WOFAPS Consensus Statement Role Of The Pediatric Surgeon In Covid19
Preface:
It has been a hard time since the outbreak of Coronavirus in late 2019. The rapidly spreading virus didn’t respect borders, race, or ethnicity. That is why we need to stand together, to learn from each other and to support each other. The medical staff in different countries are on the front lines and they doing a heroic job at a very difficult time.
Several surgical associations have come up with guidelines regarding surgical operations, mainly, postponement of elective surgical operations, while urgent and oncology cases must continue. The use of social distancing is encouraged whenever possible, the use of social media and mobile technology to communicate with stable post-operative patients is encouraged. The WOFAPS is willing to collaborate with other international surgical associations for the exchange of updated information and guidelines.
The WOFAPS executive committee, with representatives from different continents, are following closely the lessons and experiences in different parts of the world, we recommend that pediatric surgeons will take the extreme necessary measures for personal protection to be able to help and protect others, and to educate the community with the updated information to limit the spread and morbidity of the virus.
We are sure that with dedication and extreme efforts of researchers and scientists all over the world., working day and night, a drug and vaccine will be available, and the pandemic will be under control soon.
WOFAPS President,
Sameh Shehata
Author:
Prof. Muhammad Saleem
MBBS, FCPS, MME-HPE
Executive Member WOFAPS
Ex-President APSP
Medical Director/Professor of Pediatric Surgery,
The Children’s Hospital and The Institute of Child Health,
Lahore, Pakistan.
Email : msalimc@yahoo.com, msalimc63@gmail.com,
Contents
Number | Topic | Page |
1. | Introduction | 4 |
2. | Setting priority of surgeries during COVID-19 | 6 |
3. | Pediatric surgery consultation | 9 |
4. | Guidelines For The Surgical Patients In wards | 10 |
5. | Screening/testing of patients for surgery | 12 |
6. | SOP’S For Operation Theatres | 14 |
7. | Aerosol generating devices and procedures: | 16 |
8. | Personal Protective Equipment’s during surgery | 18 |
9. | SOPs for Anesthesia | 22 |
10. | Operation theater, Ventilation, and filtration | 26 |
11. | Laparoscopy and thoracoscopy | 29 |
12. | Histopathology and documentation | 32 |
13. | Conclusion and take home massage | 33 |
14. | Bibliography | 34 |
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Introduction:
The recent ongoing outburst of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), spreads all around the globe with a tendency to spread at an exponentially, significantly impacting many lives and affecting our practices as healthcare professional. By June 04, 2020, this global pandemic has infected about 66,55,352 cases in more than 212 countries/regions and 3,90,771 people have lost their lives till today(1). A significant number of pediatric cases of COVID-19 have also been reported. However, COVID 19 patients among pediatric age group are relatively fewer cases of COVID-19 compared to adult patients (2)(3)(4)(5). A recent study reported that only 2.16% (965/44,672) of infected patients were aged 19 years or younger (2)(6). In the United States 2%, in china 2.2%, in Italy 1.2% and in Spain 0.8% of confirmed cases of COVID-19 were among persons aged less than 19 years(2)(4)(5)(6)(7)(8)(9)(10). Among cases in children reported from China, most had exposure to household members with confirmed COVID-19(11)(12).
Although children are supposed to be less susceptible to COVID-19, the true infected rate of children may be understated because some children with asymptomatic and mild infections are unlikely to be tested (3). Besides, in addition to the COVID-19 itself, the relative shortage of medical resources caused by a surge in the number of coronavirus patients and accompanying economic downturn may also affect the diagnosis and management plans for children with surgical disease. Hence, the treatment plans for pediatric surgical disease during the COVID-19 outbreak deserve attention.
In the start of pandemic, generally all elective surgical and endoscopic cases were advised to be postponed. As still pandemic is running at peak in certain part of world this policy may be right, but in other part of world the peak is declining, so the decisions should be made in local circumstances, based on burden of COVID-19 patients and in the context of medical, logistical and institutional considerations. Usually, when an emergency occurs, it can be extremely essential for help to reach the location, as the situation can be time-sensitive. At that moment, you need to have the patients’ medical history at hand, and be able to ensure a smooth and streamlined transition for them so as to prevent as much further complications as possible. Hospitals that do not have emergency medical dispatch software can have difficulty managing the logistics of an urgent situation, especially during a pandemic. Not to mention, while deciding about continuity of surgical care one must consider an emergency, and emergent cases on priority and semi elective and elective cases decision based on resources, beds, intensive care facilities, and personals protective equipment (PPEs) availability. The risk factor to both patients and healthcare professionals should be taken into consideration.
Amidst the rapidly spreading SARS CoV-2 pandemic and the resultant morbidity and mortality, including healthcare personnel’s, the Executive Committee of World Federation Association Of Pediatric Surgeons (WOFAPS) 2020 are suggesting the following guidelines for the Pediatric Surgeons of all over world. So far this is thought to be a general guideline to be followed. However, this would also depend on the local authorities guidelines and different countries local guidelines considering local available resources and other logistics along with their own experiences.
