Visit our page dedicated to personal protective equipment (PPE).
For laparotomy, instruments should be kept clean of blood and other body fluids. Special attention should be paid to the establishment of pneumoperitoneum, hemostasis, and cleaning at trocar sites or incisions to prevent any gush of body fluid caused by air leakage or uncontained laparotomy incisions. Liberal use of suction devices to remove smoke and aerosol during operations and especiallybefore converting from laparoscopy to open surgery or any extra-peritoneal maneuver. Avoid using two-way pneumoperitoneum insufflators to prevent pathogens’ colonization of circulating aerosol in pneumoperitoneum circuit or the insufflator. For more information, read this article from Annals of Surgery.
It is important to be prepared for the potential need to operate on a Coronavirus Disease 2019 (COVID-19) person under investigation (PUI) or a COVID-19 patient. Preparation of a specific operating room (OR) and detailed education of the entire OR team who will be providing care for these patients during their procedure is imperative, without using stock protective equipment. The specific roles and responsibilities of all OR team members must be clear, with a common goal of minimizing the spread of infection to health care workers.
Following are links to infographics from other sources that offer additional salient details:
Short answer: Place high-quality viral filters between the breathing circuit and the patient’s airway and between the expiratory limb and the machine. The use of these filters is essential to prevent contamination of the machine. (See previous article for details on which filtration devices to use). Note: Even with filters, breathing circuits should be discarded after every patient.
The anesthesia machine needs to be protected from contamination by a potentially infected patient for two reasons. First, if pathogens can enter the internal parts of the machine, they could be passed on to a subsequent patient. Second, respiratory gases sampled for gas analysis can pass pathogens on to other patients or health care professionals after leaving the gas analyzer if improperly managed.
The good news is that the same precautions can be applied to all patients. The strategy is the same regardless of the patient’s risk of infection. A high-quality filter placed between the breathing circuit and the patient’s airway will protect the machine from contamination and also filter gas sampled for analysis. Heat and moisture exchange filters (HMEFs) are a good choice because they preserve airway humidity and are designed so that sampled gas is filtered before it enters the gas analyzer. It is possible to use a filter at the airway that is not also an HMEF. If a filter only is used, lower fresh gas flows (1-2 L/min or less) are desirable during maintenance of anesthesia to preserve humidity in the circuit.
It is also recommended to add an effective viral filter between the expiratory limb of the circle system and the machine. Not only is this second filter a reasonable backup to protect the machine from any particles that pass the primary filter, but it significantly amplifies the effectiveness of the first filter. Given the fact that the primary filter can become less effective if soiled, the backup filter is a good recommendation. Another filter between the machine and the inspiratory limb is added sometimes but is not necessary to protect the machine from the patient nor to protect the patient if the machine is kept clean. The main reason to add an inspiratory limb filter is to eliminate the chance of error by placing a single filtered limb on the inspiratory rather than expiratory port.
The American College of Surgeons (ACS) has released “COVID-19: Guidance for Triage of Non-emergent Surgical Procedures” to provide surgeons with additional guidance on the management of non-emergent operations during the Coronavirus Disease 2019 (COVID-19) pandemic. The document was developed in response to the rapidly evolving challenges faced by hospitals in response to COVID-19 outbreak, including broad calls to curtail “elective” surgical procedures. This document follows the release of the College’s “COVID-19: Recommendations for Management of Elective Surgical Procedures.”
The Centers for Disease Control and Prevention has issued guidelines on health care professional exposure to COVID-19.
The key elements of the CDC site for surgeons are the definitions of close contact, whether the patient was wearing a facemask, whether the patient is COVID-positive, and personal protective equipment the health care professional is wearing. The site defines close contact, but pertinent to surgeons is the possibility of aerosolization during an event in which they could have been exposed (cardiopulmonary resuscitation, intubation, extubation, bronchoscopy, nebulizer treatments, sputum production). Laparoscopy is not mentioned in the guidelines.
The guidelines also address postexposure isolation and monitoring based on risk level of the exposure (high, medium, or low). High-level and some medium-level exposures require 14 days restriction from work with active monitoring. Low-level exposures may only require restriction for 14 days with self-monitoring. For patients under investigation (PUI), exposure requires restriction from work until the COVID status of the patient is determined—usually 24−72 hours.
