SURGERY IN COVID-19

PANDEMIC

PROF CHARLES ADEYINKA ADISA MD,FWACS,FACS

ABIA STATE UNIVERSITY TEACHING HOSPITAL, ABA,
NIGERIA.
 LEARNING OBJECTIVES
• BASIC MICROBIOLOGY,EPIDEMIOLOGY AND PATHOLOGY
• PROTECTING THE SURGICAL TEAM FROM INFECTION
• TRIAGE OF PROCEDURES TO AVOID OVERWHELMING
FACILITIES
• OPERATING ROOM DESIGN, SAFETY AND ETHICS
• AEROSOL GENERATING PROCEDURES AND RISK
MITIGATION
• MEDICO LEGAL AND ETHICAL ISSUES MANAGEMENT
 LECTURE OUTLINE
• INTRODUCTION
• LEARNING OBJECTIVES
• BASIC MICROBIOLOGY, EPIDEMIOLOGY AND PATHOLOGY OF COVID - 19
• RISK TO THE SURGEON/MEDICAL TEAM
• MANAGING PRIORITIES
• RISKY PROCEDURES
• SPECIAL CONSIDERATIONS-CANCER,PREGNANCY
• OPERATING ROOM VENTILATION AND CONDUCT
• MEDICO LEGAL ISSUES-REFUSAL TO TREAT
• CONTROVERSIAL AREAS-MANDATORY TESTING,POST AND PRE EXPOSURE PROPHYLAXIS
• CONCLUSION
 INTRODUCTION
• In recent months, healthcare professionals worldwide have witnessed the devastating
consequences of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
virus.
• The impact has been felt in all sectors of society and it certainly was experienced
firsthand by the healthcare system.
• In the midst of this crisis, every country in the world has developed plans to contain
and to mitigate the “silent enemy.”
• As in any pandemic, mass casualty, or disaster event, with a high number of victims,
healthcare professionals do their best under difficult circumstances to save as many
lives possible and to preserve the most life-years.
• During the COVID-19 pandemic, healthcare facilities entered into a “crisis mode.”
Dr. Grace Tang andDr. Albert Kam Ming Chan, Anesthesia tutorial of the week, April
6, 2019
 TAXONOMIC STRUCTURE OF THE CORONOVIDAE
• Family*: Coronaviridae
• Coronaviridae are enveloped
• *Subfamily* and positive stranded RNA
• Coronavirinae and Torovirinae viruses.
• They could be spherical as in
• *COROVIRINAE GENUSES* (Coronavirinae), bacilliform, as
• Alpha coronavirus,
in (Bafinivirus) or found as a
• Beta coronavirus,
• Gammacoronavirus mixture of both, with
• *TOROVIRINAE GENUSES*: bacilliform particles
• Torovirus and Bafinivirus characteristically bent into
crescents (Torovirus
 TRANSMISSION
• Coronaviruses infect birds and mammals who serve as primary reservoirs.
SARS-COV2 (BATS)
• An intermediary host
• *Transmission is not by biological vectors*, but – depending on the virus
species – via fomites or via aerogenic and/or fecal–oral routes.

• *INCUBATION PERIOD OF COVID 19*

• The maximum incubation period is assumed to be up to 14 days,
• whereas the median time from onset of symptoms to intensive care unit (ICU)
admission is around 10 days.
• Recently, WHO reported that the time between symptom onset and death ranged
from about 2 weeks to 8 weeks
STRUCTURE OF SARS VOV 2
 PATHOPHYSIOLOGY
• It binds to the ACE2 receptor via its S protein(spike protein).
When it gets into the cell cytoplasm usually the type 2
pneumocytes, it releases its Single strand RNA. Several things
can occur at this stage
• 1. It can utilize the host ribosomes to produce the viral macro
proteins in a process called translation.
• 2. These viral macro-proteins are further acted upon by the host
proteinases to form the virus component like the nuclear capsids,
Spike proteins and viral enzymes etc
• 3. It can use the host RNA dependent RNA Polymerase enzyme to
mass produce more RNA strands of the virus

• 4. The virus proteins products and the new RNA strands combine to
form more virions which overwhelm the type 2 pneumocytes.
• 5. Type 2 pneumocytes get damaged and release inflammatory
mediators that attract the macrophages.