These guidelines are evolving daily with better understanding of disease with passage of time. Developing these guidelines our aim is to support you and address certain uncertainties regarding our practices, our team safety, and improve overall patient care. Through above prism, we suggest that pediatric surgeons to follow these SOPs to reduce the morbidity and mortality of the patients as well as healthcare works associated with delivering care at this hour of crisis. Since 80% of the diagnosed cases of COVID as on this date are asymptomatic, we have to consider all surgical patients and their parents and care givers as potential carriers.
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Setting priority of surgeries during COVID-19 Guiding principles during active pandemic:
The primary aim is to deal with emergency and emergent surgical cases timely during the pandemic while considering workload of COVID-19 patients, taking into account of institutional resources like hospital beds, intensive care areas, PPEs, and ventilators availability and off course human resources(13)(14).
- For decision of cases there is no substitute for sound surgical consultancy
- Surgery should be performed only during this pandemic if delaying results in more morbidity, increase chances mortality, increase hospital stay, and more admission in future.
- The children who can be managed with medical treatment should be managed medically if failed then surgery should be considered like infected brachial cyst, failed medical treatment of appendicitis etc.
- Multidisciplinary-shared approach by surgeon, pathologist, radiologist, clinical nurse specialist, oncologist and coordinator should be used regarding classifying, scheduling and prioritizing of surgeries considering available institutional resources.
Considering above factors general pediatric surgical and urological cases be classified into following categories depending upon need of surgical intervention in emergency and elective cases in terms of time, already booked in out patient department.
- Priority level 1: Emergency: should be operated within 24 hours.
- Priority level 2. Emergent : should be operated within 72 hours.
- Priority level 3. Semi-elective a: should be operated within 1 month.
- Priority level 4. Semi-elective b: should be operated within 3 months.
- Priority level 5. Elective : can be operated after 3 months.
Pediatric General And Urological Surgery
Priority Level 1 Emergency Within 24 Hours | Priority Level 2 Emergent Within 72 Hours | Priority Level 3 Urgent Elective within 1 Month | Priority Level 4 Semi-Elective < 3 Months | Priority Level 5 Elective > 3 Months . |
Neonatal Malformations needing emergency correction (life threatening) – Oesophageal Atresia, Gastroschisis, Anorectal Malformations
Emergency Neonatal Laparotomy – Necrotizing Entero- Colitis (NEC), Perforation, Malrotation Emergency laparotomy (peritonitis/ perforation/ ischemia/ Necrotizing fasciitis) Emergency laparotomy – bleeding not responding to conservative management Laparotomy for post-operative complications (eg anastomotic leaks/ bleeding) Appendicectomy – complicated or unresponsive to conservative Rx Thoracotomy / Chest Drain Insertion / Video Assisted Thoracoscopic Surgery (VATS) for Empyema Laparotomy for intussuscept ion Strangulated inguinal hernia Acute Scrotal Exploration (suspected Testicular Torsion) Trauma Thoracotomy Trauma Laparotomy Removal of Infected Central Line Renal Obstruction with infection – not responding to Conservative Rx Torsion -ovarian/testicular
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Malformations needing urgent correction – Duodenal Atresia, Small bowel obstruction, Large bowel obstruction, Congenital Diaphragmatic Hernia,
Congenital Pulmonary Airway Malformations (CPAMS) – respiratory compromise Laparotomy – small bowel obstruction not responding to conservative Rx Laparotomy – Colectomy for colitis (Ulcerative Colitis / Hirschsprung’s) not responding to conservative Rx Soft tissue infection – any site not responding to conservative Rx Central Venous Line insertion for Oncology/Enteral nutrition/Access for antibiotics/Dialysis Drainage of obstructed renal tract Peritoneal Dialysis Catheter Insertion Resection of Posterior Urethral Valves Pyloromyotomy |
Infant with Biliary Atresia –
bladder exstrophy Inguinal hernia under 3/12 of age MDT Directed surgery for Nephroblastoma/ Neuroblastoma/ Rhabdomyosarcoma Crohn’s Disease – stricture/fistula/ optimize medication/nutrition Circumcision for severe BXO Renal transplant Renal Stent Removal/Exchange Malignant tumour or Lymph node biopsy
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Congenital Malformations with delayed Management – Hirschsprung’s Disease initially managed with washouts.
Inguinal hernia 3-12 mths of age Gastrostomy for Failure To Thrive (FTT) Interval appendicectomy for recurrent symptoms Cholecystectomy
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Anoplasty / Posterior Sagittal Anorectoplasty (PSARP) – after obstruction relieved
Inguinal hernia over 12 months of age and other uncomplicated hernias (umbilical, epigastric etc.) Orchidopexy for Un- Descended Testis Fundoplication for Gastro-Oesophageal Reflux Splenectomy for haemoglobinopathy Cholecystectomy – after biliary colic/ cholecystitis Hypospadias repair Pyeloplasty for Pelvi-Ureteric Junction obstruction Surgical treatment of Vesico-ureteric reflux Stoma Closure Benign lesion excision Bladder Augmentation Upper urinary tract obstruction Vesico-ureteric reflux Bladder dysfunction (Spina Bifida) BXO Undescended testis Gender dysphoria |
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Pediatric Surgery Consultation:
- Only minimum number of personnel’s should be deployed in out patient department/clinics along with properly PPEs as required and defined by local committee/CDC/WHO(15)(16).