Use of personal protective equipment (PPE) recommended guidelines include gown, gloves, N-95 mask, and eye protection. Although N-95 masks are recommended, even non-N-95 masks lower the risk of exposure according to the CDC.
Despite all such precautions, community exposure and travel remain a possible cause of health care professional. Therefore, all surgeons should be self-monitoring for symptoms early, immediately report symptoms, and self-isolation if symptoms arise.
Patient zero arrived in Seattle, WA, January 19 after returning from a visit to his family in Wuhan, China. He tested positive for COVID-19 on January 20. By March 9, 172 cases had been confirmed in Seattle and an alarming 22 deaths occurred because of an outbreak in a skilled nursing facility in Kirkland. On that day, the leadership of UW Medicine canceled all work-related travel for UW employees, and March 12 canceled all elective operations. On that day, the Seattle area had 387 confirmed cases (despite minimal testing) and 30 deaths. The chief and associate chief of the division of vascular surgery decided to continue to offer surgery to patients with abdominal aortic aneurysms (AAA) of more than 5.5 cm and dialysis access and surgery for chronic limb-threatening ischemia. That decision quickly changed. By March 15, the counts had risen to 642 cases and 40 deaths. A call was placed to colleagues in Milan, Italy, who reported the following:
UW’s division of vascular surgery implemented the following changes immediately:
Italy, Spain, and China have experienced terrible losses during the pandemic. They have also shared their experience with the ACS. Following are recommendations from a surgeon in Spain:
SAGES included this in its newsletter: Register your center for CovidSurg, a global collaborative research effort seeking to report on the comprehensive experience and outcomes of COVID-19 surgical patients and providers. With more centers included, better knowledge can be gained to improve the safety, quality, and outcomes during this pandemic. The study protocol, registration, and details are available online at: globalsurg.org/covidsurg.
The American College of Surgeons Committee on Trauma (ACS COT) has released a guidance document, “Maintaining Trauma Center Access and Care during the COVID-19 Pandemic: Guidance Document for Trauma Medical Directors,” which was recently sent to all medical directors of trauma centers. The ACS COT recommendations provide guidance to facilitate trauma centers’ response to the COVID-19 pandemic and assist with safe access to care for injured patients who require time-sensitive life-saving interventions.
“The current worldwide COVID-19 pandemic threatens to overwhelm the health care system and thus impact the ability to care for critically injured patients and other surgical emergencies,” the document notes.
The ACS COT advises trauma medical directors and trauma program managers to engage in the regional and hospital planning process for providing care during the COVID-19 pandemic. The ACS COT recommendations cover the following aspects of the planning process:
The full guidance document is available online.
Vanderbilt University, Nashville, TN, has developed guidance on managing office visits effectively and safely. They are as follows:
No, the Summit is canceled. All registrants and invited guests will receive a separate email with information related to this meeting. We made this difficult decision out of an abundance of caution, and with concern for attendees' safety and the safety of their patients. Preliminary information regarding hotel and registration cancellations can be found at: www.facs.org/summit.
Right now, the COVID-19 landscape is continually changing. We are evaluating our meetings and events schedule daily and will make decisions on future events based on the best COVID-19 transmission guidance we have from the Centers for Disease Control and Prevention and other reliable authorities, such as local health agencies. We are posting cancellation or postponement notices on our website about specific ACS meetings and events that were scheduled to take place soon. All other ACS meetings—including the annual Quality & Safety Conference and Clinical Congress 2020—are currently scheduled to take place later this year. Check the site frequently for updates, and look for future announcements in the Bulletin Brief.
We can only provide an opinion about traveling to ACS meetings, events, and activities. Our web page dedicated to COVID-19 issues is publicly available and the link can be easily shared with other groups. Visit: www.facs.org/covid-19
Anyone who is concerned about traveling should consult with their personal physician regarding their ability to travel under current circumstances.
At this point it's premature to assume a travel ban will be in place in October. However, if there are travel restrictions or valid concerns about attending the ACS Convocation for induction into Fellowship in Chicago this coming October due to COVID-19, we will make every reasonable effort to be accommodating to ACS Initiates who will become new Fellows this fall.
The interview format is inside the purview of the ACGME and other professional societies, and would need to happen at that level.