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Table of Contents
REVIEW ARTICLE
Year : 2020  |  Volume : 17  |  Issue : 3  |  Page : 170-173

Challenges in providing surgical care during and after COVID-19 pandemic


1 Department of Orthopaedics, Apollo Hospital, Muscat, Sultanate of Oman
2 Department of Orthopedics, Indraprastha Apollo Hospitals, New Delhi, India
3 Department of Orthopaedics, Indraprastha Apollo Hospitals, New Delhi, India

Date of Submission29-Jun-2020
Date of Acceptance02-Jul-2020
Date of Web Publication01-Aug-2020

Correspondence Address:
Saseendar Shanmugasundaram
Apollo Hospital, Muscat
Sultanate of Oman
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_69_20

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  Abstract 

COVID-19 has changed the way clinical practice and orthopedic care services existed. The pandemic has affected almost all types of health-care delivery, more importantly the surgical care of patients. Although there have been a flurry of opinions and scientific reports on health-care delivery during and after the COVID-19 pandemic, no established consensus exists on the guidelines to the surgical care of patients. We summarize the available evidence on the principles and guidelines to be followed in the care of the surgical patient. Care starts with precautions of infection prevention and care in the outpatient department, which includes sufficient protection of the medical staff, planning to avoid crowding, and smart usage of resources and workforce. Surgery should be contemplated only when absolutely indicated. Surgical care of the patient should encompass not only the prevention of morbidity associated with operating on COVID-19 patients but also the prevention of transmission of infection to other health-care staff and non-COVID-19 patients. Precautions should be taken at multiple levels and include but are not limited to proper preoperative, anesthetic, and surgical considerations and a coordinated functioning of the COVID-dedicated Operating Room (COR). The health-care personnel should be trained on the dos and don'ts in every step in the execution of a surgical procedure on a COVID-19 patient. Senior health-care staff need to overlook the adherence of the health-care personnel to these guidelines. Sanitization of the OR and disposal of infected material carry prime importance after the procedure. In all, it is necessary to accept the new normal resulting from the COVID-19 pandemic to better accept and execute protective measures.

Keywords: COVID-19, orthopedics, outpatient department, pandemic, resuming services, surgery


How to cite this article:
Shanmugasundaram S, Vaish A, Vaishya R. Challenges in providing surgical care during and after COVID-19 pandemic. Apollo Med 2020;17:170-3

How to cite this URL:
Shanmugasundaram S, Vaish A, Vaishya R. Challenges in providing surgical care during and after COVID-19 pandemic. Apollo Med [serial online] 2020 [cited 2020 Oct 26];17:170-3. Available from: https://www.apollomedicine.org/text.asp?2020/17/3/170/291314


  Introduction Top


COVID-19 pandemic has unearthed many challenges in all aspects of life. The clinical practice and model for running orthopedic care services can no longer function like old times. There has been a paradigm shift in its functioning. Running the patient care services during and soon after this pandemic has to adapt to the needs and practical logistics. India being a densely populated country poses more challenges, as norms like social distancing can seldom be practiced unless strict protocols as followed. As much as a strict lockdown was eminent, all aspects of surgical services took a beating and the patients with semi-urgent and chronic problems were the worse impacted. Only emergency surgical work is being done during the pandemic times to avoid the risk to the patients and the health-care professionals. It is obvious that this pandemic has significantly affected almost all types of health-care delivery, especially the surgical care.


  What Is Presently Known? Top


There have been a flurry or “infodemic” of publications[1],[2],[3] related to the impact of COVID on several aspects of health-care delivery, including various surgical specialties, and most of these are based on recommendations and guidelines of multiple surgical bodies and organizations[4] and review articles. However, no clear consensus has been reached as to what can be followed in the current scenario with limited resources at hand. Now, as we moved ahead in the pandemic, the personal experiences of hospitals and institutions from different parts of the world are slowly coming to creep in.[1],[5],[6],[7] All the above information has been helpful in planning to provide the surgical care to the patients, depending on the availability of individual resources and the magnitude of the COVID problems in various health-care facilities. Considering the lack of direct evidence for this newly identified 2019-nCoV infection, neither systematic review of the literature nor statistics could be performed, and the effects of altering practice based on these guidelines are limited. Long-term data from different countries are required to come to a definite consensus.