- Thermal screening should be done at entrance of clinic.
- For patient consultation in outpatient department or in clinic the clinicians have to redesign their strategy. It should be tried to avoid physical consultation for non-emergency cases.
- Use the telemedicine platform if available and consultation should be provided online/Skype/phone call to the patients for normal surgical problems and follow-up till situation improves. Antenatal counseling may also be done by telemedicine/ video consultation(17).
- Please follow the statutory policies of respiratory triaging in receiving surgical emergencies.
- The social distancing, restricting the attendants to not more than one, patient/attendant masking and hand hygiene measures should be implemented mandatorily. The child should be held in a restrained position so that he or she does not touch any surroundings. The child should also wear a mask(15).
- Relevant history of patient from attendant will be taken regarding fever, cough, sore throat, shortness of breath or travel history to local or international endemic area or visit to corona center or contact with COVID 19 confirmed/suspected case, if positive, will be referred back with precaution to corona desk of healthcare facility.
- In referral or transfer from other centers, please discuss with the referring Physician in detail about the contact details, overseas travel history of the patient or family members, known contact with COVID patients, zone of origin/stay and presence of respiratory symptoms.
- Patients with emergencies, wound care, or other emergent surgical problems should be seen in emergency department with appropriate PPEs and taking all necessary measures.
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Guidelines For The Surgical Patients In Wards:
- Thermal screening should be done at the entrance of department.
- Only essential staff should be on duty with all other non-essential staff should stay at home.
- All educational activities should be done online resources.
- There should be minimum number of the patient attendants in the ward and attendants should be educated about cross infection. Preferably there should be only one accompanied attendant.
- During ward round minimum number of healthcare staff should be there taking care strict hand hygiene, antiseptic foaming, and wearing PPEs as enforced by local protocols, WHO standard, CDC guidelines.
- Emergency and emergent cases should be given priority over the elective and semi elective cases during pandemic. Each surgical specialty should rationalize/prioritize the procedures/surgeries during pandemic preferable postpone elective and semi elective surgeries till pandemic peak subside. (6)(13)(18).
- The stay of patients should be kept as short as possible.
- Daily disinfection of floor and hardware of the department should be carried out.
- The suspected/confirmed cases should preferably be shifted to corona isolation room if available. If not then a separate spaces should be dedicated in wards, ICU and other areas for these cases.
- A team of trained doctors and paramedical staff in management of COVID 19 should be appointed to take care for suspected cases.
- Single use or dedicated equipment (stethoscope, BP cuff and thermometer) should be used with proper care and after sterilization.
- If equipment needs to be shared it will be cleaned and disinfected/sterilized between usages.
- Stoppage of unnecessary movement and transportation of patients from one area to another should be ensured.
- Healthcare worker who are transporting patients should practice strict hand hygiene.
- Postoperative care: Management regarding drains, tubing, dressing catheter, and removal of stitches should be thoroughly explained to parents. Try should be made to reduce hospital.
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Screening/testing of patients for surgery:
- All the patient should be screened with a series of questions about history of fever, cough, shortness of breath, chills, sore throat, loss of smell and taste, diarrhea and headache or travel history to pandemic or contact with COVID positive person, surgery should be deferred and referred to corona disk for evaluation by RT-PCR testing to rule out COVID 19 and quarantine as required.
- In ideal circumstances, all in-patients admitted for surgery/endoscopy/laparoscopy should be tested RT-PCR for COVID-2 in pandemic area by preferably nasopharyngeal swab, if readily available and is practical and resources allows; as free availability of test is still a challenge in many part of world(19). Otherwise if not possible at least every suspected patient must be tested.
- A detailed history and contact tracing of the mother and visiting father should be done. If there is any suspicion, the parents should also be tested for COVID. All inpatient Antenatal mothers should be tested for COVID.
- If available then serological testing should also be performed to stratify the patients for surgery. This test is based on antibody production by immune response of the body within 7 to 10 days after exposure to virus. In America serological testing was introduced in the beginning of April by Cellex which is approved by FDA(20). Results are available within 15 minutes. The antibodies detected are IgM, IgA, IgG and total antibodies(21).
- Based on incubation period {median 5.1 day varying 2.2 days (2.5%) to 14 days with 97.5% become symptomatic on 11 to 12 day)(22) of the disease with help of gold standard PCR test and antibody screening test the patients can be stratified for surgery as follow:
Figure 1 : Flowchart suggesting COVID -19 testing protocol for surgical patients(19)
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SOP’S For Operation Theatres:
- Complete, informed consent regarding COVID 19 exposure and potential consequences should be taken.
- Again thermal screening should be done at entrance of OT.
- If patient is having fever > 100.4F, persistent cough or travel history of pandemic area or contact COVID-19 positive should not be scheduled for surgery.
- All Health Care Workers should wear provided facemask and necessary equipment as per local guidelines/CDC/WHO recommendation.
- Alcohol based sanitizers should be used in each operating room
- All OT tables and surfaces should be cleaned with alcohol-based liquids/sodium hypochlorite 1000 ppm and treated with hydrogen per oxide or Ultraviolet-C irradiation after each use(23).
- Patients should be allowed to come one by one for pre-operative assessment.
- N-95 Masks and appropriate PPE should be used for all known or suspected cases of Covid19.
- Only those considered essential staff should be participating in the surgical case and unless there is an emergency, there should be no exchange of room staff.
- The number of staff members present in OT for intubation/extubation should be limited to reduce the risk of encounter with the patients having mark on thumb.
- Healthcare providers should wear a mask and use hand sanitizers all the time.
- For the best benefits of healthcare providers all patients’ attendants should wear mask after entering premises of the hospital.
- At entrance of the hospital there will be a signboard with request to help and co-operate with the healthcare providers for prevention of unnecessary exposure to infected patients.
- There will be separate designated O.R and PICU room/area or in isolation room/isolation ward/HDU for confirmed or suspected 2019-nCOV infected cases(24).
- The COVID suspected/confirmed case should be assessed, induced, and recovered after completion of operation within the designated OR to reduce the contamination in single room. This patient should be directly shifted back to designated ward/HDU/ICU by passing recovery area(23).
- The pathway of shifting of corona suspected/confirmed patient from isolation ward/HDU/ICU should be predefined, cleared during shifting both to theater and back to designated area.
- Surgical instruments and other equipment used during surgical procedures with COVID-19 positive/suspected COVID patients should be cleaned separately from other surgical equipment.
- To decrease the risk of contamination and to help cleaning of OR, anesthetic machine, monitors, and other necessary equipment in theater should be covered with plastic wrap.
Special areas
- Aerosol generating devices and procedures: (25) (26)(17)(27)(28)(23)
Aerosol generating procedures can be
- Respiratory
- Surgical
- Respiratory procedures are
These conditions are evidence base AGPs
- Anesthesia induction/intubation
- Open airway suction
- Resuscitation
- Oscillating ventilation
These conditions are supposed to AGPs, although evidence is limited:
- Ongoing severe coughing
- Use of laryngeal mask anesthesia
- Noninvasive ventilation (bivalve positive airway pressure, continuous positive airway pressure) positive pressure with mask
- Extubation
- Oscillatory positive expiratory pressure (OPEP) / handheld airway clearance
- Cough assist
- High flow nasal cannula oxygen >2 L/kg
- Use of nebulized medications
- Placement of nasogastric/nasoduodenal/naso-jejunal tubes
- Surgical procedures (29)(30)(31)(32)(23)(17)
There are different devices, which can generate aerosol during surgery
- Unipolar or bipolar cautery both coagulation or cutting mode
- Advanced bipolar cautery
- High speed energy/power devices like Harmonic scalpel and LEGASURE
- Laparoscopy
- GIT endoscopy
- Laryngoscopy both direct and indirect.
- Thoracoscopy
- Bone cutter
- Bone drill
- Bone saw
- Dental procedures
- Intussusception reduction
- Passing chest tube.
- Mastoid drilling
All of these devices resulted in generation of aerosol < than 5 microns.
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Personal Protective Equipment’s during surgery:
Currently a wide global variation has been reported in access to the PPE and it will influence the implementation of some of these guidelines. All members of the OR staff should use PPE as recommended by national or international organization including the WHO or CDC and local committees. Appropriate gowns and face shields should be utilized. These measures should be used in all surgical procedures during the pandemic regardless of known or suspected COVID status. Placement and Removal of PPE should be done according to CDC/WHO guidelines.
The need of PPEs depends upon following factors, which will play an important role in deciding requirement of PPEs during surgery.
- Patient having suspected disease, active disease, or proved non-COVID disease.
- Whether tested by PCR, or immunological test.
- Whether the operative facility have negative pressure facility and laminar airflow in Operation Theater.
- Whether the procedure is aerosol generating or not.
- Whether there is need of unipolar/bipolar/advanced bipolar cautery, and using high-energy device like Hormonic scalpel /LEGA sure.
- Mechanism of suction during operation.
The situation can be as follow
- Non tested/suspected/confirmed positive patients: In areas/countries of high prevalence of COVID-19, and during surgery on patients who have not been RT-PCR-tested for SARS-CoV-2, we recommend that surgeons and the entire surgical team that scrub during the case should wear (23)(33)(34)
- A respirator mask preferably N95, KN-95, FFP2 if available N-99 or FFP3 (11.5 to 15.9 times effective than surgical masks) (NIOSH or equivalent standard)
- Preferably Powered Air-purifying Respirator (PAPRs) or FFP3/N-99 during AGP procedure along with all above case of respiratory AGPs. The surgical AGPs can be managed with FFP2/N-95 masks(35)(17)(23).
