Canadian warning: ORs should prepare for SARS

After a group of severe acute respiratory syndrome (SARS) patients in Toronto in 2003 was tracked to a surgical patient,1 health care providers there realized no guidelines from international or U.S. groups addressed how to handle SARS patients or avoid SARS transmission in the OR.2

After the initial discovery of a cluster of SARS patients in Toronto, a second cluster was discovered May 23, 2003.1 The second cluster was traced to a patient who had undergone surgery for a fractured pelvis in a hospital April 19, 2003. The patient developed SARS while in the hospital, but it was managed as post-op pneumonia. The patient infected several other hospitalized patients, which eventually resulted in 118 additional SARS cases.

SARS is spread easily, warns Philip Peng, MBBS, FRCPC, director of the Anesthesia Chronic Pain Program at University Health Network and Mount Sinai Hospital and associate director of the Wasser Pain Management Center at Mount Sinai, both in Ontario, Canada.

"All it took for the unprecedented health crisis in Toronto to occur was a delay in isolation of a single case of SARS patients, and the initial precautionary measure against that woman was deemed standard at that time," he says. Peng has published Routine Precautions for Non-Severe Acute Respiratory Syndrome Patients in the OR and Management of SARS Patients in the OR.

There is no reason to believe that SARS will not come back, Peng emphasizes. Anesthesia providers particularly are at a high risk of being infected with SARS because of their frequent exposure to patients’ oral and respiratory secretions, especially during tracheal intubation.2 SARS is spread by droplets and contact.

"Most of the patients will receive general anesthesia in the OR, and the risk of spread of droplets is very high during the process of instrumentation of the airway," he says. "A new set of guidelines such as what we proposed . . . is needed to prevent the spread of SARS."

SARS is "incredibly disruptive" in every area of the facility, says Ross Edward Grant Upshur, MD, director of the primary care research unit in the department of family and community medicine at Sunnybrook and Women’s College Health Sciences Centre Toronto. Upshur also has authored an article on SARS. (Bevan JC, Upshur REG. Anesthesia, ethics, and severe acute respiratory syndrome. Can J Anesth 2003; 50:977-982.)

"The big lessons are to be prepared and make sure infection control practices are in place and well understood by everyone," he says.

When SARS or a similar infectious disease arises at your facility, it is critically important to have clear communication and collaboration between public health, your infection control staff, and the frontline clinicians, Upshur points out. "We’ve had to learn the hard way," he says. "That’s the way you don’t want to learn."

In Canada, the level of communication and coordination following the SARS outbreak was suboptimal, Upshur adds. "We had multiple people giving directives," he says. "What you need is a clear path of communication, so everyone is on the same page and knows what to do."

Consider these other suggestions:

• Follow standard infection control guidelines rigorously.

What particular steps should you take to avoid SARS transmission? "Vigilance, vigilance, and vigilance," Peng says. Years before the SARS outbreak, Health Canada, the Canadian department responsible for helping the people of Canada maintain and improve their health, had a set of guidelines for patients who might spread of respiratory secretion, he says. "It was seldom followed," Peng adds.

In Hong Kong, health care workers who were infected with SARS usually did not follow the precautionary measures completely, he says.

"We can suggest the most stringent measures, but ultimately, the vigilance of the individual is the most important factor," Peng says.

For example, providers must be vigilant in taking off special protective covering, including hoods and the double gowns, he says. "It is very easy to recontaminate oneself," Peng says.

Also, clinicians may hear their pagers beeping and use their glove-covered fingers to stop the pager, he says. "The pager is then contaminated," Peng says.

The risk of spread of droplets is highest when an infected patient coughs, Peng says. "You can put the best available protective mask on patients with SARS when they cough," he says.

• Use personal protective equipment properly.

When handling potentially infectious patients, "it takes time, training, and assistance to put on the personal protective equipment and the PAPR [powered air-purifying respirator, EM, Berkshire, UK] system properly," Peng says.

Advance warning of such a patient in need of tracheal intubation is required to prepare properly, he says. Keep in mind that it is difficult to communicate with each other due to the noise generated by the high flow through the PAPR system, Peng says. "This noisy environment may cause errors due to its potential for miscommunication," he adds.

Also, the personal protective equipment must be removed in the proper sequence to avoid contamination, Peng says. "An extra [person] is required for the removal of PAPR to prevent contamination," he adds.

For OR personnel who don’t think SARS could spread within their facility, Upshur offers this advice: "Don’t be so naïve. If it’s not SARS, it will be the next infectious disease emergency," says Upshur, who points to West Nile, influenza, and other infectious diseases that have spread rapidly in recent years.

"OR people are good about infection control — that’s their bread and butter," he says. "But we need to be vigilant at all times."


1. Spurgeon D. Toronto succumbs to SARS a second time. BMJ 2003; 326:1,162.

2. Peng PWH, Wong DT, Bevan D. Infection control and anesthesia: Lessons learned from the Toronto SARS outbreak. Can J Anaesth 2003; 50:989-997.


For more information on severe acute respiratory syndrome in the OR, contact:

  • Philip Peng, MBBS, FRCPC, Director, Anesthesia Chronic Pain Program, University Health Network and Mount Sinai Hospital, Toronto. Phone: (416) 603-5118. Fax: (416) 603-6494. E-mail:
  • Ross Edward Grant Upshur, MD, Department of Family and Community Medicine, Sunnybrook and Women’s College Health Sciences Centre, Room 3349B, 2075 Bayview Ave., Toronto, ON, M4N 3N5, Canada. E-mail: