Michal Daniluk, Jagiellonian University Medical College, Krakow, Poland
Antonio M. Lacy, Department of Surgery, Hospital Clinic, University of Barcelona
Tomasz G Rogula, Case Western Reserve University School of Medicine & Jagiellonian University Medical College, Krakow, Poland
Antoni M. Szczepanik, First Department of General, Oncological and Gastroenterological Surgery, Jagiellonian University Medical College, Krakow, Poland
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is the virus responsible for the 2019 Coronavirus Disease (COVID-19). The main route of transmission is through droplets and close contact.1,2 As a result of their mass, droplets spread in space is limited to 1-2 meters from the source of production. Aerosolized particles, on the other hand, are smaller in size (0.3 to 100 micrometers) and have been documented to linger in the air longer than droplets and travel up to hundreds of meters before settling on a surface.3 The role of aerosolized particles in the spread of SARS-CoV-2 in the community has yet to be proven, however, their presence in the hospital setting has been of greater concern.4–6
The earliest documentation of infection coming out of Wuhan, China showed that 40 out of the first 138 (29%) people infected by SARS-CoV-2 were healthcare workers.7 In an effort to help minimize the spread of SARS-CoV-2, several hospitals have published their approach to the surgical management of infected or suspected COVID-19 patients. A recent PubMed search for “COVID-19” and ”surgery” yielded 224 results, of which 13 papers proposed detailed precautions when surgically managing a COVID-19 positive or suspected patient. From setup to post-operative management, this review will draw from the suggestions of these papers and outline some of the most commonly mentioned precautions. As many institutions have never experienced such a dramatic shift from their day-to-day operations, this document may provide useful information with regards to safe practice.
The Role of Hospital Management:
The majority of COVID-19 infected or suspected patients will not require surgical intervention throughout the course of their disease. Therefore, mainstream procedures and precautions focus on the management of respiratory distress, proper isolation of patients, safety of ICU personnel and emergency department organization.8 Senior surgeons should be heavily involved in the supervision of focused training and the development and update of protocols.9 All personnel should be familiarized with specific procedures related to 1) COVID-19 patient transport to the operating room (OR) 2) intra-operative, and 3) post-operative care.
A predesignated route should be the shortest possible distance from isolation to the OR. It should be cleared by security, use isolated elevators and have minimal contact with others.10 A recent study by van Doremalen et al. found that the survival time of SARS-CoV-2 on plastic and steel surfaces such as elevator buttons can last as long as 72 hours, thus supporting the notion of using separate lifts and routes for patient transportation.4
With Regards to operating theatres, all studies suggested the use of negative pressure environment to reduce the dissemination of viral particles.1,5,11–21 Van Doremalen et al. also found that in aerosolized form, SARS-CoV-2 can remain viable for up to three hours.4 Applicably, the use of a high frequency (25/hour) air exchange can significantly reduce viral load within the OR.17 All drugs and equipment should be prepared before the start of surgery to limit movement of staff in and out of the OR.17 Anaesthetic drugs should be placed on a tray to limit contact and potential contamination of the drug trolley. Hand washing and glove change should be performed in any case were additional supplies must be accessed from the trolley.20 Monitors, ultrasound machines and other devices that are difficult to disinfect, should be covered by transparent plastic wrap to decrease the risk of contamination.17
Personal Protective Equipment
Of the 13 studies reviewed, all recommended the use of eye protection in the form of goggles or a face shield as well as a filtered face-piece respirator (N95).1,5,11–21 Five out of 13 studies recommended the use of powered air purifying respirators (PAPRs)(protection factor of 25-1000) as a superior alternative to N95 respirators (protection factor of 10).1,11,17,18,20,22 In addition to the higher protection factor, PAPRs provide eye protection and unlike the N95 respirator, do not require fit testing.18,17 Finally, five out of 13 studies suggested the use of double gloves during intubation and/or surgery.12,17–19,23 Forrester et al. also recommended the implementation of a buddy system during donning and doffing to identify any breaches in protection which can be decontaminating using alcohol spray.5
Intra-Operative Precautions: Anaesthesia and Surgical Smoke
Five of the 13 papers analyzed were sent to anaesthesiology journals and focused mainly on the minimalization of viral aerosolization during induction of anaesthesia and extubation.1,15,17,19,20 Some suggestions include the use of shortest acting drugs at lowest possible dose, avoidance of awake intubation and aggressive post-operative antiemetic prophylaxis to avoid aerosol production during emesis.1,17 Four studies recommended that pre-assessment, induction and post-operative anaesthesia recovery should all take place within the procedure room.12,17,19,20 Patient documentation should be done electronically, if possible, on a tablet or iPad, which can be disinfected after handling.17