- A face shield with a neck cover that wraps around the face and has an extension that can be placed inside the gown.
- In the absence of a face shield, protective eyewear that provides a seal around the eyes (i.e. goggles) should be worn.
- Disposable surgical gloves preferably double gloves should be wearied.
- Full arm disposable water resistant surgical gown along with disposable fluid repellent coveralls especially for suspected/confirmed cases preferable in aerosol generating procedures(25).
- Disposable surgical gloves and fluid repellent coveralls should be disposed of after every patient.
- Rest of PPEs does not need to change with every patient.
- Patient should also be wear facemask during transport to theater and back to designated area after procedure.
- Tested patients but negative: In patients who have been tested for SARS-CoV-2 by RT-PCR within 3 days of surgery and proved negative or quarantined for 14 days prior to elective surgery, regular protective equipment (three ply surgical mask, double gloves, full arm water resistant disposable surgical gown, etc.) may be worn.
- Day to day activities in department: All personals working the department should wear
- Regular surgical masks, and
- Gloves for interaction with patients.
- Avoid unnecessary contact.
- Keep adequate distance
- Proper hand hygiene
- Disinfection of room
- Donning and doffing: There should be proper donning and doffing as per standard protocols in properly designated rooms.
- Waste management: PPEs should be disposed off as per waste management protocols.
- Training of staff:
- A comprehensive training program for use of PPEs should be started at every healthcare facility.
- The healthcare professionals should be trained to clean, disinfect, store, and recognize any damage to their PPEs.
- Mask fit-test for N-95-99/FFP2/FFP3/KN-95 should be performed before wearing mask to comply with ISO standard for its use. If not possible then at least fit-checked by trained staff should be done.
- These measures should be implemented until the pandemic ends.
Rationale: Considering that the SARS-CoV-2 appears to be mainly transmitted via respiratory droplets(36), it is reasoned that N-95-99, FFP2 or FFP3 masks provide improved protection against transmission of aerosol droplet nuclei(37). Regular surgical masks are effective against the transmission of droplets. As it is possible that a patient may need to be intubated during surgery, patients and staff may be unable to properly protect themselves or others during coughs and other situations in which aerosolization of particles may occur. Thus, wearing a N-95/99, FFP2 or P3 mask during these procedures appears to provide the best protection against transmission of any potential disease (15). Face shields can be used in order to decrease the potential contamination of the surgeon and staff from patient’s bodily fluids and particulate during the procedure (37). The neck wrap tucked into the surgical gown provides further protection in this regard. It is also important for staff to remember that hand washing should be performed both before and after the donning or doffing of PPE studied(37). However, it is imperative that staff members understand that hand hygiene alone, regardless of the use of PPE, is also effective in limiting transmission of SARS-CoV-2 (36).
Reuse of N-95/FFP2, FFP3(38)(25)(35):
It is possible that the cleaning and disinfection of N95 (FFP2 or P3) masks can be performed by using
- Ionized hydrogen peroxide
- Ultraviolet light /sanitization
- Ethylene oxide ETT
- High temperature
But this practice should not been enough to be widely recommended.
Limitation:
- It is unknown that how many times a N95 (FFP2 or P3) mask can be disinfected or
- Wearing a previously cleansed N95 (FFP2 or P3) mask may pose new risks to the healthcare provider (i.e. the inhalation of hydrogen peroxide, etc.) (38).
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Anesthesia
Carrying out surgical procedures during a global pandemic has increased risks for disease transmission during surgeries. General anesthesia requiring airway manipulation, endotracheal intubation, and positive pressure ventilation can result in aerosol generation thus more likely to predisposing the both anesthesia and surgical team to vulnerable to transmission of SARS-CoV-2. The risk of aerosol generation increases with the manipulation of the airway by performing direct or indirect laryngoscopy during endotracheal intubation(26)(39). So, every attempt should be made to reduce risk of aerosolization and spread of infectious viral particles through the air to others on priority.
The regional anesthesia although rarely used in pediatric age group, if possible, should be considered for elective surgery during the pandemic. Although, it does not completely eliminates the risk of viral transmission. Aerosolization of viral particles can also occur when simply providing supplemental oxygen, with a nasal cannula with a high-flow rate of oxygen increasing the risk for dispersion and viral spread(40). This is usually used during induction, on extubation at end of surgery and sometimes with local/regional anesthesia. So, It is important to take appropriate precautions and assume that viral aerosolization will occur with regional anesthesia also(39).
If general anesthesia is required for the procedure, certain techniques can help reduce the risk for exposure to healthcare workers. So following precautions should be employed during whole period of anesthesia.
- Team leadership: Anesthesia team in charge of patient’s airway should use proper and appropriate PPE throughout the procedure especially during aerosol generating procedures. This includes intubation and extubation, as well as airway suction(34)(16)(41).
