key: cord-261141-w4bqp9xr authors: Li, Jinpeng; Gao, Rongfen; Wu, Gaosong; Wu, Xiaolin; Liu, Zeming; Wang, Hongjing; Huang, Yihui; Pan, Zhenyu; Chen, Jincao; Wu, Xiaohui title: Clinical characteristics of emergency surgery patients-infected COVID-19 pneumonia in Wuhan, China date: 2020-05-19 journal: Surgery DOI: 10.1016/j.surg.2020.05.007 sha: doc_id: 261141 cord_uid: w4bqp9xr OBJECTIVE: We aimed to investigate clinical symptom and epidemiological features of ESP-infected COVID-19 SUMMARY BACKGROUND DATA: Almost one million of 2019 novel coronavirus disease (COVID-19) patients were diagnosed in the world wide from December 2019 to now. Thousands of emergency operations were carried out in the interim. However no one focused on the clinical symptom of emergency surgery patients (ESP) with COVID-19 pneumonia. METHODS: Retrospective cohort study of 164 ESP with or without COVID-19 pneumonia in Zhongnan Hospital of Wuhan University in Wuhan, China, from January 1 to January 20, 2020. The final date of follow-up was February 5, 2020. The associated clinical, laboratory, epidemiological, demographic, radiological and outcome data were collected and analyzed. RESULTS: Of 164 ESP, the median age was 41 years old (interquartile range (IQR), 29-89) and 136 (82.9%) were women. Associated main clinical symptom including fever (93 [56.7%]), dry cough (56 [34.2%]), fatigue (86 [52.4%]), nausea (78 [47.6%]) and dizziness (77 [47%]). Of 54 ESP-infected COVID-19 patients, the median age was 46 (IQR: 25-89) and 45 (83.3%) were women. The pathological clinical symptoms including fever (54 [100%]), fatigue (48 [88.9%]), nausea (52 [96.3%]), dizziness (46 [85.2%]) and dry cough (44 [81.5%]) were investigated; the lymphopenia (0.37×10(9)/L [IQR: 0.23-0.65]) and increased C-reactive protein (24.7×10(9)/L [IQR: 13.57-38]) were observed. The preoperative fever and postoperative fever in ESP with or without COVID-19 pneumonia were analyzed in this study. Of 54 ESP with COVID-19 patients, 15 (27.8%) patients showed preoperative fever, 54 (100%) had the postoperative fever; Of 110 non-COVID-19 of ESP, 5 (4.5%) patients had preoperative fever, 31 (28.2%) patients had the postoperative fever. The fever in ESP with COVID-19 lasted more than 7 days, markedly exceeded the non-COVID-19 patients (lasted about 3 days). Furthermore, 43 health care workers were infected from exposed to ESP with COVID-19 pneumonia. CONCLUSION: In our study, the clinical symptoms of ESP-infected COVID-19 displayed marked differences from those reported common COVID-19 pneumonia cases. Additionally, the health care workers were confirmed to expose great risk in ESP with COVID-19 pneumonia. Management guidelines of ESP were described in our paper. and human Severe Acute Respiratory Syndrome (SARS) 5 . Furthermore, the proved hospital-related transmission in COVID-19 pneumonia has been reported. Of 138 hospitalized COVID-19 pneumonia patients, 26% of patients needed ICU care and the mortality was 4.3% 6 . Deepali et al. reported one patient died in SARS after liver transplanting, that followed infection of several health-care workers and family 7 . The emergency surgery was thought to be extremely dangerous in Ebola epidemic in Africa 8 . Chen et al. reported the clinical characteristics of caesarean section with COVID-19 infection and denied the risk of vertical transmission 9 . In addition, stringent infection control procedure for operations in period of 2003 SARS was drawn out protecting the health care workers and control intrahospital transmission, and significantly decreased the intrahospital transmission of SARS in the operating room complex 10, 11 . Although these reports investigated the risk for the healthcare workers and also made the stringent relative procedure, no one focused on the risk of emergency surgery patients (ESP) with COVID-19 pneumonia. The current study analyzed the clinical symptom of these patients including perioperative patients and postoperative patients. Furthermore the relevant risk for healthcare workers in ESP was clearly described. All postoperative patients with COVID-19 pneumonia (PPCP) were collected from Zhongnan Hospital of Wuhan University from Jan 1, 2020 to 21. The throat swab samples from patients with COVID-19 pneumonia were collected and immediately extracting 2019-nCoV RNA. All infected patients were collected the samples from throat swab at least three times. The specific steps of collection of sample based on Peng's reported 9 . The RT-PCR assay was performed using a 2019-nCoV nucleic acid detection kit according to the manufacturer's protocol (Shanghai bio-germ Medical Technology CoLtd). The process also according to Peng's reported 9 . The data for fevers (figure 1) analyzed by ANOVA followed by Tukey's analysis. One-way analysis of variance followed by Tukey's multiple comparison test was used to determine significance, which was defined as P<0.05. The Mann-Whitney U test was used to analysis of median (IQR); categorical variables were expressed as number (%), median or IQR and compared by χ² test or Fisher's exact test between ESP with COVID-19 and non-COVID-19 groups. P<0.05 was considered as significance. Statistical analysis was performed by SPSS, version 25.0. We collected 164 ESP in Zhongnan Hospital of Wuhan from January 1 to January 21. Of these patients, the median age was 41 years (IQR, 29-89), 136(82.9%) were women, 28(17.1%) were men (Table 1) . Women outnumber men because of lots of cesarean section were analyzed in our study. All the ESP-infected COVID-19 pneumonia patients had a close history of epidemic patients showed preoperative fever, 54 (100%) had the postoperative fever; Of 110 non-COVID-19 of ESP, 5 (4.5%) patients had preoperative fever, 31 (28.2%) patients had the postoperative fever. These data suggested that more ESP-infected COVID-19 displayed the clinical symptom of fever than non-COVID-19 patients. Furthermore, we analyzed the duration of fever between them, the results showed that the fever in ESP with COVID-19 lasted more