key: cord-275784-n6jv72l7 authors: Spina, Alfio; Boari, Nicola; Gagliardi, Filippo; Bailo, Michele; Calvanese, Francesco; Mortini, Pietro title: The Management Of Neurosurgical Patients During The Covid-19 Pandemic date: 2020-04-30 journal: World Neurosurg DOI: 10.1016/j.wneu.2020.04.161 sha: doc_id: 275784 cord_uid: n6jv72l7 ABSTRACT The rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is, to date, the major challenge for healthcare systems worldwide. Hospital represents one of main vector amplifying the spread of the disease among both patients and healthcare professionals. Adequate department organization is pivotal to reduce hazards while still ensuring the highest quality of care. In this document we aim to share the recent experience of a Neurosurgery department located in one of the first and largest coronavirus disease 2019 (COVID-19) pandemic epicenters. A review of the available literature was also performed. Case selection, operating room and postoperative management of neurosurgical patients were discussed. COVID-19 pandemic has upset healthcare organizations, requiring a deep reorganization in many respects. An adequate management protocol can reduce hospital viral spread, improving safety both for patients and healthcare professionals. The entire whole world is fighting for the first time in the modern history of mankind a borderless war that has profoundly distorted the social, economic and political setting of many countries. The rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) represents the major actual challenge of healthcare systems worldwide. In response to this spread, several conflicting actions have been taken such as social distancing, lockdowns and quarantine of suspected or less symptomatic cases. 1 The management of an ever-increasing number of patients, particularly those suffering from coronavirus disease 2019 (COVID-19) pneumonia has deeply affected the organization of healthcare facilities. 2 Furthermore, preserving financial and human resources is crucial, and a good and a preventive organization are mandatory in this phase of mass casualty. 3, 4 In this scenario, healthcare providers represent the frontline in the fight against the coronavirus. COVID-19 outbreak has upset the way to deliver medicine among different medical specialties, including neurosurgery. Surely, SARS-COV-2 infection may cause fever, pneumonia and other medical issues not pertaining to the neurosurgical practice. However, management of neurosurgical cases has been deeply affected, leading to a complicated and difficult selection of the patients to candidate for hospital admission and surgery, together with their pre and postoperative management that must take into account their potential contagiousness. 1 . The presence of a high viral load in the nasal cavity, brain surgery and even more trans-sphenoidal surgery, make neurosurgery one of the high risk surgical specialties, along with otorhinolaryngology, anesthesiology, oral-maxillofacial surgery 1, 5-7 ; endoscopic procedures through the mouth and nose (such as in gastroenterology) could be considered at high risk too. Ultimately, in several hospitals, neurosurgeons have been reassigned to COVID-19 units due to the growing demand for medical personnel. SARS-CoV-2 entail a long and incompletely known incubation period, ranging from 0 to 27 days after first virus exposure; additionally, I significant rate of completely asymptomatic patients have been reported. 8 The aforementioned reasons represent a noteworthy risk of accidental virus transmission for all the personnel employed in Neurosurgical departments, outpatient clinics, and operating rooms 1 . SARS-CoV-2 transmission seems to be mainly related to respiratory droplets but, COVID-19 also showed surface stability over a long time. 9 For healthcare professionals, both the two transmission modalities must necessarily considered to reduce the risk of accidental contagion. 10 This requires a complete department and operating room reorganization to protect patients as well as medical staff from unnecessary and dangerous infections. Data coming from the first and largest COVID-19 Eastern Asian epicenters, suggest that these problems will not end soon and therefore the risk of infection will also have to be considered in the upcoming months. 11 In a single-center Chinese case series of 138 hospitalized patients, presumed hospitalrelated infection of COVID-19 was suspected in 41% of patients, with a reported mortality of 4.3% and an intensive care unit admission rate of 26%. 12 Furthermore, COVID-19 transmission rate to healthcare worker was reported up to 20% 13 These data suggest that, inadequate hospital setting may represent a relevant route of SARS-CoV-2 spread both for patients and healthcare professionals. The aim of this study was to report a series of recommendations derived from our experience and from the recent pertinent literature, to prevent viral spread during neurosurgical activities. San Raffaele Hospital (Milan, Italy) is located in one of the first and largest COVID-19 pandemic epicenters worldwide; here we described the actual organization of its Neurosurgery Department and current practice adopted. A literature review was also performed via Pubmed, Web of Science and Google Scholar using the search terms surgery, neurosurgery, COVID-19, coronavirus, SARS-CoV-2. Some additional studies were selected from the references of the articles retrieved. Last online research was performed on April 15 th , 2020. After the pandemic explosion, many hospitals have cancelled outpatients activities or reduced them only to urgent ones. 2, 11, 14 Consequently, the number of elective surgical cases have dramatically decreased, also because of the lockdown measures. 2, 5 Surgical treatment should be considered only in selected non-postponable cases or in emergency ones. 15, 16 Elective surgeries should be rescheduled to allow a correct assessment of patients' clinical condition and to give correct allocation in the ward. 1, 16 The creation of COVID-positive (suspected or definitive cases) and COVID-free sectors, with dedicated healthcare professionals, might be desirable even inside the same department. Patients' clinical evaluation must be performed by maintaining contact and droplet precautions, the social distancing has to be maintained for every patients if not for unavoidable evaluations or maneuvers such as neurological examination; adequate personal protection equipment (PPE) must always be used and have to be easily available in clinics. Each patient, even if tested negative for SARS-CoV-2 infection at real-time reverse transcriptase polymerase chain reaction (RT-PCR), should be considered and approached as potentially contagious. Complete information about relative's health condition, friends or history of recent travels and contacts has to be investigated. The assessment of class-risk group should be evaluated before and at hospital admission. Whenever possible, elective surgery for confirmed cases (i.e. Group 1) should be rescheduled, because of this class of patients show higher risks of intensive care need and death. 