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| REVIEW ARTICLE |
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| Year : 2020 | Volume
: 6
| Issue : 3 | Page : 163-175 |
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Surgery in Covid 19 Times: A Comprehensive Review
Lovenish Bains1, Anurag Mishra1, Lalit Gupta2, Rajdeep Singh1, Pawanindra Lal1
1 Department of Surgery, Maulana Azad Medical College, New Delhi, India
2 Department of Anesthesia, Maulana Azad Medical College, New Delhi, India
| Date of Submission | 20-Jul-2020 |
| Date of Decision | 14-Sep-2020 |
| Date of Acceptance | 24-Sep-2020 |
| Date of Web Publication | 16-Dec-2020 |
Correspondence Address:
Lovenish Bains
Associate Professor, Department of Surgery, Maulana Azad Medical College, New Delhi
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/mamcjms.mamcjms_83_20
The problems faced by surgeons are unique during the Covid pandemic. In the absence of concrete information, we have to resort to extreme degrees of precautions during surgery. Precautions have to start from the point patient enters the hospital, to the point he is discharged. Changes in the patient flow and having sanitization protocols can help in this regard. Since the epidemiology of SARS-Cov 2 is still evolving, the consent process has to necessarily include the risks involved. Preoperative testing is not full proof and the increased risk for the COVID positive patient undergoing surgery has to be communicated. The operating room has to be modified with regard to the number of air changes, an aspect which the surgeons were unaware of prior to this pandemic. Changes in the follow-up protocol, such as use of telemedicine, will help minimize patient contact.
Keywords: COVID 19, surgery, laparoscopy, anesthesia, triage, operation theatre, PPE, safety
How to cite this article:
Bains L, Mishra A, Gupta L, Singh R, Lal P. Surgery in Covid 19 Times: A Comprehensive Review. MAMC J Med Sci 2020;6:163-75 |
| Introduction | |  |
The Covid-19 crisis has affected all medical professionals. In the absence of complete information about the epidemiology of the virus, surgical specialties have been left wondering about what is the best way to ensure safety for the patient and healthcare professionals. Apart from dire emergency and obstetric cases, all elective surgical procedures were put on hold during the lockdown. The high risk to anesthesiologists is obvious. Similarly, ear, nose, and throat (ENT) professionals and Endoscopists are expected to be at high risk. But the risk from blood and other bodily fluids is not known for sure. To be on the safe side, most recommendations include personal protective equipment (PPE) for the operating team also, although this is not based on evidence. Soon we will have to start surgical services for the community, despite the fact that the virus is expected to persist for at least a year, albeit at a low level. Surgical societies all around the world, including India, have been working on this issue and have come out with guidelines.[1],[2] The Intersociety guidelines for Minimal Access surgery and Indian society of Ansthesiologists advisory in India is a case in point.[3],[4] The pertinent issues facing surgeons and anesthesiologists are discussed here, expecting that it will help them to start procedures in a safe working environment.
| Minimize Patients Coming to Hospital and Crowding | | |
The main strategy in any hospital and so in surgical practice is to avoid unnecessary crowding in hospital and all its areas including outpatient department (OPD), wards, and operating rooms. Various strategies need to be in place to achieve this and still ensuring continued satisfactory patient care and follow-up.
Telemedicine
Telemedicine is a boon in such a time and most of the clinicians are turning to use this tool. Initial screening as well as follow-up can easily be conducted using telemedicine. Initial screening can help in broadly defining the problem and referring to concerned specialty.[5] It will also help in drafting clinical plan even before patient’s first visit, hence minimizing repeated contacts. When the proper plan is in place and goals of the patient’s in person appointment defined, clinicians can use the time more efficiently. The follow up, similarly can be via telemedicine or messaging like Whatsapp, etc. Public have very easily adjusted to messaging-based communication and healthcare can also tap into this utility.[6]
Proper instructions
Crisp and easy to understand messages can be drafted and delivered to patients as per plan. Also a dedicated line should be available to sort out queries of patients, if any.
Zonal hospitals/CHC to take care of the population with sound referral (telephonic)
Authors believe that if the health care follows a tier plan where patients are screened by a local hospital, which can manage most of the day-to-day problems. Only for complex issues they may be properly referred to a higher center. This will unload lot of patient number from tertiary care and also it will provide a reliable and convenient healthcare for the public.[7]
Token/appointment system and time effectiveness
For OPD, hospitals need to decide number of appointments it can handle and patients should be given time-slot based appointment. It will certainly reduce crowd at any given time and maintain good overall attendance. Strategies must be made to minimize time in waiting for patients. Using health technology or other methods such as centralized appointment scheduling with coordinated efforts among departments can aid patient experience and utilize time effectively.
Medicines from nearby dispensary
Another area where lot of crowding happens is in medicine dispensing areas where patients queue up to receive prescribed medicines. The hospitals can create a network of pharmacies (e.g., CGHS dispensaries) to dispense medicines based on prescription.
