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procedures increase the odds of transmitting an acute respiratory infection to the surgical team by six-fold. The Anesthesia Patient Safety Foundation (APSF) recommends distancing in the post-anesthe- sia care unit from patients who are coughing or sneezing repeatedly due to airway irritation. These patients might require an enclosed room with limit- ed personnel who practice full airborne precau- tions, according to the APSF. Of course, many out- patient surgery facilities have limited space avail- able to allocate for this kind of use. The recommen- dation, though, underscores the importance of reducing patient coughing to the extent possible. A practice that may help stem patient coughing in the OR or recovery unit is pulling the endotracheal tube or extubating while the patient is still asleep in the OR. By replacing the endotracheal tube with a less invasive device, coughing can be limited as the patient emerges from anesthesia. One such option is a pharyngeal airway device with tubing long enough to stent open the airway, but short enough that coughing and gagging are reduced when it is removed from a waking patient. This type of airway management tool also can maintain a patient airway without the need for a chin lift or jaw thrust, reduc- ing prolonged patient-provider contact. During the administration of general anesthesia, oxygen is supplied through the anesthesia gas machine circuit that connects either to a mask, laryngeal mask airway (LMA) or endotracheal tube. Air leakage around a mask or LMA with positive pressure ventilation, along with the process of intu- bating and extubating, can increase viral spread and surgical team exposure. The type of oxygen delivery and flow rate deter- mines the possibility of aerosol generation and how far droplets travel. Oxygen delivery modes depend on the procedure and anesthesia depth, which ranges from minimal sedation to general anesthesia. Sedation anesthesia typically involves delivering oxygen through nasal cannula, an oxygen mask or pharyngeal airway device. When nasal cannulas are the oxygen source, the patient's nose and mouth are completely uncovered and exposed. Droplets in exhaled air jets can result in potentially infectious aerosols. To help prevent airborne pathogen spread, patients using nasal cannulas should wear a surgical mask when practical. With any oxygen delivery device, oxygen flow rates should be kept to the low- est possible levels to maintain saturation while min- imizing aerosol spread. Masks developed for certain procedures can be helpful, too. In the endoscopy suite, for example, a mask created for endoscopic procedures features a port that accommodates the endoscope. The mask enables higher FiO 2 delivery, while serving as a sim- ple barrier. Oxygen face masks can help act as a mechanical barrier when patients cough or sneeze. Another recommendation from the American Society of Regional Anesthesia and Pain Medicine suggests using regional anesthesia rather than gen- eral anesthesia given the high risk of aerosol gener- ation during administration of the latter. Regional anesthesia with deep sedation provides patient comfort and depression of consciousness while pre- serving spontaneous ventilation. Regional anesthe- sia and sedation/monitored anesthesia care (MAC) are associated with lower risk of postoperative complications than general anesthesia. With any MAC, anesthesia providers must have the appropri- ate PPE available if an unsuccessful anesthetic quickly requires converting to a general anesthetic. Keeping the patient safe and comfortable while minimizing risk is an appropriate goal. An uncertain future No one knows which COVID-driven practices will continue after the pandemic ceases to be at the forefront of our thinking. Today, though, anesthesia providers and their clinical colleagues can do a great deal to help mitigate the spread of COVID-19 when caring for surgical patients. With procedures continuing across the country and the U.S. heading into the respiratory illness season of colds, flus and COVID-19, now is a good time to implement and refine practices that might not have been applied in the early months of the pandemic. As we learn more, we can provide safer and better care — together. OSM Dr. McMurray (rmcmurra@umn.edu) is a CRNA and educator in the anesthesia program at the University of Minnesota in Minneapolis. N O V E M B E R 2 0 2 0 • O U T P A T I E N T S U R G E R Y . N E T • 7 5