• 6. Macrophages release cytokines (IL2, IL6, TNF) into the cells.

• 7. Cytokines attack the vascular endothelium leading to vasodilatation and
increase capillary permeability.

• 8. Increased vascular permeability leads to interstitial edema causing the

typical ground glass opacities seen on CT and Xray of the chest.

• 9. Damage of the type 2 pneumocytes lead to loss of the surfactants it

produces leading to increase alveolar tension and pressure and eventual
collapse of the alveoli.
• 10. This progresses to poor air exchange in the lungs, hypoxemia and
increased work of breathing.
• 11. Cytokines invites more wbcs which in an attempt to destroy the virus particles release
reactive oxygen and proteases that further damage the type 1 and 2 alveoli leading to
pulmonary consolidation.

• 12. All these eventually lead to ARDS.

• 13. Cytokines released into the circulation gets into the brain and at the hypothalamus
resets the thermostat leading to pyrexia.

• 14. Systemic effects of the cytokines lead to multiple organ failure.

• 15. Other organs with abundant ACE2 receptors include the heart and the bowel.
• This results in myocarditis, several instances of direct effects on the heart have been
reported in the literature.
• If bowels are involved, you have enteritis and colitis with GIT symptoms.
• 16. In some cases, you have cytokines storm which could be severe and lead to
multisystemic organ failure. Another word for cytokine storm is
*hypercytokinemia*

• 17. Another mechanism is it's ability to bind with great affinity to the heme
component of the hemoglobin displacing Fe3+ radicals, and placing its own
protein subunits there causing a methemoglibinemia equivalent state, and also
allow free Fe radicals to snatch up electrons from tissue molucules from organ
systems, the lungs, causing further injury... and also heme rings which can get
into circulation can injure tissue. The release of Fe radicals probably explains
the high level of ferritin in the blood of COVID 19 patients.

• The high affinity of SARS-COV2 to vascular endothelium because of the

abundance of ACE-2 Receptors accout for the clotting disorders and the
widespread multi systemic nature of COVID-19
AGE AND SEX DISTRIBUTION OF COVID-19
IN NIGERIA
 SOURCES OF TRANSMISSION DURING
SURGERIES
• Transmission of SARS-CoV-2 is via particles or
droplets containing the virus (>5um-10um,
travel<1m) when coughing, sneezing
• Aerosol
• Fomites
• Direct contact (touching eyes, nose or mouth)
AEROSOL GENERATING PROCEDURES
AGP ALGORITHM
 STRIKING THE BALANCE
•Surgical services need to balance
supporting the whole hospital response and
minimizing the risk of nosocomial spread of
COVID-19
AGAINST
•continuing care for acute surgical
conditions and managing urgent elective
surgery.
 REFERRALS AND OUTPATIENT
CLINICS
• Outpatient clinic activity should be decreased dramatically to reduce the
risk of cross-infection, particularly of vulnerable patients.

• New clinic referrals should be triaged, with as many as possible offered

telephone/telemedicine/social media consultations.

• Patients should be advised not to attend surgical clinic if they develop

respiratory symptoms or fever, or are diagnosed with COVID-19 infection.

• Surgical teams should be trained to identify and respond to possible

COVID-19 infection during face-to-face and telephone consultations.
 ELECTIVE SURGERY
• Reducing elective activity, including day-case surgery, has three key
benefits.

• First, it releases general ward and ICU beds, increasing capacity for patients
infected with COVID-19

• Second, it releases surgeons and theatre teams to perform drills and support
wider emergency care.