Minimum attendants
In any typical hospital, the ratio of attendants to patient is 3 to 4 for one patient. This has to be changed favorably by strongly implementing one patient-one attendant policy. However, the hospital needs to be patient friendly in order to achieve this. Also good number of hospital staff must be available to help patients in times of need.
| Screening and Triage | | |
All visitors and patients to be screened for fever/travel/contact for ‘stealth transmission’
All persons who are entering hospital should be screened for symptoms of coronavirus disease (COVID 19). The screening area must be located at entrance or just outside the entrance to the building; it helps by reducing exposures for other patients and healthcare personnel, helps prevent the spread of disease within the facility and helps ensure PPE is used effectively.[7] All suspects should undergo testing as per existing protocols. Patients to be assigned to COVID/Non-COVID areas after he/she has been checked to avoid unnecessary mixing. Till the time any visitor is not cleared by screening procedures, he may be deemed as positive.[3],[9],[10] At present, screening means symptoms and temperature check (thermal screening) only, so it cannot be sure that patient is negative especially asymptomatic ones. Various screening protocol suggested are:- If supplies allow, then provide a cloth face covering or a facemask to patients not wearing the same.
- Temperature by using Infra-red thermometers/ thermal scanners: though being unreliable with high-false negativity, but still a very useful tool to screen large numbers of people.
- Rapid antigen test kit can detect positive cases with a fairly confident process in very short time (about 55%–60% accuracy with specificity of 98%).[11] Such test performed at the time of admission can help hospitals avoid mixing of Covid-19 cases with non-Covid 19.
- Proper signages and posters at entrances and in strategic places around the facility with instructions for patients with fever or symptoms of respiratory infection.
Approach and risk stratification (All cases, urgent only, emergency only)
The surgical decision in a Covid-19 positive case needs to consider the risks and benefits. At any time, the hospital needs to decide which procedures (All, only urgent, or only emergency life threatening) are allowed and which are not. It will be based on ratio between patient load of Covid-19 cases and resources (Personnel, protective equipment, etc.). Non-operative management should be considered where ever possible (such as for early appendicitis and acute cholecystitis), but with Covid-19; strategy must be worked out to start routine practice.[1],[3],[7],[12],[13] A risk stratification/triage proposed by Inter Association surgical practice recommendations in Covid-19 era, Elective Surgery Acuity Scale (ESAS) developed by American College of Surgeons and Prioritization criteria for elective surgery during Covid-19 pandemic by NHS can be utilized for triage of surgical procedures [Table 1].[3],[14],[15]
All operative/ severely sick patients to be tested
Since long and significant exposure is expected during surgery and in ICU, all cases admitted to ICU and those planned for surgery must be tested with high fidelity test like reverse transcription-polymerase chain reaction (RT-PCR) antigen test.[3] The hospital cannot afford a health care worker getting positive as it poses a danger of infection spread to other patients in hospital. If readily available and practical, surgical patients should be tested preoperatively for Covid 19.[1],[10],[13],[16]
| Patient Wards | | |
Separate self-sufficient blocks
The hospital should be designed so that Covid-19 cases are kept in a self-sufficient block. The Covid-19 block should be equipped as a hospital within hospital so that all needs of these patients are met in the block.. If this is not possible, it has to be ensured that there is no mixing of cases and area is regularly sanitized. The patients in Covid-19 ward must follow the social distancing and hygiene recommendations and have to be wearing masks. The ward design should ensure that patients can isolate themselves without hampering the patient care and monitoring. Use of cubicles with glass walls can prove very useful. When patients are kept in isolation and social meetings are not possible, their recreation can be taken in consideration. Installing Television, wireless internet, music can prove to be of great help. Interacting with patients in our hospitals, many patients pointed out this problem and when the problem was addressed them, the response was became very positive. For patient monitoring use central console for VITALS and camera surveillance is recommended. This can also avoid cross infection and still maintain standard monitoring for patients. SOS/panic buttons must be installed on every bed.
Personal hygiene
The ward hygiene has to be a high standard. Though it was always a priority but its importance is even more in these times of Covid-19. All patients also must be encouraged to participate in keeping themselves and surroundings clean. All staff and patients must be taught and retaught about self-hygiene using prerecorded videos.