  Outpatient Clinic Management Top


All the required precautions of infection prevention and care are needed in the outpatient department (OPD). The doctor and all staff in the OPD must wear an N-95 or a triple-layered mask, Latex examination gloves, and face shield. No aerosol-generating procedure should be performed in the OPD. There should be atleast 1 m distance between the patient and doctor. The doctor may examine the patient on the sanitized couch or from behind plastic curtains.

Lal et al.[8] demonstrated the importance of e-registration and usage of online appointment portals to avoid crowding and help in the smooth functioning of outpatient clinics. de Caro et al.[9] proposed a six-level approach model for the smooth functioning of outpatient clinics. A possible second or ever third wave of the deadly virus is a possibility. Hence, resumption of the OPD services based on the need should not be delayed. As restrictions are progressively lifted, older patients and patients with comorbidities should be kept away initially. Adequately filtering and routing these patients is another point of attention and should be done preemptively. Chhabra et al.[10] focused on the other aspects of the resumption of the OPD services. According to them, around 10% of the staff usually is unavailable during these times due to self-isolation. Furthermore, it is advisable to use only 50% of the available OPD rooms at a time. After using these, the others may be used on subsequent days after sanitizing the previous ones.

It is important to maintain a proper record of all the people visiting the clinic along with their contact details and address. On arrival, it is eminent to check their status on the “Arogyasetu” application.


  Surgical Considerations Top


If the surgery is considered as an absolute indication for a patient, and when no nonoperative measure is successful or is not indicated, then the surgical procedure can be done with several precautions, as highlighted below. It has been advised and practiced that only emergency cases such as severe fractures, limb-threatening injuries, aggressive cancers, and acute abdomen are being operated. Hence, a large majority of patients suffering with chronic painful disorders such as arthritis and spinal canal stenosis are being neglected and made to live with pain, disability, and discomfort.

Iyengar et al.[11] emphasized on setting up temporary minor injuries setup. This will reduce the load inside the main setup. One can perform various minor procedures such as wound lavage, suturing, suture removal, cast removal, and casting here.

It is known that the major surgical procedures, involving general anesthesia, older patients (especially with medical comorbidities such as diabetes, obesity, respiratory, and heart problems), and significant aerosol generation (such as some orthopedic, dental, general anesthesia, and ear, nose, and throat procedures [Table 1]) are associated with increased risk of postoperative mortality.[6]
Table 1: Procedures associated with high aerosolized particle generation

Click here to view


Preoperative considerations

It is essential to rationalize the indications, timing, and consider the preparedness of the operating room (OR) and OR personnel when considering a patient with diagnosed or suspected COVID-19 for surgery. Whenever possible, the least invasive and time-consuming procedure should be considered. The protocols for the management of these patients should be clearly defined and must be readily available to health-care professionals. Dedicated senior staff should be allocated at key management roles to oversee adherence to such protocols. All health-care workers (HCWs) dealing with the patient should be trained to don, doff, and dispose of personal protective equipment (PPE) safely.

The COVID-dedicated Operating Room

Dedicated ORs should be allocated for the COVID patients, preferably the one that is closest to the entrance of the theater block. This will minimize environmental contamination during transit of the patient to the OR. When possible, COVID-dedicated ORs (CORs) should be negative pressure rooms.[12] However, the most commonly used ORs have positive pressure air circulation. In this scenario, it is recommended to opt for a high air exchange cycle rate of ≥25 cycles/h[13] and allow for adequate time duration between cases and between anesthetic and operative procedures in order to minimize possible contamination from aerosols. Most air-handling systems can exchange the air in 15 min, hence this is considered an optimum time between transits.[14]

A minimal but efficient number of staff should be allotted to the designated COR. Protective equipment should be adequately stocked for use. Any equipment deemed not necessary for the management of the patient should be moved out of the area. A record of all personnel involved in the care of the patient should be maintained. HCW involved in the transit of the patient and in receiving the patient in the COR should be protected with PPEs. Patients, unless intubated, should continue to wear a surgical mask. All medical records should remain outside the COR and should be updated after adequate doffing, in order to minimize contamination.

