COVID-19: considerations for optimum surgical team protection before, during and after operation
Keywords:COVID-19, Personal protective equipment, Aerosols generating procedure, N95 mask, Social distancing
SARS CoV-2, the virus responsible for coronavirus disease 2019 (COVID-19), has caused a global pandemic. Surgeons’ obligation, as always, will be to provide timely, high-quality surgical care that achieves the best outcomes for patients. It is imperative to ensure the safety of health-care workers not only to safeguard continuous patient care but also to ensure they do not transmit the virus further. Viral particles have been found in nasal swabs, pharyngeal swabs, sputum, bronchial swabs, gastrointestinal tissue, blood, and stool.Surfaces in isolation rooms and even clinician shoe covers have tested positive as well. Some key considerations for protecting surgical teams; structure frequent communication before key events; assume the entire operation theater will be contaminated; choose personal protective equipment (PPE) effective against aerosolized particles; adapt surgical technique to reduce exposure risks; use a “buddy system” for donning and doffing; after operation/recovery; going home – what should be done to keep your family safe. Though careful planning and appropriate PPE are essential, the most effective way to prevent viral exposure is to avoid performing non-essential surgical procedures. Non-operative approaches may be a safe alternative to surgery for some patients. Many patients, however, will require emergency operative intervention.
Gale SC, Shafi S, Dombrovskiy VY. The public health burden of emergency general surgery in the United States: A 10 years analysis of the Nationwide Inpatient Sample - 2001 to 2010. J Trauma Acute Care Surg. 2014;77:202-8.
Wang W, Xu Y, Gao R. Detection of SARS - CoV-2 in Different Types of Clinical Specimens. JAMA. 2020;323(18):1843-1844..
Guan WJ, Ni ZY, Hu Y. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020;382:1708-20.
Chang D, Xu H, Rebaza A. Protecting health - care workers from sub-clinical coronavirus infection. Lancet Respir Med. 2020;8:13.
Ong SWX, Tan YK, Chia PY. Air, Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS - CoV-2) From a Symptomatic Patient. JAMA. 2020;323(16):1610-2.
Doremalen VN, Bushmaker T, Morris DH. Aerosol and Surface Stability of SARS - CoV-2 as compared with SARS - CoV-1. N Engl J Med. 2020;382(16):1564-7.
Kwak HD, Kim SH, Seo YS. Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery. Occup En viron Med. 2016;73:857-63.
Stephenson DJ, Allcott DA, Koch M. The presence of P22 bacteriophage in electrocautery aerosols. In: Proceedings of the National Occupational Research Agenda Symposium, Salt Lake City, UT. Available at: https://www.researchgate.net/profile/Dale_ Stephenson/publication/242419093_the_presence_of_p22_bacteriophage_in_electrocautery_aerosols/links/00b7d52 a09d15f05f3000000.pdf. Accessed on 18 March 2020.
Ti LK, Ang LS, Foong TW. What we do when a COVID - 19 patient needs an operation: operating room preparation and guidance. Can J Anaesth. 2020;67(6):756-8.
UW Medicine COVID-19 Protocols Available at: https://covid-19.uwmedicine.org/Pages/default. aspx. Accessed on 19 March 2020.
UCSF Health COVID - 19 Clinical Resources | UCSF Health Hospital Epidemiology and Infection Prevention. Available at: https://infectioncontrol.
ucs-fmedicalcenter.org/ coronavirus. Accessed on 19 March 2020.
Wax RS, Christian MD. Practical recommendations for critical care and anaesthesiology teams caring for novel coronavirus (2019 - nCoV) patients. Can J Anaesth. 2020;67:568-76.
Air Appendix Environmental Guidelines, Guidelines Library, Infection Control, CDC. Available at: https://www.cdc.gov/infectioncontrol /guidelines/environmental/appendix/air.html. Accessed on 20 March 2020.
Qian Y, Willeke K, Grinshpu SA. Performance of N95 respirators: filtration efficiency for airborne microbial and inert particles. Am Ind Hyg Assoc J. 1998;59:128-32.
Farmer WM, Nataupsky M, Gorochovskaya R. Identification of Aerosol Production during Surgical Procedures. 00229128; NIOSH. Available at: https://www.cdc.gov/niosh/nioshtic-2/00229128. html. Accessed on 18 March 2020.