Communication with attendants
As attendants are not allowed in Covid wards, the lack of family or attendant support can be a cause of their despondency. Hospital must encourage them talking to their relatives using phones, video chats and all help must be provided, if patient is unable to do it on their own. Hospitals on their own must update relatives on regular intervals using messaging/ phone calls. All efforts have to be made so that patient is discharged as soon as possible. The Enhanced recovery protocols such as Enhanced Recovery after surgery, which is proven to lower both recovery time and postoperative complication rates can be utilized.[17]
| Operation Theatre | | |
OT layout and workflow
Dedicated operation theatres (OT) to be used for all confirmed or suspected Covid 19 infected patients and should be labeled “COVID 19 Operation Theatre” with clear and large signage. The OT closest to the entrance of the OT block entrance should be the first one designated for COVID 19 patients, this will restrict movement of staff between OTs and helps in avoiding cross-contamination. The COVID 19 OT should preferably be located near high dependency unit (HDU), COVID 19 ICU, Emergency Ward with two functional lifts (one for staff on COVID 19 duty and one for other purposes). There should be preferably two OTs; one for obstetric cases with neonatal resuscitation facility and second for other general surgical operative procedures with appropriate facilities for all age groups.[4],[18],[19],[20] Donning Room with adequate PPE kits with adequate hand sensitization facility should be near to OTs and a separate doffing room to avoid mixing with donning area with adequate sanitization facility and PPE disposal as per biomedical waste management protocol should be near exit, preferably a separate exit. A short and direct path must be kept for transfer and away from other patients and people in general within the hospital in order to minimize the chances of infection. In case of transfer from other blocks or buildings within the hospital is required, a dedicated vehicle or trolley should be used with personnel wearing adequate PPEs. After transfer, the used vehicle or trolley, used lift etc must be sanitized. The patients should be wheeled directly in the OT. All operation theatre staff should wear adequate PPE including anesthetists, surgeons, nurses, technician, nursing orderly and sanitation workers as recommended.[4],[14],[16],[18],[19],[20] Once in the OT, they should not leave until the operation is completed, and once out they should not re-enter. Medical records/files must remain outside the OT and notes must be entered in the designated area after doffing. Intraoperative document consultation is to be avoided.
OT communication
A good clinical outcome is based on sound communication and teamwork. A team briefing before the start of a case is helpful, as communication is limited when using PPE and N 95 masks or similar. Therefore, the voice should be loud and the message should be clear. It is advisable that team should learn and practice sign language for easy and correct communication. Writing the name and designation on the PPE kit or N-95 with a marker helps easy identification.
Intraoperative management
The OT should be pre-equipped with supplies and instruments needed for particular surgery. The OT door must be kept closed at all times and personnel present in the OT must not leave during surgery. Electromedical devices (e.g., ultrasound) must be used with adequate protective cover and adequately sanitized at the end of the operation.
OT pressure, Air changes and Air Conditioning of OT
The mode of transmission of COVID 19 is likely via contact and droplet transmission directly or indirectly through fomites. Airborne transmission of the virus can occur in health care settings where specific medical procedures, called aerosol generating procedures, generate very small droplets called aerosols.[21] Keep minimum number of personnel in the OT with appropriate PPE, as airway manipulation is considered to be aerosol generating. OTs have been traditionally designed to have positive pressure air circulation. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can survive for days on multiple operating room surfaces, including plastic and stainless steel; therefore, OTs with negative pressure capabilities are recommended. In absence of negative pressure facility, the positive pressure system and air conditioning must be turned off. Laminar flow and the functional high-efficiency filters are preferable. In well maintained OTs 15–20 air changes per hour can take place, which corresponds to 14–18 min to ensure clean OT air for the next patient and OT staff. At 10 air changes per minute, it needs about 30 min to reduce 99% air contamination, therefore there should be a minimum of 12 air changes per hour during standard times. It must be remembered that these time estimates are based on an empty, uncluttered room, therefore infection control guidelines must be in accordance. A high air exchange cycle rate (20-25 cycles/h) contributes to effectively reduce the viral load within OTs.[2],[3],[4]
Laminar flow/air conditioners in the OT has to be started after induction of anesthesia and laminar airflow/air conditioners should be stopped 20 min before extubation. All airway devices should be removed in the OT and not in the recovery area. Next patient should be wheeled in after minimum of 30 minutes after cleaning and sanitization or minimum 1 h time gap to be given between two procedures/surgeries. one percent Sodium hypochlorite solution cleaning is recommended for OT tables and trolleys as soon as the patient is transferred.[4],[18],[22],[23]