Previous studies have demonstrated that ultrasonic scalpels and electrocautery equipment produce surgical smoke or plume, capable of transmitting active viruses in aerosolized form.24–26 The risk of SARS-CoV-2 aerosolization via electrical surgical equipment has not yet been shown, however, several sources recommend the implementation of appropriate precautions. A recent publication by Zheng et al. suggested that the aerosol formed during laparoscopic surgery accumulates in the abdominal cavity.14 Sudden release of trocar valves and deflation of pneumoperitoneum may expose the healthcare team to aerosolized viral particles.21 Therefore, some collegiate bodies suggest the use of laparoscopy, only in select cases where clinical benefit to the patient substantially exceeds the risk of potential viral transmission to the environment and OR staff.27
Other committees indicate that the evidence of such viral transmission during minimally invasive surgery is weak, but nevertheless proper safety measures are recommended. The Society of Gastrointestinal and Endoscopic Surgeons (SAGES) and the American College of Surgeons recommend the liberal use of suction devices and smoke evacuators to limit surgical smoke release into the OR.14,16 Gas filtration systems such as the ultralow particulate air filter (ULPA) might potentially achieve COVID-19 purification of the surgical plume, but this has still to be confirmed.28
When doffing PPE, the first pair of gloves must be removed first, followed by the surgical gown, shoe covers, cap and goggles. The face mask must then be removed by the ear laces, taking care not to touch the external side. The second pair of gloves must be removed last.29 Upon leaving the operating theatre, all staff should take a whole-body shower before changing into clean scrubs and returning to their clinical duties.12,16,17,20
With regards to disinfection, the United States Environmental Protection Agency (EPA) has created a list of products for use against SARS-CoV-2.30 The most commonly mentioned protocols suggest the use of sodium hypochlorite, chlorine containing disinfectant, wipes that contain quaternary ammonium and alcohol, hydrogen peroxide vaporization, and ultraviolet (UV-C) light (for inactivation of aerosolized viruses).15,17,19,20,31
A major constraint reported by several centers is the shortage of PPE such as masks and gowns. Dr. Peter Tsai, the inventor of the N95 respirator, has made several suggestions regarding the re-usability of his equipment. The first recommendation is air drying for 3-4 days.32 Alternatively, masks can be oven dried for 30 minutes at 70oC.32,33 More recently, a study out of Duke University evaluated the utilization of hydrogen peroxide vapor to decontaminate N95 respirators. This validation study concluded that N95 respirators still met performance requirements even after 50 disinfections.34 It is important to note, however, that these recommendations are constantly changing and it is of utmost importance that healthcare professionals regularly assess the most up-to-date guidelines regarding N95 re-usability and the disinfection process.
The conclusions drawn from the present literature are limited by the novelty of this disease. Most of the studies presented in this review were viewpoints and recommendations based on personal experience. Due to limited experience of single institutions, efforts should be made to increase international collaboration in the era of this unprecedented pandemic. Specific data on the risk of infection among surgeons has not yet been documented, however, this should not undermine the importance of strong occupational safety. The included studies suggest a need to develop a universal, effective and affordable protocol for perioperative management of COVID-19 patients to ensure surgical staff wellbeing.
1. Rajan N, Joshi GP. The COVID-19: Role of Ambulatory Surgery Facilities in This Global Pandemic. Anesth Analg. 2020. doi:10.1213/ane.0000000000004847
2. CDC. How Coronavirus Spreads. Available at: https://www.cdc.gov/coronavirus/2019- ncov/prepare/transmission.html. Accessed April 7, 2020.
3. Wang J, Du G. COVID-19 may transmit through aerosol. Irish J Med Sci (1971 -). 2020;(5):5-6. doi:10.1007/s11845-020-02218-2
4. van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med. March 2020:NEJMc2004973. doi:10.1056/NEJMc2004973.
5. Forrester JD, Nassar AK, Maggio PM, Hawn MT. Precautions for Operating Room Team Members during the COVID-19 Pandemic. J Am Coll Surg. 2020. doi:https://doi.org/10.1016/j.jamcollsurg.2020.03.030
6. Ong SWX, Tan YK, Chia PY, et al. Air, Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS- CoV-2) From a Symptomatic Patient. JAMA. March 2020. doi:10.1001/jama.2020.3227.
7. Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with, novel coronavirus–infected pneumonia in Wuhan, China. JAMA 2019; DOI: https://doi.org/10.1001/ jama.2020.1585.
8. Ahmed S, Wei T, Glenn L, Chong Y. Surgical Response to COVID-19 Pandemic: A Singapore Perspective. J Am Coll Surg. 2020.
9. Lancaster EM, Sosa JA, Sammann A, et al. Journal Pre-proof Rapid Response of an Academic Surgical Department to the COVID-19 Pandemic: Implications for Patients, Surgeons, and the Community Rapid Response of an Academic Surgical Department to the COVID-19.
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11. Vukkadala N, Qian ZJ, Holsinger FC, Patel ZM, Rosenthal E. COVID-19 and the otolaryngologist – preliminary evidence-based review. Laryngoscope. 2020. doi:10.1002/lary.28672
12. Di Saverio S, Pata F, Gallo G, et al. Coronavirus pandemic and Colorectal surgery: practical advice based on the Italian experience. Colorectal Dis. 2020. doi:10.1111/codi.15056
13. Pryor A. Pryor A. SAGES Recommendations Regarding Surgical Response to Covid-19 Crisis. SAGES. https://www.sages.org/recommendations-surgical-response-covid-19/.