- There should be one consultant anesthetist and a properly trained anesthesia technician in OR for induction of case. If any difficulty arises in case of intubation, another anesthetist should be readily available nearby outside OR(33).
- A good seal is required for an endotracheal tube to avoid additional exposure to aerosols.
- At a minimum, a surgical mask should be fitted to cover the patient’s face before induction while shifting from ward to theater, preoperative area, and after extubation(33).
- If needed and possible, intubation and extubation should take place within a negative pressure room(41).
- Patients should be properly pre-oxygenated to avoid multiple attempts at endotracheal intubation, and modified rapid sequence intubation with deeply paralyzing the patient preferably no bag mask ventilation or two provider bag and mask ventilation is appropriate all patients(24)(41)(33).
- The endotracheal tube cuff should inflated before starting controlled ventilation.
- A laryngeal mask airway may be appropriate, in particular after a failed attempt at endotracheal intubation and to avoid multiple attempts, but a good seal is absolutely necessary to avoid exposure. Again, a HEPA filter should be used, especially with high-risk patients even with a previous negative test.
- During intubation and extubation the number of personnel in the room should be minimized as much as possible. The surgical team should not be inside operation room during induction. They should enter the OR at least 3 to 5 cycle of room air exchange(33).
- It is essential to place a Heat Moist Exchange Filter (HMEF) between the tracheal tube and breathing circuit at all times. (24)(41)(42). It should be replaced after each patient or if it is soiled with secretions to avoid blocking. HMEFs are used to maintain humidification and these can filter up to 99% of airborne particles 0.3 microns or greater thus preventing spread of possibly COVID 19(24). Since increase in dead space in pediatric patients is a concern so it is recommended to use device with an acceptable dead space i. e 10 ml and a minimum tidal volume of 30 ml (5 kg patient). Furthermore ETCO 2 lead must be attached to the HMEF to avoid contamination of lead.
- To protect the anesthesia machine from increased viral load, a High Quality Mechanical Viral Filter (HQMVF)/HEPA filter should be placed between the end of expiratory limb and the machine. High quality filters with VFE ratings of 99.999% and above are available and should be used if possible. The filter, placed at the end of the expiratory limb, does not affect dead space. It should be preferably changed between the patients if adequate supply is available or simply wipe its surface.
- The water trap in the anesthesia machine has a continuous flow of gas from the patient. If we use HQMVF, the water trap is not contaminated and does not need to be changed. Simply wiping off the external surface of water trap between the patients is sufficient. However gas sampling tubing needs to be changed.
- If possible, an enclosed oxygen mask with a proper seal should be used to deliver oxygen, especially if high-flow rates are required.
- If the filter in the water trap is confirmed to have an effective VFE, gases sampled from the airway do not require additional filtering. Otherwise placing a 0.2 micron drug injection filter at the entry to the water trap will provide an added measure of protection
- Since tracheal suctioning is an aerosol generating procedure so it is important to use closed suction system whenever possible. It should be placed between ETT and filter immediately after ETT insertion. Similarly inline, nebulizers should be used by placing on the patient side of the filter.
- At any time if circuit needs to be changed or while placing closed suction or inline nebulizer, the ventilator should be paused and ETT clamped to avoid risk to HCW in the OR.
- If water trap is used with a COVID positive patient then it should be changed.
- Scavenging: A formal scavenging is usually not available many anesthesia machines. By applying corrugated tubing to scavenging port and dipping it in a bucket with 1% hypochlorite solution will resolve the issue(42).
- Clean the room 20 minutes after tracheal intubation or aerosol generating procedures.
Regarding cleaning and starting surgical procedure after intubation or aerosol generating procedures is different in different literature and it depends on whether the facility have air handling units with HEPA filters or not.
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Operation theater, Ventilation and filtration:
The ventilation system of operating room should be designed in such a way that it reduces the presence of airborne pathogens to a minimum. As already discussed that there are many steps while doing surgery that can result in aerosols production ultimately subjecting the theater staff to SARC-COV-2 infection(25) (26)(17)(27)(28)(32)(15). Moreover one study highlighted that SARS-COV-2 virus particles may be present in blood, bone and fat in significant numbers in COVID 19 patients up to 1% of patients(43). So its safe to presume that surgical procedure in suspected/confirmed cases, can contaminate theater staff (32)(43)(44).
Its already known that intubation/extubation, endoscopy, laparoscopy, and use of energy devices are aerosol generating procedures and risky as virus is known to be present in the nasopharynx of infected patients, different body fluids and blood(32)(36)(45)(46)(28).
It is recommended that air-conditioning and ventilation systems should be designed to reduce the minimum spread of virus by these aerosol generation procedures(37)(15)(41)(47). Ventilation system usually varies between operating rooms even in a single hospital and more broadly between operating rooms in different hospitals within different cities and countries.
