Operating on patients with COVID-19
In preparation for the COVID-19 pandemic, Wong et
al.39 reviewed
operating room (OR) outbreak response measures. Several recommendations
can be implemented worldwide, others must be adapted according to the
resource availability. An OR with a negative pressure environment is
ideal to reduce dissemination of the virus. A high frequency of air
changes (25 per hour) reduces viral load within the OR. Separate ORs
can be designated for surgery in patients suspected or confirmed to have
COVID-19. Each OR must have its own ventilation system with an
integrated high-efficiency particulate air (HEPA) filter. These ORs
should be separated from the main OR complex to reduce the risk of
contaminating other ORs. Traffic and flow of contaminated air can be
minimized by locking all doors to the OR during surgery, with only one
possible route for entry and exit. It is considered important to have a
program for the use of PPE. All healthcare personnel must be trained in
the use of PPE. Postoperative visits must be suspended and replaced by
phone calls to reduce movement of staff around the hospital.
Ti et
al.40 recommend
that an OR with a negative pressure environment with separate access
must be used to operate suspected or confirmed cases of COVID-19
infection. They also advocate that the same room and the same anesthesia
machine should be used for all COVID-19 patients during the epidemic.
During the surgical procedure a runner wearing PPE is stationed outside
the OR in case other drugs or equipment are needed.
The current recommendations of the American Academy of
Otolaryngology-Head and Neck Surgery is that all elective surgical
treatments should be rescheduled, but it is unavoidable to provide
surgical care to patients with time-sensitive, urgent or emergent
medical conditions
(https://www.entnet.org/content/coronavirus-disease-2019-resources). 41 Many
of these patients have cancer, are older, have nutritional problems,
comorbid conditions and some have undergone radiation and chemotherapy
with possible depressed
immunity.42 To
date there is insufficient information on the effect of COVID-19 in
cancer patients.
No reported series of patients who underwent emergency head and neck
surgery exist till date. Hence, one must extrapolate from the experience
in other areas to develop a strategy for patients with head and neck
cancer requiring emergency surgery. According to Chen et
al.43,
the National Health Commission of China recommends collecting
nasopharyngeal swab samples to test for COVID-19 and have a chest
computed tomography (CT) for all pregnant infected patients. Patients
must be transferred between the isolation ward and the OR by a negative
pressure isolation transfer cabin. All the personnel involved must wear
level 3 protective medical equipment (BSL-3). A negative pressure
operating room must be used and its preparation and personal protection
include the use of BSL-3 (N95 masks, goggles, protective suits,
disposable medical caps and rubber gloves). Medical personnel should
enter and exit the operating room in accordance with the principles of
clean area, contaminated pollution area, and two buffer zones.
Designated nurses must ensure the implementation of standard
procedures.43 For
those who receive general anesthesia, endotracheal intubation and PAPR
are
mandatory.44
Chen et
al.43 used
rapid inhalation (2 minutes) induction of general anesthesia (8%
sevoflurane in 100% oxygen) followed by intravenous injections of 2%
lidocaine (1–1.5 mg/kg), remifentanil (1–2 mg/kg) and succinylcholine
choline (1–2 mg/kg) to ensure optimal intubating conditions. All the
patients included in their study were parturients and sevoflurane was
used to maintain anesthesia before delivery, with sufentanil (0.25–0.35
µg/kg) and an infusion of propofol (50–100 µg/kg/min) used to maintain
anesthesia after delivery.
After the surgical procedure, the anesthesia workstation was disinfected
for two hours with an anesthesia circuit sterilizer (containing 12%
hydrogen peroxide). Chlorine-containing disinfectant (2,000 mg/L) was
used to clean the OR floor and wipe the surface of all reusable medical
equipment. All medical devices, such as surgical instruments, were
soaked for 30 min in 2,000 mg/L chlorine-containing disinfectant, then
sealed and collected into double-layer disposable medical waste bags in
the cleaning room and sent to the designated disinfection area. After
the OR was cleaned, the air purification system was shut down after 30
min of continuous operation of negative pressure laminar flow. Then, an
ultra-low volume of 3% hydrogen peroxide (20–30 mL/m) was used to
closed fumigate the OR for two hours. Finally, the negative pressure
ventilation of the OR was turned on again. All medical staff who were
involved in surgical procedure were required to have a SARS-CoV-2 virus
detection test (RT-PCR of nasopharyngeal swabs) and CT scans once every
two
weeks.43
Surgeons performing endoscopic sinus surgery seem to be at particular
risk due to the high concentration of viral particles in the
nasopharyngeal region. The most recent Stanford University guidelines
advise canceling elective cases. For COVID-positive patients that cannot
be rescheduled, use powered air-purifying respirators (PAPR) if at all
possible. 16