The doors of the CORs must be kept closed at all times after the commencement of the anesthetic or operative procedure. Staff transits in and out the COR should be minimized. Anesthetic trolleys should be equipped with minimal but adequate stock. All necessary surgical materials must be made available inside the COR. Disposable material should be preferred whenever possible. The time spent by the patient and the HCW inside the COR should be minimized. However, once inside the COR, personnel should be allowed to leave only after the surgery is complete.

Anesthesia considerations

Careful preoperative planning is recommended before the surgical procedure. The anesthetic plan and risks should be discussed in detail with the patient. When possible, regional anesthesia should be preferred to reduce both risk of exposure to the OR personnel and to reduce morbidity to the patient. However, the choice of anesthesia should take into consideration the need to avoid unexpected complex endotracheal intubation procedures that could increase the risk of infection of personnel. If the patient is not intubated, they should continue to wear a protective mask for the entire duration of the procedure.

Disposable airway equipment is preferred. FFP3 filters are recommended for high aerosol-producing procedures such as laryngoscopy and intubation. Repeated attempts to intubation should be avoided.[15] A dedicated ventilator should be used in the OR for general anesthesia in positive or suspected positive COVID-19 patients. High-efficiency particulate air filters are recommended when general anesthesia is required.[13],[16]

After the surgical procedure is complete, it is recommended that the patient be transferred directly from the COR to the inpatient room. The transfer of the patient should follow the dedicated COVID access routes and should be assisted by personnel wearing adequate PPEs different from the ones worn in the COR.

Operative considerations

It is recommended that the use of electrocautery, bone saws, reamers, and drills be limited as much as possible to limit the release of aerosols[17],[18] and the possible risk of virus spread. In case their use cannot be avoided, their power settings should be as low as possible. Suction devices should aid removal of smoke and aerosols.[19],[20] Simple methods to cover splashing particles from these power tools and methods to dispose the irrigating fluid without floor contamination are useful. The choice of the operating team members should be judicious to balance the experience that comes with seniority with the risk of disease transmission and higher morbidity associated with older age.[4]

Sanitization of the COVID-dedicated operating room

A minimum of 1 h should be allowed between cases to allow for the decontamination of the COR and equipment. Human coronaviruses can be effectively inactivated by surface disinfection procedures, such as 70% ethanol or 0.5% hydrogen peroxide.[21] All exposed surfaces in the COR and exchange areas must be sanitized at the earliest after each procedure. Potentially infected and single-use materials should be disposed of through infectious-risk health waste containers. Reusable materials should be disinfected or sterilized. Full PPE must be worn during the sanitizing procedure.


  Postoperative Care Top


The length of stay in the hospital must be minimized as much as possible. A coordinated planning of the surgical procedure and rehabilitation will enable to achieve this goal. Home care for dressing and intravenous antibiotics should be considered. The availability of telemedicine can enable the surgical team to follow-up on the patient without risking themselves and other hospital staff.[4] Early mobilization should be targeted whenever possible for early recovery and avoidance of thromboembolic complications. Rehabilitation could be provided at home or through teleconsultations.[22],[23]


  Covid-19 – the New Normal? Top


At present, it is not possible to predict a timeline for return to the pre-COVID-19 normalcy. The precautions advised during the COVID-19 are most likely expected to stay at least in the near future. Hospitals will need to make a balance between increasing backlogs in surgeries and the greater turnover time required for each surgical procedure. Both the longer use of the OR facility and the requirement of PPEs for the care staff are likely to translate as increased costs to patients. The costs of these equipment are however likely to come down with greater production capacity by manufacturers in future. Restrictions on the number of visitors for the patients are likely to stay and the same has to be communicated to the patient to avoid disappointment.


  Conclusion Top


COVID-19 pandemic has severely impacted and disrupted the surgical care for all surgical specialties. Only emergency surgeries are being done at present, leading to a significant backlog of semi-urgent and planned surgery for chronic, painful conditions. Surgical procedures are associated with increased risk of mortality and disease transmission and hence as far as possible, conservative management is being practiced during this difficult time. Resumption of surgical practices must be done in gradual fashion, by appropriate selection of low-risk patients and taking full safety precautions as being practiced currently. Optimistically, we can presume and sum up that

“Tough times never last, but tough people do!”

- Robert H. Schuller (Author)

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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