So we suggested following recommendation for safe and effective environment for resumption of elective surgery:
- Operating rooms for presumed, suspected or confirmed COVID-19 positive patients if possible, should be different than rooms used for other surgical patients which surely non COVID confirmed by PCR(24)(42)(33)(23). Preferably should be located separate from main operation theater, near the COVID-19, ICU/HDU/Isolation rooms with separate change rooms, separate donning and doffing rooms, separate entries and exit and scrub areas. This facility should have separate heat ventilation air condition (HVAC) system with separate air handing unit (AHU) from rest of hospital facility(42)(23) with HEPA filtration for filtration of virus contaminated in theater from patient and AGPs procedure. This HEPA filter should be installed in the ducts which is sucking air back for recirculation thus filtered air should be re-circulated. Minimally opening the door during transfer of patient and then locking the door during surgery and reducing trafficking by using one entry/exit door can minimize the flow of contaminated air(23)(33).
- Preferably this operative facility should be negative pressure operation room at least for induction of patient to reduce the spread of contaminated aerosol in suspected/confirmed cases of SARS-COVID-2 patient to surroundings(37)(26)(41)(23)(48) these are rarely available in 3rd world countries(24). The ventilation system of most of the operation theaters are designed be positive room pressure to reduce ingress of contaminated air from the surrounding of theater to reduce wound infection. To convert a positive pressure operative room to AIIR is difficult time consuming, costly and complex(48)(31).
- If this HVAC system is attached with rest of hospital and other non-COVID OR, it should be detached from them or duct going to them should be blocked.
- If HVAC system with air recirculation have not the facility of HEPA filtration then this system should be converted to non re-circulatory type by converting AHU to take full new fresh air for circulation (100% once through), and discording all exhausted air out side after proper treatment either by
- 1% hypochlorite or
- UV light for 15 minutes or
- Heating it up to 75 degree f, or
- Disposing it about 6 feet higher than rooftop away from air sucking source of AHU and populated area.
There will be some compromise on air-conditioning but chances of recirculation of contaminated air will reduced much.
- Normal positive pressure rooms for elective cases. Another suitable, practical, and cost effective option is without converting a positive pressure room to negative pressure rooms, the facility can be made useful with help of modalities that decrease efflux of contaminated air into the hallways(31). These can be
- In-room air filters and
- Negative pressure antechambers.
- There must be HEPA (High Efficiency Particulate Air) filter installment in the ducts of the HVAC system in every operation theater to minimize aerosol and droplets but it is still not present in many of 3rd world countries hospital usually in periphery district and tehcile hospital settings(24).
- Minimum requirement is that the ventilation system to produce a minimum of 20-25 air exchanges per hour as at this rate, 99.9% of viral particles will be removed in 21 minutes (7 cycles)(31)(42)(23)(49).
- If permanent fitted HEPA filters in the HVAC system are not there, then portable HEPA filter system should be installed in the theater to remove viral particles without converting them to a negative pressure room(31).
- By implementing vertical laminar flow; aerosols production at the surgical site will possibly flow down to the floor level and will exit through vents. In this way it may not circulate widely in the operating room. So this will help to reduce spread of aerosol in theater minimizing exposure of equipment and theater staff(24)(31).
- To make laminar airflow more effective there should be minimum staff trafficking in the theater and spare staff should not present in the theater especially at intubation/extubation(24).
- There should be minimum and necessary equipment in theater for required surgical procedure and it should be rationally streamlined in theater to prevent hindrance to airflow.
- Urgent future planning should made for dedicated COVID OR with proper central air-conditioning with dedicated fresh air cycles, separate AHU, and having facility of negative pressure, equipped with HEPA filter to filter 0.3 micron virus particles and totally separate from non COVID OR.
-
Laparoscopy/Thoracoscopy:
Practical Measures for Laparoscopy
Laparoscopy and thoracoscopy are Optional as per Hospital/ Departmental Guidelines. Usually in the initial phase of this pandemic. It was highly recommended not to do laparoscopy and prefer open surgery to reduce the risk of aerosol spread(34)(46)(14)(13).
Although many studies have shown increased risks of aerosol spread with laparoscopic/thoracoscopic procedures in this pandemic, but conclusive evidences are not yet available(45)(46). Novel research on this matter is needed. As these procedures have potential to generate aerosolized viral particles which can be discharged in the Operation room atmosphere under increased pressure and can infect theater staff and also pollute equipment to be potential source of COVID-19 infection(45)(46), so protective measure to safe the medical workforce should be strictly implemented. As we have to live with pandemic and also peak is declining in some part of world, majority of surgeon will wish to start laparoscopy again. More over laparoscopy definitely has advantage of much shorter length of stay at hospital along with less chances of complication(46). Another advantage of laparoscopy is that one can control aerosols by attaching some device to tubing while filtration of aerosolized particles may be more difficult during open surgery so may has advantage in COVID 19 patients(31). Hence the following precautions should be taken if at all one decides to go for these procedures.
- Incisions for ports should be as small as possible to allow for the passage of ports but not allow for leakage around ports.
- If Hassan method is used to place the first port, it should be thoroughly fixed to the skin to minimize air leak.
