What a Surgeon should know during the COVID pandemic.

1. Under guidance of Dr Deshmukh and team
By
Dr Aravind S Hosamani
3rd year surgery resident
RCSM GMC Kolhapur.

6.  Why there are so many cases?
 Why almost elective surgeries and
procedures are deferred?
 High infectivity of COVID.
 Preserving resources and manpower
 Increased mortality in COVID patients.

7.  Surgery involves many short procedures
which involve aerosole production
 For example;
 Suctioning
 Intubation
 Diathermy usage
 CO2 insufflation desufflation
 Spillage
 CPR

9. Infective Clinical Specimens
According to an article Detection of SARS-CoV-2 in
Different Types of Clinical Specimens by Wenling
Wang et al,
 Bronchoalveolar lavage fluid specimens showed the
highest positive rates (14 of 15; 93%)
 sputum (72 of 104; 72%)
 nasal swabs (5 of 8; 63%)
 fibrobronchoscope brush biopsy (6 of 13; 46%)
 pharyngeal swabs (126 of 398; 32%)
 feces (44 of 153; 29%)
 blood (3 of 307; 1%).
 None of the 72 urine specimens tested positive

10.  But a new study by Federico Coccolini
Italy says SARS-CoV-2 is detected in
peritoneal fluid at a higher
concentration than in respiratory tract.

11.  Only way to protect is preplanning.
 Designing and define everything in prior
 From ER/wards to OT to recovery to
wards
 Adequate training to all medical and
nonmedical workers involved in patient
care.

12.  Some operational guidelines given by
team of senior surgeons and research
workers published in World Journal of
Emergency Surgery.

13. Location of OR
 Operation room closest to the entrance
of the OT complex is allocated for
COVID patients undergoing any surgical
procedure.
 To prevent/minimize the OT
environmental contamination.

14. Patient transport
 As quick as possible(both to n fro).
 Predefined path viz shortest possible route.
 Dedicated stretcher and/or vehicle with
trained and equipped personnel for
intra/inter-hospital transport.
 If possible biocontainment unit should be
used.
 Sanitization measures of the equipments
as frequently as possible.

15.  Any non-intubated patient must wear a
surgical mask, disposable waterproof gloves,
disposable cap, and shoe covers during
transport.
 The patient’s hands should be sanitized
before transport.
 Transport operators must sanitize hands and
wear PPEs before transfer and should
minimize contact with patients.
 Professionalism and confidentiality
maintained.

16. Operating area
 Minimize the total number of operators
working (on call shift basis).
 This might require overnight or out of hours
activities to optimize resource usage.
 PPEs and stock required for hand hygiene
must be constantly replenished in OR.
 All the OR doors must be kept closed
 Any equipment not necessary for the
intervention must be moved away from COVID
patients transit route.
 Equipped with PPEs, hand hygiene station,
and a dedicated waste disposal bins.

17.  Staff taking responsibility for positive or
suspected infected patients must be
limited to those who need to be primarily
involved in each operation.
 Record must be maintained and kept
outside the OR.
 Person wearing PPE should receive and
transfer the patient in and out of the OT
table.

18. OR preparation
 Negative pressure ORs would be ideal to minimize
infection risk.
 However, ORs are normally designed to have
positive pressure air circulation.
 A high air exchange cycle rate (≥ 25 cycles/h)
contributes to effectively reduce the viral load within
Ors.
 Minimal instruments
 Minimal in & out transit of the staff.
 Standard anesthetic trolleys should be replaced with
dedicated pre-prepared ones with minimal but
adequate stock.
 All required surgical material (i.e., stitches, scalpel
blades) must be preemptively prepared in a
sterilizable steel wire basket.

19.  Disposable material in general should
be preferred, including linen.
 A senior trained person should be there
in the operating team.
 All operators (i.e., surgeon, anesthetist,
nurses, technicians) should enter the
OR timely, aiming to minimize time
spent within the OR itself.
 Once in the OR, they should not leave
until the operation is completed, and
once out they should not re-enter.