Normally, OTs are connected by a heating, ventilating, air conditioning (HVAC) system that is of a recirculatory type, wherein the air from the OT is taken back to the air handling unit (AHU) for thermal conditioning and brought back. The same system or central system is also connected to a few other areas of the hospital. This poses a significant risk of the virus laden particles spreading out from the designated OT. In order to convert an existing OT into a COVID 19 OT, it is first necessary to change to a non-recirculatory system or AHU dedicated to Covid 19 OT only. An independent exhaust blower can be used to extract the room air and exhaust out into the atmosphere, preferably, after suitable “exhaust air treatment”. The exhaust air quantity should be greater than the supply air quantity so that a negative pressure of minimum 2.5 Pa (preferably >5 Pa) is achieved in the room. Another option can be having stand-alone room air-conditioners, the number and tonnage of ACs depend on the room size. As these ACs cause recirculation of cool air, there must be outdoor air intake through slightly open windows and exhaust by natural exfiltration or intermittent exhaust fan usage. Keep the room temperature between 24°C and 28°C and maintain relative humidity between 40% and 70%. In humid climates, set the temperature closer to 24°C for de-humidification and in dry climates closer to or at 30°C and use fans to increase air movement. This will make working somewhat comfortable while wearing PPE, especially during the summers.[3],[4],[7],[12],[19],[20],[22] Negative pressure could be created by putting up exhaust fans which will drive air out of the room. Treatment of exhaust air can be performed preferably by high efficiency particulate air (HEPA) filtration. If filtration is not possible, then the exhaust air shall be let off into the atmosphere through an upward plume at a height of 3 m above the tallest point of the building, thereby lowering the viral load concentrations to insignificant levels by dilution. For this to be achieved the exhaust outlet shall be connected to ducts reaching the top of building and away from air intake points. The other two options available for exhaust air treatment being Ultraviolet (UV) irradiation (15 min) and heating (45 min at a temperature of 75°C).[4],[19],[20],[22],[24],[25]
A recent Expert panel Consensus guideline from AMASO suggests Rule of 20 in 2020 PANDEMIC which is; [26]- 20 number of air changes per hour minimum (ideally > 25) in the theater
- 20 minutes before endotracheal intubation and extubation to keep AC and positive pressure switched off
- 20 minutes after intubation to enter OT for surgeons and nurses
- 20°C AC temperature setting
- 20 minutes minimum waiting time after patient is transferred out to start cleaning the theatre
| Anesthesia | | |
General considerations
Anesthesiologists need to participate in an encompassing and hierarchical strategy to contain COVID 19 viral transmission. They play multidimensional roles as experts in emergent airway management, acute and intensive care, and perioperative anesthesia. The care they provide imposes a significant risk to their own health. Therefore, while giving anesthesia and handling airway in corona times, few considerations are to be incorporated in anesthesia practice.[27]
Your personal protection must be the first priority. PPE should be available for all healthcare providers at all times to ensure protection from droplet/contact. Protocols for donning and doffing PPE must be well defined and already practiced. Prophylactic administration of anti-emetic drug must be a practice to reduce the risk of vomiting and viral spread before transferring the patient to OT. Place all essential drugs and equipment needed for an anesthetic management in a tray and avoid repeated handling of the drug trolley during the case. Regional anesthesia, where ever possible should be the technique of choice. A surgical mask or N95 mask must be applied to the patient throughout the length of stay in the OT. In case supplementary oxygen is needed, the oxygen mask can be applied over the surgical mask or N95 mask.[4],[28],[29],[30]
Airway manipulation and anesthesia
Always use double glove technique with disposable mask, goggles and footwear. Standard routine anesthesia monitoring to be used in every patient without any compromise to patient’s safety. Preoxygenate for 5 minutes with 100% oxygen, but avoid high flow oxygen and paraoxygenation to prevent aerosolization in general anesthesia cases. Employ anaesthetic strategies to reduce cough (IV lignocaine 1.5 mg/kg before intubation/ extubation to avoid coughing). Patient’s nose and mouth can be covered with two layers of wet gauze to block some of the secretions.[4],[28],[31]
A transparent, light-weight and durable “improvised aerosol-box” can be used to perform endotracheal intubation through the two arm-ports at the proximal end in a reasonable time-frame with shielding from droplets and macro-aerosols. Further this chamber can be connected to a suction machine to maintain relative negative pressure and reducing aerosol spill. Awake fiberoptic intubation, must be avoided unless specifically indicated as atomized local anesthetic used during fiberoptic intubation can aerosolize the virus. Video-laryngoscope (if available) should be the first choice as it may increase the distance between the patient’s airway and that of an anaesthesiologist who performs the intubation. Rapid sequence induction and tracheal intubation (with cricoid pressure) to be done in the first attempt and by the most experienced anaesthesiologist in OT. Avoid trainee intubation for sick patients Ensure adequate neuromuscular blockade to avoid bucking to prevent aerosolization. If desaturation occurs during apnea period of rapid sequence intubation (RSI), can do manual ventilation with small tidal volume breaths. The cuff of tracheal tube should be immediately inflated before starting ventilation. If first attempt at intubation is not successful, do not reattempt intubation. Use a 2nd Generation disposable intubating supraglottic device (LMA Supreme, ProSeal LMA or I-GEL)TM. Chest auscultation after intubation is not recommended − instead rely on capnography, chest movement and SpO2. The choice of induction drugs is dictated by hemodynamic considerations. Order of administering drugs must be − muscle relaxant followed by Induction agent followed by opioid. Fentanyl is recommended for analgesia. If no contraindications, succinylcholine 1 mg/kg should be administered for tracheal intubation. Use low gas flows and closed circuits. Limit the ventilatory disconnections and, if needed, do at end expiratory phase. Closed suction catheter for endotracheal suction, if required. No open tracheal suction to be done. During tracheal extubation cover the patient’s head with plastic sheath or plastic box. Extubation in deeper plane of ansthesia in a spontaneously breathing patient is recommended to reduce coughing.[4],[28],[31],[32],[33] Should tracheostomy be needed, a transparent drape can be stretched over the OT table arms or self-retaining retractors forming a barrier between the operative field and the surgeon, while still allowing for good visualization of the operative field.[34]