- Once placed, the ports should not be used to evacuate smoke or desufflation during the procedure where possible.
- CO2 insufflation pressure should be kept to a minimum and an ultra-filtration device (smoke evacuation system or filtration) should be used, if available(46)(50) to absorb the aerosols.
- All pneumoperitoneum should be safely evacuated via a filtration system before closure, trocar removal, specimen extraction or conversion to open.
- During desufflation, all escaping CO2 gas and smoke should be captured with an ultra-filtration system and desufflation mode should be used on your insufflator if available. If desufflation feature is not available, be sure to close the valve on the working port that is being used for insufflation before the flow of CO2 on the insufflator is turned off. Without taking this precaution, contaminated intra-abdominal CO2 can be pushed into the insufflator when the intraabdominal pressure is higher than the pressure within the insufflator(46)(50).
- The patient should be flat and the least dependent port should be utilized for desufflation.
- Specimens should be removed once all the CO2 gas and smoke is evacuated.
- Surgical drains should be placed only if absolutely necessary.
- Suture closure devices that allow for leakage of insufflation should be avoided. The fascia should be closed after desufflation.
- Intraoperative, filters are recommended to remove smoke and particulate matter including viruses. Viruses are known to transmit through the surgical smoke. Currently, two filters namely ULPA (ultra low particle aspirator) and HEPA (high efficiency particle aspirator) are capable of clearing the virus particles. An alternative or an additional method is attaching the suction apparatus through a chest drainage bottle or bag containing hypochlorite solution at the base so that the sucked air goes through the solution.
- Electrosurgery units should be set to the lowest possible settings for the desired effect. Use of monopolar electrocautery, ultrasonic dissectors, and advanced bipolar devices should be minimized, as these can lead to particle aerosolization(46)(31)(29). If available, monopolar diathermy pencils with attached smoke evacuators should be used(50)(51) otherwise these energy devices should be used at low power.
- Energy source usage should be minimal and the smoke thoroughly aspirated during open as well as laparoscopic procedures. “Aerosolization of viral and bacterial RNA/DNA may occur during use of energy devices. The mechanism is different – rather than gas moving over fluid, it result from pyrolysis of tissues, an inherently destructive process. The various energy sources lead to different sizes of particles, electric cautery and LASER having the smallest, hottest particles and ultrasonic surgical devices larger, cooler particles. So there minimal use and short bursts are advised.
- The surgical procedure and at crisis situations of bleed may expose the team to a dangerous level of atmospheric spill of high risk aerosols when involving multiple exchange of instruments and during handling gas mixed abdominal fluids. It is advised to use appropriate smoke evacuation systems in the hour of crisis(50)(51).
- It is suggested that the current best practice for mitigating a viral infection transmission during a endoscopic, laparoscopic and thoracoscopic procedure is to use a multi-layered approach, which includes proper ventilation, appropriate PPE and smoke evacuation devices with a suction and filtration system(46)(50)(51) along with other standard safety precautions.
12.Histopathology specimen
The staff handling histopathological specimen should trained and well versed with handling these specimens during transport and should proper PPEs. The specimen should be completely immersed in 10% buffered formalin. The specimens and histopathology requisition forms should be labeled properly with all patient details and clearly marked regarding the status of CoViD-19 (negative, suspected, positive or Not Tested)). it should not handled with contaminated gloves and any infected material. During pandemic fresh frozen section/biopsy should be preferable avoided.
Documentation
Along with all routine operative and non-operative documentation of the patient, the attending parents/relatives detailed should be recorded. The full names and contact details with addresses of complete Anesthetists team, Surgeons team, nurses and technicians and supportive staff should be mentioned. The operation theatre room number, time the patient was brought in and shifted out should be noted. Hospital guidelines to be followed for All other Admission and Infection Control Policies, PPE and Testing.
Take Home massage:
Finally this is uncertain time. Situation is ever changes day by day. Presently pandemic is at peak, and now toward declining trend in many parts of world but still now we do not know whether there will be the second surges of COVID-19. Vaccination is still far away. Pediatric surgeons have to take leadership role. Shortage of PPEs and testing kits is still a challenge to the management teams. The pediatric surgical, anesthesia and nursing team has to work closely to learn to live with this COVID-19 for next probably 1 or 2 years. We have to think over resuming the elective cases and to start laparoscopy and other endoscopies with the lessons we learned till now from our and otherworld team leaders. The most important learning lessons is to observe basic points of hand hygiene, wearing masks, and maintaining social distances to safe our own lives. Then we have to reorganize our self to carryout surgical procedures by wearing proper PPEs and redesigning our futures theater facilities to combat such sort of fatal infections.
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Congratulations Team WOFAPS specially Prof Muhammad Saleem n Prof Sameh Shahata.
Great contribution towards Paediatric Surgery. Hope maximum number ll be benefitted following these.
Congratulations and Best wishes to WOFAPS team for this excellent contribution for Paediatric Surgery. Thanks a lot.