Keys to Mitigate Casualties in Surgery during and after COVID-19

The Coronavirus outbreak has evolved into a crisis, and the government has imposed stringent precautionary measures in order to restrain mass spreading. In contribution to this attempt, professional bodies of the healthcare sector have put forth a recommendation of postponing or canceling elective surgeries. This action is attributed to two primary factors: clearing hospital capacities to best possible, and protection of patients from avoidable exposure.

On the contrary, a significant backlog of surgical work is being created, along with patients on the waiting lists before the crisis. In order to tackle this, retention of resources and workforce is critically demanded. But with the ongoing exhaustion of the healthcare workers, the achievement of such a task will require key considerations in combination with multi-level recovery plans.

Global Statistical Study

An international COVIDSurg Collaborative report assessed 1128 adults postoperative outcomes with COVID-19 while undergoing an array of surgeries. The study further revealed 605 men and 523 women, among the targeted age range of 50-70 years. The SARS-CoV-2 (Severe acute respiratory syndrome coronavirus 2) was diagnosed post-operation in almost two-thirds of patients. The primary outcome of mortality resulted in pulmonary complications within the time scale of 30 days postoperative in these patients.

Other factors pushing the rate of risk among the patient of 70 years or older is the poor preoperative physical health status. Moreover, data from China also showed that geriatric patients with comorbidities, including diabetes and hypertension, boost the vulnerability to infection. A similar clinical profile and demographic is typical in various surgeries, which hypes the probability of risks in the process.

Potential of Transmission

A reliable estimation is withdrawn from several reports that a large pool of COVID-19 patients are diagnosed asymptomatic. For instance, the epidemiological data presented by Mizumoto et al. of 3,063 passengers of the Diamond Princess cruise ship revealed that almost half of the infected patients were asymptomatic. Another similar study by Nishiura et al. stated that among the 565 evacuated Japanese from Wuhan, China, who tested positive, were asymptomatic. Hence, a sufficient number of resources point out the potential of transmission from pre-symptomatic or asymptomatic patients.

  • Route of Transmission

Infectious Aerosols  

The primary pathway of the Coronavirus transmission is through inhalation of infectious aerosols, comprising large respiratory droplets and droplet nuclei. Aerosol generating procedures create the potential for ARI transmission that otherwise may only be transmissible by the droplets. Hence, additional infection control measures are recommended for surgeons and HCWs providing services to infection suspected patients.

Surgical Smoke – Organs with higher sensitivity towards the COVID-19 infection include lungs, kidney, bladder, heart, and esophagus. There are several uncertainties associated with the possibility of transmission through inhalation of surgical smoke emitted during open and laparoscopic surgery by energy devices. Substantial evidence has proven the presence of viable viruses in surgical smoke. Thus, conventional instead of laparoscopic surgery is recommended during the COVID-19 pandemic.

  • Other Outcomes

The effects of general anesthesia and the surgical outcome on respiratory functioning and postoperative courses in infected patients are problematic to conclude. A case study was submitted by Aminian et al. of 4 patients with postoperative pulmonary impediments within the few weeks of the outbreak in Tehran, Iran. Three patients died due to severe COVID-19 pneumonia and ARDS. The above clinical report clearly highlights the potential risk of fatality created due to avoidable surgery during the pandemic.

Based on the above considerations, screening for SARS-CoV-2 in all surgical patients is rational to avoid unexpected casualties on patients, as well as, surgeon sides.

Safety Considerations and Risk Assessment

During the early stages of the COVID-19 pandemic, the healthcare system in Italy, Spain, the UK, and the USA were largely overwhelmed. The capacity of PPE, staff training, intensive care unit (ICU) beds, and ventilators were significantly scarce and insufficient. Furthermore, the hospital staff is also in clear risk if patients are not diagnosed in the possible time scale. However, it must be understood that few of the elective and non-elective surgeries like cancer surgery or cesarean section are essential to continue throughout any pandemic.

The attempt of postponing or canceling surgeries has its own challenges, and also the deferring repercussion, resulting in either deteriorating patient’s condition or adding risk with the operation. This has raised inevitable questions: 1) competing with risks of delaying the surgery until recovery from COVID-19 versus progression of disease or distress in the intervening period. 2) need for efficient perioperative guidelines associated with elective surgery or emergencies during the pandemic. 3) check on community prevalence to ensure adequate supplies of PPE, along with hospital workforce and capacities before recommencing. 4) availability of effective chemoprophylaxis treatments to mitigate infection in the postoperative period in the absence of a vaccine.

Preparedness before Resuming Surgical Services

Hospitals that are preparing to resume or expand surgical services during the COVID-19 crisis will need to perform under certain restrictions. Here is the checklist of some critical criteria to consider in the initial stages of resuming planned surgery.

  • Timing: It is vital that the hospital has passed the peak and seeing a sustained reduction in new COVID-19 cases to ensure the availability of associated facilities and necessary staff.
  • Testing: Hospitals are recommended to consider the availability of diagnostic testing before formulating policies on account of testing utilities and frequency of workers and patients.
  • Availability of Perioperative Services: It is one of the prime components of any surgery. Thus, care must be taken in ensuring the fulfillment of essential services before resuming elective surgery. In the current crisis, it is also viable for hospitals to engage in external partnerships for such services for temporary support.
  • PPE: Hospitals must ensure the appropriate quantity and types of PPE and surgical supplies are available, and clear policies are directed for their practical usage.
  • Care Pathways and Protocols – For the smooth functioning of the above requirements, and appropriate management of patients’ care pathway, clear and stringent protocols must be enforced so that the resumption of services is safe and efficient.

Road Ahead

Many government and policymakers in the healthcare system around the world are preparing to reopen elective surgery with extensive risk assessing considerations, including necessary restrictions. The COVID-19 pandemic has severely affected access to safe surgery, especially in low-and middle-income economies and for migrants, homeless people, and refugees, which is a serious concern to address. Although surgery is considered a critical aspect of modern medicine, additional risks must be carefully reviewed during and after the pandemic.

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