• Third, it reduces the risk of cross-infection of elective patients and hospital

visitors
with COVID-19 by infected patients and staff, preventing subsequent spread of
infection from the hospital to the community
 ELECTIVE SURGERY
WHEN TO OPERATE
• Making decisions can be very difficult.
• ACS have recommended two scoring systems to aid
in this decision making process:
• I. Elective Surgery Acuity Scale (ESAS)
• II. Medically Necessary Time-Sensitive (MeNTS)
Prioritization
 MEDICALLY NECESSARY TIME
SENSITIVE(MENTS) PRIORITIZATION

• 21 factors are divided into 3 broad categories:

• procedure (7 factors)
• disease (6 factors)
• patient (8 factors).

• •Each factor is scored on a scale of 1 to 5

• •Total score ranges from 21 to 105 is computed for each case
• •The higher the score: the greater the risk to the patient,
• the higher the utilization of health care resources, and
• the higher the chance of viral exposure to the health care team
 CANCER CARE
• Surgical cancer care poses unique dilemmas, because delayed
diagnosis and definitive treatment could worsen oncological
outcomes and will cause distress for patients and their
families.
• Patients at high risk of COVID-19 complications, such as the frail and
elderly, can be offered neoadjuvant treatments while definitive surgical
management is delayed.
• Radiological and endoscopic investigations for cancer patients and
suspected cancer patients should be prioritized.
• Elective cancer BJS
surgery should
2020; 107: be offered
1097–1103. 2020 BJSto as many
Society patients as
Ltd www.bjs.co.uk
possible. Published by JohnWiley & Sons Ltd
 EMERGENCY SURGICAL CARE
• Non-operative treatment options should be considered
carefully, particularly if resources are limited and
survival after major surgery is unlikely.
• A dedicated COVID-19 operating theatre should be designated,
ideally a negative pressure theatre that is close to the theatre
complex entrance to allow clear routes for movement of patients,
without passing through non-infected areas.

• The COVID-19 theatre should be adequately stocked with the

equipment required for specific procedures.
 SURGICAL TEAM STRUCTURES
• The risk of surgical team members cross-infecting patients and other
staff is high. Optimize team by:

• doubling or cross-covering rotas in anticipation of high levels of

staff absence owing to sickness and self-isolation,

• reducing doctor-to-patient ratios in some parts of the hospital, and

• augmenting surgical teams with retired surgeons, clinical

academics or final-year medical students who have received training
in managing Covid -19 patients.
 SURGICAL TEAM STRUCTURES
• Social distancing should be maintained by
cancelling face-to-face meetings, and promoting
teleconferencing, including that for multidisciplinary
team meetings.
• Consideration should be given to which staff
members are at high risk of COVID-19 complications
(such as pregnant surgeons, older surgeons, those
with co-morbidities) and whether their duties should
be altered to reduce the risk of infection.
CREDIT : Prof Oluwadiya
 SUMMARY
•To mount an effective response to the
COVID-19 pandemic, hospitals should
prepare detailed context-specific
pandemic preparedness plans for
surgical services, addressing the key
domains identified here
 CHARITY BEGINS AT HOME

• Have a wash hand stand (Veronica bucket or tap and

liquid soap) by the gate of your compound.
• All visitors and family members must wash their hands
before entering the main house. Wipe the handles of
your doors at least twice daily with 0.05%hypochlorite
solution.
• Clean other surfaces that are commonly touched by
many people.
 CONCLUSION
• Coronavirus disease 2019 (COVID-19) mainly transmits via
droplets and contact
• Airborne precautions are required for aerosol-generating
procedures such as manual ventilation, intubation, extubation,
non-invasive ventilation (NIV) and cardiopulmonary
resuscitation (CPR)
• Modifications in airway management are required to minimize
aerosol generation
• Regional anaesthesia should be considered where possible
• Disease transmission can be minimized when perioperative
care is thoroughly planned
THANK YOU
STAY SAFE