14. Zheng MH, Boni L, Fingerhut A. Minimally Invasive Surgery and the Novel Coronavirus Outbreak. Ann Surg. 2020:1. doi:10.1097/sla.0000000000003924
15. Chen R, Zhang Y, Huang L, Cheng B heng, Xia Z yuan, Meng Q tao. Safety and efficacy of different anesthetic regimens for parturients with COVID-19 undergoing Cesarean delivery: a case series of 17 patients. Can J Anesth. 2020. doi:10.1007/s12630-020-01630-7
16. American College of Surgeons. COVID 19: Considerations for Optimum Surgeon Protection Before, During, and After Operation. 2020. https://www.facs.org/covid-19/ppe.
17. Wong J, Goh QY, Tan Z, et al. Preparing for a COVID-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in Singapore. Can J Anesth. 2020. doi:10.1007/s12630-020-01620-9
18. Givi B, Schiff BA, Chinn SB, et al. Safety Recommendations for Evaluation and Surgery of the Head and Neck during the COVID-19 Pandemic. JAMA Otolaryngol – Head Neck Surg. 2020;1:1-6. doi:10.1001/jamaoto.2020.0780
19. Dexter F, Parra MC, Brown JR, Loftus RW. Perioperative COVID-19 Defense. Anesth Analg. 2020:1. doi:10.1213/ane.0000000000004829
20. Ti LK, Ang LS, Foong TW, Ng BSW. What we do when a COVID-19 patient needs an operation: operating room preparation and guidance. Can J Anesth. 2020:19-21. doi:10.1007/s12630-020-01617-4
21. Spinelli A, Pellino G. COVID-19 pandemic: perspectives on an unfolding crisis. Br J Surg. 2020:3-5. doi:10.1002/bjs.11627
22. Institute of Medicine. The Use and Effectiveness ofPowered Air Purifying Respirators in Health Care: Workshop Summary. National Academies Press; 2015.
23. Lui R, Wong S, Sánchez-Luna SA, et al. Overview of guidance for endoscopy during the coronavirus disease 2019 (COVID-19) pandemic. J Gastroenterol Hepatol. 2020;2019(852):0-3. doi:10.1111/jgh.15053
24. Choi SH, Kwon TG, Chung SK, Kim TH. Surgical smoke may be a biohazard to surgeons performing laparoscopic surgery. Surg Endosc. 2014, 28 (8): 2374-80.
25. Kwak HD, Kim SH, Seo YS, et al. Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery. Occup Environ Med. 2016, 73:857––863.
26. Johnson GK, Robinson WS. Human immunodeficiency virus-1 (HIV-1) in the vapors of surgical power instruments. Journal of Medical Virology. 1991;33(1):47-50.
27. Anderson I, Fearnhead N, Toogood G. Updated Intercollegiate General Surgery Guidance on COVID-19. The Royal College of Surgeons of England. https://www.rcseng.ac.uk/coronavirus/joint-guidance-for-surgeons-v2/. Published 2020. Accessed April 8, 2020.
28. Morris S, Fader A, Milad M, Dionisi H. Understanding the “Scope” of the Problem: Why Laparoscopy is Considered Safe During the COVID-19 Pandemic. J Minim Invasive Gynecol. 2020.
29. Coccolini F, Perrone G, Chiarugi M, et al. Surgery in COVID-19 patients: operational directives. World J Emerg Surg. 2020;15(1):25. doi:10.1186/s13017-020-00307-2.
30. List N: Disinfectants for Use Against SARS-CoV-2. United States Environmental Protection Agency. https://www.epa.gov/pesticide-registration/list-n-disinfectants-use- against-sars-cov-2. Accessed April 09/2020.
31. Kim DK, Kang DH. UVC LED irradiation effectively inactivates aerosolized viruses, bacteria, and fungi in a chamber-type air disinfection system. Appl Environ Microbiol 2018; DOI: https:// doi.org/10.1128/AEM.00944-18.
32. Bauchner H, Fontanarosa B, Livingston EH. Conserving supply of personal protective equipment: a call for ideas. JAMA. Published online March 20, 2020.
33. APSF: Update: potential processes to eliminate coronavirus from N95 masks. https://www.apsf.org/news-updates/potential-processes-to-eliminate-coronavirus-from-n95-masks/. Accessed April 9, 2020.
34. Schwartz A, Stiegel M, Greeson N, et al. Decontamination and Reuse of N95 Respirators with Hydrogen Peroxide Vapor to Address Worldwide Personal Protective Equipment Shortages During the SARS-CoV-2 (COVID-19) Pandemic. Appl Biosaf. 2020;2:1535676020919932. doi:10.1177/1535676020919932