESTHESIA MACHINE BE USED AS AN ICU VENTILATOR?

What is the best strategy for protecting the anesthesia machine from
contamination by a potentially infected patient?
Short Answer: Place a “high quality*” HMEF (heat and moisture exchange filter) between the
breathing circuit and the patient’s airway and a viral filter between the expiratory limb and the
machine.

The good news is that this is the same precaution for all patients. The strategy is not different
depending upon the patient’s risk of infection. A “high quality*” HMEF (heat and moisture
exchange filter) placed between the breathing circuit and the patient’s airway will protect the
machine from contamination. The gas sampling line should be connected to the HMEF on the
machine side of the filter to insure sampled gas is not contaminated as it enters the gas analyzer.
This is a very important recommendation as it will prevent internal contamination of the machine.

It is a common practice to add another filter between the expiratory limb of the circle system and
the machine. In theory, this is not necessary if the primary filter is completely effective, but is a
reasonable backup to protect the machine from any particles that pass the primary filter. Given the
fact that the primary filter can become less effective if soiled, the backup filter is a good
recommendation. Adding another filter between the machine and the inspiratory limb is also done
sometimes but is not necessary to protect the machine from the patient, nor protect the patient if
the machine is kept clean.

^ Back to Top

What type of breathing circuit filter is likely to prevent passage of the SARS
COV-2 virus from the patient to the anesthesia machine?

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 Short Answer: A pleated (mechanical) high efficiency HMEF that is highly effective for particle
sizes as low as 0.1 microns.

There are no data testing the efficacy of breathing circuit filters for preventing infection from SARS
COV-2. The information presented here is based upon the best reference material identified to
date. Pleated (mechanical) filters are more effective than electrostatic filters. As the surface area of
the filter increases, the filtration efficiency increases, but the dead space increases as well which
can be a problem in small patients. Simply choosing a “HEPA” filter may not be sufficient since that
definition applies to filters that have an efficiency of 99.97% for particles greater than 0.3 microns.
Commercially available filters typically have specifications describing the filtration efficiency for
both bacteria and viruses. In some cases, the efficiency for filtering even smaller sodium chloride
particles is also reported. The coronavirus is approximately 0.125 microns which is similar in size to
the influenza virus. Recommendations for filters to be used during an influenza pandemic include a
high quality viral HMEF on the airway and at the exhalation port of the ventilator. In the absence of
evidence for the minimum acceptable filtration performance, it makes sense to select a pleated
filter that is highly effective for particle sizes as low as 0.1 microns.

APSF does not promote any particular product or manufacturer. For reference, the following are
some sources for filters that would satisfy the requirements described above. Additional resources
will be added as they become available.

Draeger Medical: Breathing Filter/ HME Guide [PDF] (https://www.apsf.org/wp-

content/uploads/patient-safety-resources/covid-19/Dräger-Breathing-Filters-HMEs.pdf)

SafeStar Filter Information [PDF] (https://www.apsf.org/wp-content/uploads/patient-safety-

resources/covid-19/Dräger-Filter-SafeStar.pdf)

PALL: https://medical.pall.com/en/mechanical-ventilation/coronavirus.html
(https://medical.pall.com/en/mechanical-ventilation/coronavirus.html)

Medtronic: https://www.medtronic.com/content/dam/covidien/library/us/en/product/ventilator-
filters/dar-sales-sheet.pdf
(https://www.medtronic.com/content/dam/covidien/library/us/en/product/ventilator-filters/dar-
sales-sheet.pdf)

A NOTE ON PEDIATRIC PATIENTS:

HMEFs that minimize dead space are typically used for pediatric patients. If the dead space of the
filter is less than about 70 mls, the filtration efficiency is reduced. Although these filters are still
highly rated for viral filtration efficiency, they are not as good as larger adult filters. It is not clear at
this time if the decreased efficiency is less protective or not. High quality HMEFs that have
appropriate dead space for small patients should continue to be used. This information will be
updated if additional evidence is discovered.

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 References:

1. Wilkes, A. R. (2002). Measuring the filtration performance of breathing system filters using
sodium chloride particles. Anaesthesia, 57(2), 162–168.