Surface contamination of anesthesia equipment
Contamination of the external parts of the anesthesia machine and other anesthesia equipment is always a risk in COVID surgeries. A simplified but standard protocol must be adopted to prevent surface contamination of anesthesia-related equipment. The anesthesia machine can be covered with plastic (i.e., a large plastic bag/cellophane plastic sheets,) to reduce the contamination. Patient monitor, video laryngoscope monitor, and the ultrasound machine and monitor should also be plastic covered. All used airway equipment must be sealed in a double zip-locked plastic bag. It must then be removed for decontamination and disinfection. Similar apart from external surface contamination, internal components of anesthesia machine are also liable to be contaminated, if proper measures are not taken. Two high quality Heat and Moisture Exchange Filters (HMEFs) should be used. First, between facemask and breathing circuit or between facemask and reservoir bag and the other between expiratory limb and anesthesia machine. These HME filters can remove up to 99% of airborne particles of size 0.3 microns or greater, thus are very efficient in preventing contamination of OT atmosphere from aerosoles. In children less than 20 kg, one filter should be placed on the expiratory limb of the breathing circuit, but a standard size filter should not be added at the patient end of the breathing circuit because of added dead space. In case airway filter is omitted, a filter should be placed on the inspiratory limb and separate 0.2 micron filter should be added to the gas analyzer sampling line. Fresh HEPA filters and soda lime must be used for each case. CO2 sampling line and water trap also should be changed after the case. The gas sampling tube must also be protected by a HEPA filter.[29],[30],[31],[32]
Postextubation and transfer
During transfer the team should wear proper PPE outside the operating room. The patient should be covered with one disposable operating sheet and then transferred through a dedicated lobby and elevator. The patient also must wear a surgical mask or N95 mask during transfer. The surfaces of passage ways and the elevator should be cleaned. If the patient is kept intubated, a single-patient-use Ambu bag with HME filter attached must be used during transfer. Do not use a ventilator during transfer. A minimum of one hour is planned between cases to allow OT staff to send the patient back to the ward, conduct through decontamination of all surfaces, screens, keyboard, cables, monitors and anasthesia machine with 2% to 3% hydrogen peroxide spray disinfection, 2 to 5 g/L chlorine disinfectant, or 75% alcohol wiping of solid surfaces of the equipment and floor. CPR during transfer involves a series of events that increase the risk of aerosol generation, including suctioning, mask ventilation and intubation. If CPR is required during transfer of patient, do compression only CPR with Airway interventions (Supraglottic devices, Endotracheal intubation) only by experienced persons.[4],[28],[29],[31]
Regional anesthesia
For Regional anesthesia, follow standard droplet and contact level precautions bearing in mind the possibility of converting to general anesthesia, should regional anesthesia fail. Use a pencil-point spinal needle for spinal anesthesia. It may reduce the risk of introducing viral material into the CNS, as there is less tissue coring compared with cutting tip spinal needles. Patients under regional anesthesia should wear a surgical mask at all times. If supplemental oxygen is required, the oxygen facemask should be placed over the surgical mask, or nasal prongs can be placed under a facemask. The lowest flows possible to maintain oxygenation should be used.[4],[28],[31],[35],[36]
Viral filters
The SARS-CoV-2 virions are approximately 0.125 µm in size and are most commonly transmitted as larger (>20 µm) respiratory water droplets. The virus may also be aerosolized and transmitted in smaller droplets (< 10 µm) in gas suspension. Particle size has implications for suspension time and filtration requirements. Filters mounted at the airway are susceptible to progressive occlusion by secretions and may need to be changed, if resistance to flow and airway pressures become too high. Filters at the expiratory limb are less likely to need replacement due to occlusion. As long as the filter is not soiled, viral filtration, effectiveness should be maintained. The patient side of the filter contains whatever particles the patient exhaled, including virus if present. This filter will need to be changed between every patient. If sampled gases are returned to the breathing circuit they need to be filtered. Water traps have built in filters and the viral filtration efficiency (VFE) determines the effectiveness. Commercially available filters may include a 0.2 micron filter with a VFE of 99.999%.[37] Standard electrostatic filters (HME filters) used in ventilation machines can filter bacterial and viral loads with great efficacy. These filters may provide > 99% protection against hepatitis C virus (HCV) and hepatitis B virus (HBV) having a diameter of >30 nm. HEPA can remove up to 99.97% of contaminants (≥0.3 microns in diameter) and ULPA (ultra-low particulate air filters) up to 99.99% (≥ 0.12 microns).[39],[39]