Tream IC. Aerosol Generating Pro cedures (AGPs). Health Protection Scotland. Available at: https://hpspubsrepo.blob.core.windows.net/hps - website/nss/2893/documents/1_tbp - lr - agp - v1.pdf. Accessed on 23 November 2019.
Mellor G, Hutchinson M. Is it time for a more systematic approach to the hazards of surgical smoke: reconsidering the evidence. Workplace Health Saf. 2013;61:265-70.
Schultz L. Can Efficient Smoke Evacuation Limit Aerosolization of Bacteria. AORN J. 2015;102:7-14.
Liu Y, Song Y, Hu X. Awareness of surgical smoke hazards and enhancement of surgical smoke prevention among the gynecologists. J Cancer. 2019;10:2788-99.
CDC. Coronavirus Disease 2019 (COVID - 19). Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/coronavirus/2019 - ncov/hcp/respirator - use - faq.html. 2020. Accessed on 18 March 2020.
For different groups of people: how to choose masks. Available at: http://en.nhc.gov.cn/2020-02/07/ c_76344_2.htm. Accessed on 18 March 2020.
Recomendaciones para manejo de pacientes con infeccion por Covid-19 en el contexto de una intervención quirúrgica urgente O electiva. Asociacion Espanol de Cirujanos (AEC). Available at https://www.aecirujanos.es/files/noticias/152/ documentos/Recomendacio nes_caso_cirugia.pdf. Accessed on 18 March 2020.
Australian Health Department. Interim recommendations for the use of PPE during hospital care of people with COVID-19 Version 2. Available at:https://www.health.gov.au/sites/default/files/documents/2020/03/interim-recommendations-for-the-use-of-personal-protective-equipment-ppe-during-hospital-care-of-people-with-coronavirus-disease-2019-covid-19.pdf. Accessed on 18 March 2020.
Kaixiong T, Bixiang Z, Peng Z. Recommendations for general surgery clinical practice in novel coronavirus pneumonia situation. Chinese J Surg. 2020;58:E001.
World Health Organization. Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19): Interim Guidance. WHO/2019- nCov/IPC PPE_use/2020.1; WHO. Available at https://apps.who.int/iris/bitstream/handle/10665/331215/WHO-2019-nCov-IPCPPE_use-2020.1-eng. pdf. Accessed on 18 March 2020.
Tran K, Cimon K, Severn M. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One. 2012;7:35797.
Coteaux DJG, Picard P, Poulin EC. Preliminary study of electrocautery smoke particles produced in vitro and during laparoscopic procedures. Surg Endosc. 1996;10:152-8.
Li CI, Pai JY, Chen CH. Characterization of smoke generated during the use of surgical knife in laparotomy surgeries. J Air Waste Manag Assoc. 2020;70:324-32.
Yu GY, Lou Z, Zhang W. Several suggestions of operation for colorectal cancer under the outbreak of Co rona Virus Disease 19 in China. Zhonghua Wei Chang Wai Ke Za Zhi. 2020;23:9-11.
Ball K. Compliance with surgical smoke evacuation guidelines: implications for practice. ORNAC J. 2012;30:14-6.
Moore D, Gamage B, Bryce E. Protecting health care workers from SARS and other respiratory pathogens: organizational and individual factors that affect adherence to infection control guidelines. Am J Infect Control. 2005;33:88-96.
Centers for Disease Control. Sequence for putting on personal protective equipment (PPE). Available at: https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf.
COVID-19: Removal and disposal of Personal: Protective Equipment (PPE). UK: NHS. Available at https://youtu.be/oUo5O1JmLH0. Accessed on 19 March 2020.
NIOSH. NIOSH Fact Sheet: The Buddy System. Available at: https://www.cdc.gov/vhf/ebola/pdf/ buddy/system.pdf. Accessed on 18 March 2020.
COVID-19: Guidance for Triage of Non-emergent Surgical Procedures. American College of Surgeons. Available at https://www.facs.org/about -ACS/covid - 19/information - for - surgeons/triage. Accessed on 19 March 2020.
Radonovich LJ, Simberkoff MS, Bessesen MT. N95 Respirators vs Medical Masks for Preventing Influenza Among Health Care Personnel: A Randomized Clinical Trial. JAMA. 2019;322:824-33.
American College of Surgeons: COVID-19: Considerations for Optimum Surgeon Protection. 2020. Available at: https://www.facs.org/covid-19/clinical-guidance/surgeon-protection. Accessed on 15 April 2020.