2. Wilkes, A. R. (2010). Heat and moisture exchangers and breathing system filters: their use in
anaesthesia and intensive care. Part 1 – history, principles and efficiency. Anaesthesia, 66(1),
31–39.

3. Wilkes, A. R. (2010). Heat and moisture exchangers and breathing system filters: their use in
anaesthesia and intensive care. Part 2 – practical use, including problems, and their use with
paediatric patients. Anaesthesia, 66(1), 40–51.

4. Fehr, A. R., & Perlman, S. (2015). Coronaviruses: An Overview of Their Replication and
Pathogenesis. In Coronaviruses (Vol. 1282, pp. 1–23). New York, NY: Springer New York.

5. Sprung, C. L., Zimmerman, J. L., Christian, M. D., Joynt, G. M., Hick, J. L., Taylor, B., et al. (2010).
Recommendations for intensive care unit and hospital preparations for an influenza epidemic or
mass disaster: summary report of the European Society of Intensive Care Medicine’s Task
Force for intensive care unit triage during an influenza epidemic or mass disaster. Intensive
Care Medicine, 36(3), 428–443.

^ Back to Top

Do I have to worry about transmitting the SARS COV-2 Virus from the
Anesthesia Machine to a patient?
Short Answer: As long as the machine is protected during every case with high quality filters as
described in the previous FAQs there is no risk to subsequent patients.

None of the manufacturers are recommending cleaning procedures that involve the internal
components of the machine as long as high quality filters are used with each patient to prevent
exhaled virus from entering the machine and gas sampling lines are connected to the machine
side of the filter.

^ Back to Top

Should the sampled gas be returned to the breathing circuit or scavenger?

Short Answer: Gas sampled from the machine side of an HMEF is not contaminated and can be
returned to the breathing circuit or the scavenging system.

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 Inspired and expired gases should be routinely sampled during anesthesia care for measurement
of gas concentrations. HMEFs are readily available that include a port for sampling gas on the
machine (protected) side of the filter. Gas can then be routed through the gas analyzer to either
the breathing circuit or scavenging system, there is no risk of contamination. Routing gas back into
the breathing circuit has the advantage of reducing waste.

If the gas sampling line is connected to an elbow or other connector on the patient side of the
HMEF, for example to obtain a better capnogram, potentially contaminated gases will enter the gas
analyzer typically through a water trap. There is a filter in the water trap but the typical
specifications for these filters are not available at the time of this writing and will be updated as
they become available. If the HMEF is bypassed by the sampled gas, it is recommended that
sampled gas not be returned to the breathing system.

^ Back to Top

Do I need to replace the water trap for sampled gas after each patient?
Short Answer: No, if the sampled gas passed through a high quality HMEF before entering the
water trap.

The water trap has a continuous flow of gas from the patient into the machine. If that gas was
filtered by an HMEF, the water trap is not contaminated and does not need to be changed. It is
recommended to change the gas sampling tubing and wipe off the external surface of the water
trap between patients.

If the water trap should become potentially contaminated by sampled gas that did not pass
through an HMEF, it is a good idea to change the trap.

Water traps should, of course, be changed according to the recommended schedule.

^ Back to Top

What is the proper method of cleaning the anesthesia machine between

patients, including patients potentially infected with SARS COV-2?
Short Answer: Cleaning procedures are the same for all patients if a high quality HMEF is
placed between the circuit and the airway. Discard disposable items – breathing circuit,
reservoir bag, gas sampling tubing, mask and wipe all exposed surfaces. Manufacturers’
cleaning recommendations are useful for individual devices.

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 As noted previously, a high quality HMEF as described above will protect the internal components
of the anesthesia machine from contamination. Single use items must be discarded and not used
between patients. Practices of using an HMEF and reusing the breathing circuit between patients
should be abandoned in part because it is virtually impossible to decontaminate the external
surfaces of the circuit. Manufacturers typically have recommendations for cleaning solutions that
are safe and effective for cleaning between patients. Usual practices for surface cleaning are
acceptable.