The vast majority of aerosols that may be produced by human cough are less than 1 micron in Size. HEPA filters of higher grades are considered to be very effective (efficiency up to 99%) in removing air-borne virus particles.[38] Not only can HEPA filters capture viruses, but they also create a cleaner work area in general. According to the centers for disease control and prevention (CDC), devices with HEPA filtration can increase the effective air changes per hour of clean air to the patient room, reducing risk to individuals entering the room without respiratory protection. Recirculating devices with HEPA filters may have potential uses in existing facilities as interim, supplemental environmental controls to meet requirements for the control of COVID-19 Spread from OT complex (Category II recommendation).[39] HEPA filter with additional Ultraviolet light (UV) sterilization may also afford significant protection against the spread of the virus by killing microbes that deposit on the filter itself. When UV germicidal irradiation (UVGI) is employed as a supplemental engineering control, fixtures can be installed on the wall near the ceiling or suspended from the ceiling as an upper air unit or in the air-return duct of an airborne infectious isolation (AII) room (Category I recommendation).[40]
| Surgery | | |
Consent and ethics
Informed consent for surgery, which is a critical component of surgical practice, has become a challenging issue in the time of COVID 19 infection. The true impact of asymptomatic or pre-symptomatic COVID 19 disease on physiologic risks of surgery and/or anesthesia is not yet understood. The risk of nosocomial COVID 19 acquisition for a patient coming to the hospital, nor the risk of transmission of COVID 19 from unsuspectedly infected patients to the operative team members is known.[41] It is important to recognize the scientific, ethical, and moral uncertainties that surround the patient care during this pandemic and how they might be reflected in informed consent discussions. COVID 19 has added an additional imperative to the informed consent process, transparency about potential but unknown risks and an honest admission of how little we currently understand about the surgical outcomes of COVID 19 positive patients and patients with unknown COVID 19 status [Figure 1]; [Table 2].[41],[42] | Table 2 Deviations from standard management are required for multiple factors such as [43]
Click here to view |
For anesthetics, the consent process includes engaging the patient in a discussion of the types of anesthesia or sedation that are available, the risks and benefits of each type, and any alternatives. The discussion should include the modifications of anaesthetic practice that will be required in managing patients who are confirmed to have COVID 19 in order to prevent aerosol generation. While emerging evidence suggests increased cardiorespiratory and microembolic/thrombotic complications in symptomatic COVID 19 positive patients, there remains considerable uncertainty the extent to which the risks of undergoing an operation or general anesthesia are increased in asymptomatic or pre-symptomatic individuals. It has become important to convey to the patients that the COVID 19 pandemic has changed day-to-day hospital operations in ways that have the potential to significantly impact their perioperative care and experience due to man power and resource shortages. The treatment of postoperative complications can be impacted by limitations in diagnostic or interventional services including imaging, interventional radiology, or endoscopy due to COVID 19 disruptions in services. A patient who requires emergency room evaluation or readmission due to complications that develop after hospital discharge may be impacted by bed availability.[41],[42]
Checklist
Though Surgical Safety Checklist [most commonly World Health Organization (WHO) checklist][45] is being used in many heatlhcare facilities, the current pandemic has forced to think beyond the routine checklist. A modified Surgical Safety Checklist developed by Lifebox, the World Federation of Societies of Anesthesiogists, and Smile Train is worth mentioning which includes many points related to COVID 19 [Table 3] and [Table 4].[46] | Table 4 Preoperative testing/screening processes for surgical patients [47]
Click here to view |
Energy sources
No studies have identified SARS-CoV-2 in surgical smoke till date, and even if found, it is not known whether these viral particles are infectious. The various energy sources lead to varying particle sizes with electrocautery and laser having the smallest, hottest particles and ultrasonic devices larger, cooler particles. Energy devices and surgical plume for Electrocautery < 0.1 microns, Laser ablation 0.3 microns and ultrasonic scalpel 0.35–6.5 microns.[48]
Cold hemostasis is the method of choice. Surgical drains should be used only if necessary. Ultrasonic scalpels or electrical energy devices used in surgery can produce large amounts of surgical plumes during laparoscopic or open surgery, and smoke evacuation and filtration systems can be used both at the time of laparoscopy and laparotomy. Out of all the energy devices, Harmonic ScalpelTM produces maximum aerosol and bipolar scalpel being the least producing. The energy sources should be used at the lowest power setting and charring of tissues should be avoided to minimize the creation of smoke. Use of monopolar electrosurgery, ultrasonic dissectors, and advanced bipolar devices should be minimized, as these can lead to particle aerosolization. If available, monopolar diathermy pencils with attached smoke evacuators should be used. The smoke evacuator must be ideally placed within 2 cm of the source, with 50% loss of capture for every 1 cm from the source of the plume.[1],[4],[13],[20],[49],[50],[51]
Open or laparoscopic surgery