than 7 days, markedly exceeded the non-COVID-19 patients (lasted about 3 days) (Figure 1 A) . The level of fever in ESP with COVID-19 was also higher than non-COVID-19 patients ( Figure 1B) . Additionally, more clinical symptoms of dry cough, fatigue, nausea and dizziness in ESP-infected COVID-19 were observed when compared with non-COVID-19 patients. Interestingly, of 54 ESP-infected COVID-19, the incidence of dry cough, fatigue, nausea and dizziness in our study was higher than the reported common COVID-19 pneumonia cases 6, 12 . The The blood counts of patients from laboratory tests displayed the significant difference in the lymphocyte and C-reactive protein concentration between ESP-infected COVID-19 and non COVID-19 pneumonia, and no significant difference in neutrophil, monocyte, ALT, AST, BUN and ACR ( These data is same as reported finding for COVID-19 pneumonia 12 (Table 3) . Of 164 ESP, 54 patients were assumed to be infected in hospital after the emergency surgery. In addition, 43 health care workers were infected by contacting the associated ESP-infected COVID-19 patients. Of the 54 hospitalized patients, 29 (53.7%) patients were from obstetrics and gynecology, 7 (13%) patients were from hepatobiliary surgery, 4 (7.4%) patients were from gastrointestinal surgery, 7 (13%) patients were neurosurgery, 2 (3.7%) patients were from orthopeadic surgery, 3 (5.6%) patients were from urology surgery ( Table 2) . Of 43 infected health care workers, almost them were from operation room (anesthesiologist and nurses) and associated surgery departments. All of infected health care workers were directly contacted the ESP with COVID-19 patients, and infected in the January. The number of health care workers who infected in ESP-infected COVID-19 pneumonia significantly decreased after January. Immunosuppressive state was thought to be a common phenomenon in postoperative patients 15, 16 , and will be susceptible to infect severe pneumonia and respiratory pathogens. Jessica et al. reported that cataract surgery was safety in patients who detected negative of Ebola virus in ocular fluid specimens 17 . In Ebola epidemic in Africa, the emergency surgery was thought to be extremely dangerous 8 ESP-infected COVID-19 (100% with fever); 56.4% showed the ground-glass opacity in lung, less than our study (100%); 83.2% of them had lymphocytopenia which was also less than our investigation (100%). One reason for this phenomenon may be the immunosuppressive state or postoperative stress response in patients. Furthermore, 7 (13%) mortality in our report, obviously higher than those reported cases in China, also proves our hypothesis. Another main focus of this research was to observe the huge risk of ESP-infected COVID-19 pneumonia for the health care workers. In the early stage of COVID-19 pneumonia, the research reported the characteristics of human transmission 4, 18 . However, no one concentrated for the ESP in this meantime. In our study, we analyzed all of ESP (164 patients) from January 1 to January 21, 2020, the final date of follow-up was February 5, 2020 in our hospital. We found that these patients had a great threat for health care workers by the February 5. 43 of health care workers, including surgeon, anesthesiologist and associate nurse, were infected by ESP. Two of them were treated in intensive care unit (ICU) because of serious illness. One reason for this phenomenon is that incomplete preoperative examination especially lack of CT scans in lung and nucleic acid detection of COVID-19 pneumonia was carried out in that time. In addition, lack of self-protection not only in gears (N-95 surgical mask and medical disposable chemical protective safety suit) but also in consciousness was a critical cause. In addition, lack of the relative knowledge of respiratory infectious diseases for surgeons is another reasons, conversely, no health care workers of respiratory, contagion section and ICU were infected in this epidemic situation, which proved our hypothesis. Our report aims to remind the health care workers especially take care of ESP to keep their eyes on the COVID-19 pneumonia even in the later stages of work. Some limitations present in our study, first this study is limited by the short time of cases review (from January 1, 2020 to February 5, 2020). Second, the data statistics of health care workers-infected COVID-19 was incomplete. Third, we did not describe the management for ESP when they are accepted outpatient consultations. Here, we added the sketch of consultation for the ESP according to COVID-19 pneumonia guide of Hubei Provincial Health Council (Figure 3) . In this process, all surgeon need to be three-level protection when they take care of emergency surgery (Figure 3 ). In summary, ESP-infected COVID-19 pneumonia has a great threat for health care workers. This paper expounded the typical clinical symptom and laboratory examination, and provided directly evidence to identify the ESP-infected COVID-19. We believe that this study may give lots of assistance to health care workers in hospital. JL performed most of the study and participated in writing the original manuscript. RG supervised the study and was involved in writing the results and discussion. GW, XW involved in collecting original data and discussion. HW participated in data analysis. XW proposed the original idea and design of the study, supervised the study, and edited the manuscript. JC provided intellectual input and involved in discussion. ZP participated in original idea and discussion. We declare no competing interests. In our study, the clinical symptoms of ESP-infected COVID-19 displayed marked differences from those reported common COVID-19 pneumonia cases and the health care workers were confirmed to expose great risk in ESP with COVID-19 pneumonia. The importance of this findings is these will provide early warning for health care workers who take care of the ESP-infected COVID-19 patients on now and in the future. 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