1, 5, 11, 12, 21-24 Group 2 must undergo prompt laboratory RT-PCR or serologic testing in order to confirm COVID-19 infection or to diagnose other viral or bacterial pneumonia. Surgery for group 2 patients should be carefully evaluated together with the anesthesiologist team, to balance the risk-benefit ratio of a surgical treatment at this time. Group 3 and 4 patients should undergo laboratory testing and chest CT scan to exclude a developing infection. 17, 18 Early identification and isolation of infected patients minimize virus transmission to other patients and to healthcare professionals. 1 Patients included the three first groups must be kept in a single room, and disinfection and isolation measure have to be put in action. Contact and droplet isolation precautions through gown, gloves, head cap and facial FFP2 (N95) mask must be taken. 5, 11 Also patient must wear surgical facemasks or mask without exhalation valves. 6, 11 In the absence clinical information or swab test, those patients needing emergent neurosurgical procedure should be considered as Group 1-2 patients and require the same perioperative management as well. 3 A limited number of people have to be warranted in the operating room (OR). 1 Confirmed cases must be treated in a negative pressure theater. 5 For the entire anesthesiologist, neurosurgical and nurse staff, high protection PPEs are recommended; personnel should not wear the same PPEs inside and outside the OR. 11 FFP3 (N99 or equivalent) are suggested since FFP2 (N95) mask did not seem to adequately protect surgeons in China; triple layered protection gowns, eye or facial protection, single use head caps and glows are also recommended to prevent accidental transmission. 1, 11 An experienced anesthesiologist should perform patient's intubation to reduce coaching and the number of attempts. 5 Video-guided laryngoscopy can be considered to attempt this goal. 4, 25 Surgeon should enter in the OR about 20 minutes after intubation; with the abovementioned adequate PPEs to minimize aerosol transmission. 5 The surgical team should enter the theater after 20 min of intubation with appropriate PPE to minimize the aerosol-based transmission. All objects and instruments that come in contact with the patient included in the group 1-2-3 have to be considered contaminated. Viruses have been reported to survive in surgical smoke, consequently, the latter must be minimized through continuous aspiration and irrigation and minimizing the effective power of electrosurgical equipment. 5, 9, 11 Care must be taken to prevent accidental needle or scalpel injury. Absorbable sutures should be considered to reduce unnecessary trip to the hospital for their removal. Patients developing fever or cough after surgery have to perform chest CT scan and laboratory testing for COVID-19. It has to be noted that previous negative results do not preclude COVID-19 infection, due to limitation in tests sensibility and incubation periods. 5 Confirmed coronavirus cases should be treated with oxygen delivery, medical support therapy; and a multidisciplinary management with the anesthesiologist and infectious disease specialist is also recommended. It is well known that COVID-19 patients harbor a higher risk of thrombosis and secondary pulmonary infections, hence adequate treatment has to be warranted. 11, 24 ; these COVID-related risks add up to those already present in neurosurgical patients. Unfortunately, in the neurosurgical setting the need for anticoagulant therapy has to be balanced with the risk of delayed postoperative bleeding, which may cause dramatic consequences. Confirmed COVID-19 cases should be discharge after clinical resolution and when the RT-PCR or antibody test is negative on two consecutive occasions (sampling interval ≥ 24 h). 11 Those negative cases with uneventful postoperative course may go back home, complying with a 14-days quarantine, to prevent postoperative infections. COVID-19 represents one of the largest and deadliest pandemic infection of the modern era. The number of positive patients is, at the current time, still growing around the world and, unfortunately, chances are that we will have to deal with this infection for many more months to come. Hospital represents one of the vectors that may amplify the spread of the disease. Adequate hospital and especially surgical unit organization are therefore essential to improve both patients and staff safety. Careful management through a well-known protocol can minimize the risk for the neurosurgical team and for the other patients. We hope to continue providing the best possible standard of care to our patients. We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us. We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In so doing we confirm that we have followed the regulations of our institutions concerning intellectual property. We understand that the Corresponding Author is the sole contact for the Editorial process (including Editorial Manager and direct communications with the office). He is responsible for communicating with the other authors about progress, submissions of revisions and final approval of proofs. We confirm that we have provided a current, correct email address which is accessible by the Corresponding Author and which has been configured to accept email from spina.alfio@hsr.it. Approaches to the management of patients in oral and maxillofacial surgery during COVID-19 pandemic A Commentary on Safety Precautions for Otologic Surgery during the COVID-19 Pandemic Navigating the Ethics of COVID-19 in Otolaryngology Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1 Protecting health care workers from SARS and other respiratory pathogens: a review of the infection control literature Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan COVID-19: protecting health-care workers The impact of the COVID-19 pandemic on the provision of surgical care Time-Sensitive Procedures: A Scoring System to Ethically and Efficiently Manage Resource Scarcity and Provider Risk During the COVID-19 Pandemic How to risk-stratify elective surgery during the COVID-19 pandemic? A diagnostic model for coronavirus disease 2019 (COVID-19) based on radiological semantic and clinical features: a multi-center study A British Society of Thoracic Imaging statement: considerations in designing local imaging diagnostic algorithms for the COVID-19 pandemic Coronavirus disease 2019: What we know Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases Preliminary recommendations for lung surgery during COVID-19 epidemic period Guidelines for Ambulatory Surgery Centers for the Care of Surgically Necessary/Time-Sensitive Orthopaedic Cases during the COVID-19 Pandemic Rapid Response of an Academic Surgical Department to the COVID-19 Pandemic: Implications for Patients, Surgeons, and the Community The authors report no conflict of interest