Box 1.

Suggested intubation/extubation protocol for a normal operating room (non-ISO3.4).

1. intubation to be performed only with anaesthetist, one surgical doctor and anaesthetic unit (AU) nurse present in the OR. (Note: surgeon to wear N95 if assisting in intubation)

2. All personnel in the OR during intubation should be with N95 and eye protection.

3. Surgical team complete ’Sign-in’, then vacate OR; only anaesthetic team to remain in OR during intubation/aerosol-generating procedure.

4.Anaesthetist to announce "Clear OR, intubation now" to vacate personnel out of OR during intubation. No vendors allowed in OR till support is required.

5. For all non-laparoscopic surgeries: the surgical team must wait 5 min after intubation to allow clean scrub of air. (Note: The OR performs 25 cycles of air exchange per hour; 100% clean air will be circulated in OR within 2.5 min; the 5 min allowance will ensure 2 cycles of air exchange are performed). Operation to proceed with surgical masks.

6. Extubation to be done only with anaesthetist team in OR. Anaesthetist to announce "Clear OR, extubation now" to initiate extubation. The rest of the surgical team to vacate the OR.

7. Anaesthetist to announce "Extubation complete" after patient is full extubated. The rest of the surgical team to wait 5 min after extubation before entering OR.

8. For all elective and emergency laparoscopic surgeries: All staff in laparoscopic surgeries to be in N95 throughout the case and can remain in OR during intubation and extubation.

9. Doors (OR main door and scrub door) are locked at induction of anaesthesia and will remain so until 15 min after deflation of pneumoperitoneum; circulating nurse to start timer countdown for 15 min. Doors to remain closed until 15 min is up.

10. Upon final deflation of pneumoperitoneum, circulating nurse to start timer countdown for 15 min. Doors to remain closed until 15 min is up.

11. During extubation, staff in N95 can remain. OR doors to remain closed till 5 min after end of extubation.