Though laparoscopy can lead to aerosolization of blood borne viruses, there is no evidence to indicate that this effect is seen with COVID 19, nor that it would be isolated to minimal invasive surgery (MIS) procedures. SARS-CoV-2 RNA has also been detected in blood and stool specimens, but it is unknown if infectious virus is present in these extrapulmonary specimens or transmission of COVID 19 has been documented through this route. Furthermore, surgery in patients with HIV and hepatitis B and C has been ongoing for decades, without documented increased risk of transmission from the surgical plume or laparoscopic pneumoperitoneum to surgeons, anesthesiologists, or OT personnel. Laparoscopic techniques, in fact significantly minimize exposure of surgeons to blood-borne pathogens as compared to laparotomy.[3],[12],[13],[49],[50]
Assumptions like “laparotomy is better during the COVID 19 pandemic because of theoretic aerosolization risks” can be erroneous. Laparotomy has its own consequences, including prolonged hospital stays and bed use, an increased likelihood of intensive care unit stay, and greater risks of COVID 19 exposure for both the patient and healthcare providers. Proven benefits of MIS of reduced length of stay and complications should be strongly considered in these patients, in addition to the potential for ultrafiltration of the majority or all aerosolized particles. In laparoscopy specifically, all the studies of aerosolization are related to electrosurgical smoke produced in a closed environment and the consequent aerosolized debris into suspended particles from energy devices. Thus, in the absence of electrosurgical devices, we do not know the ability of CO2 alone to aerosolize particles in the abdomen.[3],[12],[13],[49],[50]
Given the lack of data to support the claim that COVID-19 virus spreads through the laparoscopic smoke plume or pneumoperitoneum, one cannot justify the increased use of precious resources, greater number of surgical complications, and infectious exposure risks to the patient and the caregivers that would result, if laparoscopic approaches were abandoned during this period. Performing laparoscopy with lower intra-abdominal carbon dioxide pressures and minimizing the use of energy will limit the production of surgical plume and pneumoperitoneum. In addition, the use of a smoke evacuation/filtration system allows for controlled release and filtration of the surgical plume. Ideally, gas and plume evacuation and filtration are accomplished with the use of an ultralow particulate air filter rated to screen particles of 0.1 µm in diameter.[3],[12],[13],[49],[50]
Laparoscopy offers unique advantage of being able to almost entirely contain the surgical plume in the abdominal cavity. An evacuation/filtration system can be used to minimize the release of potential airborne virus into the OT environment, while simultaneously evacuating the surgical smoke actively or passively. It is important to avoid a sudden release of the pneumoperitoneum which is most relevant before tissue extraction and at the completion of the surgery. The abdominal cavity should be actively desufflated through a filtration system or with a simple piece of tubing attached to a suction canister. The gas should not be released into the OT. This is in contrast to smoke evacuation at the time of laparotomy, when containment of the surgical smoke is very challenging. Use of intelligent, integrated flow systems is recommended for the maintenance of low intra-abdominal pressure which ensures a self-maintained constant pneumoperitoneum. Integrated flow systems should be configured in a continuous smoke evacuation and filtration mode, preferably through a ultra-low particulate air (ULPA) filter.
The practical tips for laparoscopy are:- Incisions for ports should be as small as possible to allow for the passage of ports but not allow for leakage around ports;
- CO2 insufflation pressure should be kept to a minimum and an ultra-filtration (smoke evacuation system or filtration) should be used, if available;
- All pneumoperitoneum should be safely evacuated via a filtration system before closure, trocar removal, specimen extraction or conversion to open.
There is not enough scientific evidence to support the use of open surgery over laparoscopy or robotic surgery to reduce viral transmission of COVID 19; however, there is still much to learn about the disease and transmission. There seems to be no reason to abandon laparoscopic surgery in favor of open surgery.[1],[3],[12],[13],[49],[50],[51] However, the risks should not be under estimated, surgery should be performed on patients with COVID-19 only when necessary. Surgeon must consider open or laparoscopic surgery depending upon expertise, resources available, minimum exposure to operating room (OR) staff and most importantly considering the safe outcome of the patient along with performing surgery in a safe and protected environment.
| Appliance Disinfection, Hygiene and Waste Management | | |
Environmental sanitization
Environmental cleaning is complex infection prevention and control intervention that requires a multipronged approach, which may include training, monitoring, auditing and feedback, reminders and displaying SOPs in key areas. Cleaning should progress from the least soiled (cleanest) to the most soiled (dirtiest) areas and from the higher to lower levels so that debris may fall on the floor and is cleaned last. After cleaning, the following disinfectants and defined concentrations can be used on environmental surfaces to achieve a >3 log10 reduction of human coronavirus, and they are also effective against other clinically relevant pathogens in the health-care setting.[52] Apart from medical devices, surfaces of operating tables, IV stands, footstools etc., and all areas where COVID 19 patients have transited must be carefully sanitized too. Some recommended agents are:- Ethanol 70% to 90%
- Chlorine-based products (e.g., hypochlorite) at 0.1% (1000 ppm) for general environmental disinfection or 0.5% (5000 ppm) for blood and body fluids large spills
- Hydrogen peroxide >0.5% Contact time of a minimum of 1 minute is recommended for these disinfectants or as recommended by the manufacturers.