20. Personnel dressing
 All operators must wear the required PPE
before meeting the infected patient.
 Gloves should be changed immediately
after contact with infected material (objects,
surfaces, etc.) or if any damage occurs.
 Operator with a beard should exert special
attention to the fit of the mask ensuring
adequate protection.
 FFP3 for aerosole generating procedures
 Visors/goggles to prevent trans-conjuctival
transmission.

21. Instructions for donning

23. Intraoperative care
 OR doors kept closed
 Minimal transit, minimal instruments
 Adequate covering and sanitization of
electromedical instruments of the OR.
 The surgical team will drape the patient
according to the surgical procedure, replacing
the surgical mask with FFP2 filter and wearing
long shoe covers before doing so.
 If possible powered air-purifying respirator
(PAPR) should be used
 Double pair of gloves at all times, even while
operating.

26.  Duration between 2 procedures should
be as lengthy as possible.
 Air exchange cycles should be
increased whenever possible to ≥ 25
exchanges/h
 All areas at risk of contamination must
be cleaned and disinfected
 Efforts should be made to minimize the
contamination risk associated with
specimens sent to the pathology
department.

27. PPE removal(doffing)
 Staff not directly involved in the patient’s
care should leave the OR at the end of the
operation and remove all PPEs in a
dedicated doffing area following the
sequence.
 A clean area should be accessed only after
the doffing procedure is complete.
 All PPE disposed in waste disposal bins.
 Scrubs must be replaced after each
procedure following showering, whenever
possible.

28. Instructions for PPE removal

29. Environmental sanitization
 As soon as possible after each procedure including.
 All personnel must contribute to minimize the
contamination.
 Use disposables.
 Reusable materials should be decontaminated,
washed, dried, and or disinfected/sterilized, based
on the likelihood of infection.
 Electromedical equipment must be cleaned with
chloro-derivate solution, rinsed and dried, and then
disinfected with chloro-derivate solution in a
concentration ≥ 0.1% or 1000 ppm (parts per million)
with contact time superior to 1 min.
 Disposable PPE worn during cleaning

30. Waste disposal
 Dedicated container
 Containers should be closed and sealed
before being transferred to the collection
point.
 Sharps segregation.

31. Linen management
 All linen (sheets, pillowcases, crossbars,
etc.) should be handled wearing PPE
during collection, not placed on surfaces
or floors, but directly inside dedicated
containers.
 Sealed and immediately sent for
cleaning and sterilization.
 Disposable materials as far as possible.

32. Post exposure care
 Entire team should be quarantined
 Person should be tested and treated as
per guidelines of ICMR and MOHFW.

33. Non COVID patient care
 Elective Ots are deferred so as to divert
the resources and manpower to COVID
care.
 Only emergencies should be attended
that too with care
 Preferably in a non COVID setup

34. To summarize

35. Take home messages
 Only to perform undefrrable procedures
in COVID positive/suspects.
 Minimize surgeries in non-COVID
patients to preserve resources
 Adequate training of staff.
 Instituting precise well-established plans
for minimizing the contamination of staff
as well as the environment.

36. Sources
 Times of India
 The Hindu
 India TV
 The Indian Express
 Characteristics and outcomes of patients undergoing surgeries
during the incubation period of COVID-19 infection by Shaoqing
Lei et al ; EClinicalMedicine Elsevier publication
 Detection of SARS-CoV-2 in Different Types of Clinical
Specimens: Wenling Wang et al JAMA. 2020 Mar 11 : e203786.
 SARS-CoV-2 is present in peritoneal fluid in COVID-19 patients.
Federico Coccolini MD et al ; annals of surgery
 WJES https://wjes.biomedcentral.com/articles/10.1186/s13017-
020-00307-2#Tab3

37. THANK YOU