References:

1. GE devices: https://www.gehealthcare.com/support/support-documentation-library
(https://www.gehealthcare.com/support/support-documentation-library). The Cleaning and
Sterilization manuals are found when searching for document type “User and Operator Manual”
or click HERE (https://customer-doc.cloud.gehealthcare.com/#/cdp/dashboard/2067226-001/D).

2. Draeger devices: Draeger has issued documents guiding cleaning procedures for their devices.
These documents can be found here:

Draeger Letter Response Regarding SARS-CoV-2 and Anesthesia Workstation [PDF]

(https://www.apsf.org/wp-content/uploads/patient-safety-resources/covid-19/SARS-CoV-2-
and-Handling-of-Dräger-Anesthesia-Workstations.pdf)

Draeger Cleaning Guide [PDF] (https://www.apsf.org/wp-content/uploads/patient-safety-

resources/covid-19/Dräger-Cleaning-Agent-Guide-Recommended-Cleaning-Solutions.pdf)

In the event a hospital has questions regarding cleaning following the review of the IFU, we ask
that they contact their respective Draeger representative, or our 24×7 hotline at 1-800-4-DRAGER.

3. Mindray devices: Pending

^ Back to Top

Do the internal components of the anesthesia machine ever need to be

decontaminated/sterilized?
Short Answer: No, if recommended practices are followed. The only time this may be needed is
when an HMEF is not used, or fails to protect the machine from internal contamination, e.g.
overwhelmed by patient secretions.

If internal contamination of the machine is suspected, the manufacturers’ recommendations for

cleaning and sterilization should be followed. This can be a time consuming, labor intensive
process, and may result in keeping the machine out of service longer than desired. In short, it

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 should be avoided if at all possible. Placing a filter between the expiratory limb and the machine
can help if the HMEF fails and avoid having to clean and sterilize the internal components of the
machine.

^ Back to Top

How can the internal parts of the machine be sterilized?

Short Answer: Follow the manufacturer’s recommendations.

^ Back to Top

Can an Anesthesia machine be used as an ICU ventilator?

Short Answer: Anesthesia machines generally have highly capable ventilators that should meet
the needs of a large majority of patients with respiratory disease requiring mechanical
ventilatory support. Anesthesia professionals should provide consultation and support to
insure that anesthetics are not delivered by mistake and ventilator settings are managed
properly.

ICU ventilator shortages are expected to be a problem if the number of infected people with
ventilatory failure exceeds the supply of ventilators. Using an anesthesia machine as an ICU
ventilator is considered an off label use but certainly should be considered as a life-saving
intervention. Each institution will need to determine how best to logistically use the anesthesia
machines for long term mechanical ventilation. Existing procedures for ICU ventilators for long
term humidification and replacement of filters and breathing circuits should be applied to the
extent possible. Anesthesia professionals should be involved with modifying procedures and
helping to manage the use of the device. At the time of this writing, manufacturers are expected to
provide additional guidance on this topic.

^ Back to Top

Patient Safety Resources

Patient Safety Resources (https://www.apsf.org/patient-safety-resources/)

Novel Coronavirus (COVID-19) Resource Center (https://www.apsf.org/novel- "

coronavirus-covid-19-resource-center/)

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 coronavirus-covid-19-resource-center/)

Perioperative Considerations for the 2019 Novel Coronavirus (COVID-19)

(https://www.apsf.org/news-updates/perioperative-considerations-for-the-2019-
novel-coronavirus-covid-19/)

FAQ on Anesthesia Machine Use, Protection, and Decontamination During the

COVID-19 Pandemic (https://www.apsf.org/faq-on-anesthesia-machine-use-
protection-and-decontamination-during-the-covid-19-pandemic/)

RAPID Response to questions from readers (formerly Dear SIRS)

(https://www.apsf.org/rapid-response/)

Current Anesthesia Drug Shortages (https://www.apsf.org/anesthesia-drug-

shortages/)

Perioperative Multi-Center Handoff Collaborative (https://www.apsf.org/patient-

safety-resources/perioperative-multi-center-handoff-collaborative/)

Clinical Safety Tools (https://www.apsf.org/patient-safety-resources/clinical-safety- #

tools/)

Helpful Links (https://www.apsf.org/patient-safety-resources/helpful-links/)

APSF Video Library (https://www.apsf.org/videos/)

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