PPE undressing and removal
The healthcare professional must take all care not to become infected while removing PPE; this must be done through an adequate procedure preventing re-contamination of the operator’s clothing and hands. The first pair of gloves is likely to be heavily contaminated and must be removed first. All other PPEs must be considered infected as well and removed with care during the doffing procedure. Protective suit, shoe cover, and head cap must be subsequently removed. Face mask and glasses must be then removed, taking care to handle the face mask by the ear laces and without touching its external side. The second pair of gloves must be removed as the last component and hands disinfection must be performed immediately after. The use a “Buddy System” for Donning and Doffing can be effectively utilized in which providers assist with and oversee the doffing of a colleague. A colleague’s oversight significantly improves anxiety among staff and may lead to less self-contamination during PPE removal.[53],[54]
Waste disposal
The importance of waste management according to the biohazard principles needs strict attention and preferably supervised. It is advisable to set up a dedicated container for hazardous medical waste immediately outside the OT, to immediately dispose of all contaminated disposable material and PPEs. National, State and institutional policies must be adhered and instruction/sign boards clearly displayed. It is recommended to use double layered bags to pack/store Covid 19 related biomedical waste with “Covid-19 waste” label. Containers should be closed and sealed before being transferred to the collection point. All sharps should be disposed off in a dedicated rigid plastic container. There is an important and urgent need for all health care worker (HCWs) to be sensitized about segregated and protected disposal of Covid 19 waste. If safety issues are not addressed, it can pose risk to the health of sanitary workers and thereafter the community. They must wear recommended PPE while handling and transporting the waste.[55]
Hand hygiene
Hand hygiene is the single most important practice to reduce the transmission of infectious agents in healthcare settings. The term “hand hygiene” includes both hand washing with either soap and water, and use of alcohol-based products (gels, rinses, foams) that do not require the use of water. It is important to ensure the availability of hand rub products at all times in the ambulance to ensure hand hygiene compliance.[56] Hand hygiene should be meticulously performed recalling the “5 movements of hand hygiene” as advocated by WHO. Using alcohol based handrub (ABHR) with greater than 60% ethanol or 70% isopropanol in healthcare settings is suggested by CDC. Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. Promoting good hand hygiene is one of the most basic yet powerful tools that health care workers must continue to leverage to reduce the spread of COVID 19.[57],[58]
Linen management
Disposable laundry should be preferred, when possible. In order to minimize the possibility of dispersing virus through the air, do not shake dirty laundry. All linen (sheets, pillowcases, crossbars, etc.) should be handled wearing PPE during collection, not placed on surfaces or floors, but directly should be placed in clearly labeled, leak-proof bags or containers. These must be sealed and immediately sent for cleaning and sterilization. Routine processes for laundry management of linen apply. Usually, there are no additional controls required for laundry management for linen used for patients with suspected or confirmed COVID 19 infection. Laundry workers should wear the PPE, that is, normally used as appropriate to the task being undertaken. The carts or trolley for transporting laundry should be sanitized after every transfer.[59] There is absence of information about transmission of virus from soiled linen and sterilization needs. The following approach may be utilized. In washing machine- wash at 60 to 90°C with laundry detergent followed by soaking in 0.1% chlorine for approximately 30 minutes and dried; for Non-machine washing, it must be soaked in hot water with soap/detergent in a large drum, Use a stick to stir and avoid splashing, Empty the drum and soak linen in 0.1% chlorine for approximately 30 minutes and rinse with clean water and let linens dry fully in the sunlight.[60]
Manpower
Manpower has to be used efficiently to maintain good clinical care and also to minimize exposure to health workers. The number of health workers posted is determined by the nature and severity of sickness of patients [Table 5].
If the healthcare staff follows the safety norms, there should not be any need of quarantine as PPEs are quite effective. High-risk contacts will be quarantined for 14 days, tested as per Indian Council of Medical Research (ICMR) testing protocol, actively monitored for development of symptoms and managed as per laid down protocol. Low risk contacts shall continue to work.[61] However, a cooling off period, if possible is desirable after a posting in COVID 19 area. An efficient training module with refreshers must be in place to train all health workers. The instruction to follow the personal safety guidelines must be circulated and displayed widely to ensure adherence. Effective communication is essential for optimizing throughput and capacity, which are the key to managing patient surges anticipated during a pandemic of this scale.
| Conclusions | | |
SMS viz. ‘social distancing’, ‘masks’, ‘sanitizers’ must be practiced sincerely. In the absence of epidemiological data on this new virus, the hospital administration will have to implement stringent precautions for the safety of patients and hospital staff. Proper PPE is the most important in this regard. It is recommended that the risks of Covid infection are clearly mentioned in the consent form. The role of proper air circulation and conditioning while doing procedures is to be stressed, as there is some evidence that the virus may be airborne instead of spreading by droplet infection. One has to remain vigilant, keep updating information and implement evidence based measures. As more evidence-based knowledge of SARS-Cov 2 is gathered, these measures can be made part of universal precautions.
Disclaimer: This document is based on current literature, resources, society guidelines, and expert opinion. The knowledge in this field is evolving rapidly and continually. It is pertinent to state that new evidence is continuously emerging and guidelines are being modified and updated regularly. The readers are therefore urged to check the most recent versions of the guidelines and resources as the evidence evolves.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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