key: cord-0704489-2upbpr8b authors: Wen, Jun; Qi, Xiaoming; Lyon, Kristopher A.; Liang, Buqing; Wang, Xiangyu; Feng, Dongxia; Huang, Jason H. title: Lessons from China When Performing Neurosurgical Procedures During the Coronavirus Disease 2019 (COVID-19) Pandemic date: 2020-04-25 journal: World Neurosurg DOI: 10.1016/j.wneu.2020.04.140 sha: 906b13a6e6b7cdbca705d81566554bb0b9e42d77 doc_id: 704489 cord_uid: 2upbpr8b The novel coronavirus disease 2019 (COVID-19) pandemic poses a substantial threat to the health of health care personnel on the front line of caring for patients with COVID-19. The Centers for Medicare and Medicaid Services have announced that all nonessential planned surgeries and procedures should be postponed until further notice and only urgent procedures should proceed. Neurologic surgeries and procedures should not be delayed under the circumstance in which it is essential at saving a life or preserving functioning of the central nervous system. With the intent to advise the neurosurgery team on how to adequately prepare and safely perform neurosurgical procedures on confirmed and suspected patients with COVID-19, we discuss considerations and recommendations based on the lessons and experience shared by neurosurgeons in China. Perioperative and intraoperative strategies, considerations, as well as challenges arisen under the specific circumstance have been discussed. In addition, a case of a ruptured aneurysm in a suspected patient with COVID-19 is reported. It is advised that all health care personnel who immediately participate in neurosurgical surgeries and procedures for confirmed and suspected patients with COVID-19 should take airborne precautions and wear enhanced personal protective equipment. Following the proposed guidance, urgent neurosurgical surgeries and procedures can be safely performed for the benefit of critical patients with or suspected for COVID-19. T he novel coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first reported in the city of Wuhan, China, in December 2019. Despite strenuous efforts to contain the virus, it quickly turned into a pandemic that has swept through all continents except Antarctica. With an exponentially increasing number of patients being diagnosed, COVID-19 heavily strains our health care system and resources. In response to the escalating pandemic of the COVID-19, the Centers for Medicare and Medicaid Services announced that all nonessential planned surgeries and procedures be postponed until further notice. As per the Centers for Medicare and Medicaid Services tiered framework, neurosurgery falls under the category of tier 3a (high acuity surgery), and it should not be postponed. 1 The Centers for Disease Control and Prevention informed that COVID-19 could spread through close contact or respiratory droplets between persons and from contact with contaminated surfaces or objects. 2 However, whether COVID-19 could be airborne is still in dispute. Nonetheless, airborne precautions should be taken while performing neurosurgical procedures on all confirmed or suspected patients with COVID-19. The first case with a wide nosocomial spread of COVID-19 in Wuhan was an endoscopic endonasal transsphenoidal pituitary tumor resection. 3 All 14 people who spent time in the operating room (OR) during the procedure became infected. The standard surgical gowns and masks worn by health care personnel do not protect them from contracting COVID-19. With the intent to advise the neurosurgery team on how to adequately prepare and safely perform life-saving neurosurgical procedures amid the pandemic of COVID-19, we discuss the following considerations and recommendations based on the lessons and experience shared by neurosurgeons in China. Rather than serving as stand-alone guidance, these recommendations should be integrated into the systemic planning and preparation implemented by health care facilities and systems. Except for emergent and urgent neurosurgical procedures that can save a life, preserve the brain, or restore spinal cord function, other nonurgent elective spine surgeries, peripheral nerve surgeries, pain procedures, and functional procedures should be postponed. When deemed emergent or urgent, airborne precautions must be taken before and during contact with confirmed or suspected COVID-19 cases. Inpatients with suspected COVID-19 should be treated as a confirmed case for neurosurgical bedside procedures. Each patient should be placed separately in a negative-pressure isolation room. Only essential health care personnel should be allowed to treat patients with COVID-19 to minimize medical trainees or students' exposure to the virus. A properly fitted N95 or higher respirator must be used. All health care personnel should undergo respirator fit testing before participating in the patient's care. It is recommended that men with beards shave their face to ensure a tight seal between their face and the mask. A gown spanning and covering the entire body (coverall gown), protective goggles, and shoe covers are recommended. Avoid touching the eyes, nose, or mouth after taking off the face mask or goggles at the completion of the procedure. Collaborate with the anesthesia team and hospitality team to secure a smooth transition between perioperative care and the neurosurgical procedure. A designated patient transport route should be established for patients with COVID-19. The patient should wear an N95 respirator during transit. If the patient is already intubated, a mask should be placed over the mouth to avoid any respiratory secretions or droplets contamination due to cough reflex. The preoperative holding area and the postanesthesia care unit should be bypassed if an isolation room is not available in these areas to limit potential contamination of these units. When obtaining consent, telecommunication is strongly recommended. If the patient is to return to the designated intensive care unit or medical ward directly, extubation and postoperative recovery should be allowed in the OR to further minimize the number of staff members directly exposed to the patient's airway. The patient care team should be prepared with enhanced personal protective equipment (PPE) for possible immediate medical intervention and avoid procedures performed with inadequate protection. Wearing a minimum of 2 sets of gloves is recommended during perioperative care and patient transit. All health care personnel in the OR should be prepared Q2 both mentally and physically. The operation should be performed in a negative-pressure OR paired with an anteroom implemented with airborne precautions. 4 In the case in which a negative-pressure OR is not available, an HEPA (i.e., high-efficiency particulate air) standard filtering system should be implemented. Surgeons in the OR must undergo a careful sequence for putting on proper PPE in addition to sterile surgical gown prior to performing the neurosurgical procedure. 5, 6 First, a visual inspection of PPE is performed to ensure that no gross defects are present. Hand washing is performed with soap and water for a minimum of 20 seconds. Shoe covers and nonsterile inner gloves are obtained. A gown is worn that covers the entirety of arms, legs, head, and trunk (coverall gown). Then, a properly fitting N95 or higher respirator is used. Next, a surgical hood, goggles, and face shield are put on. Sterile gloves, sterile gown, and a second set of sterile gloves are fitted and worn outside of the sterile gown. Wearing goggles will prevent the use of surgical loupes. Goggles with an anti-fog coating are recommended, as they may block vision when covered in fog. Furthermore, wearing goggles and face shield makes performing surgery under the neurosurgical microscope exceedingly difficult. Three layers of gloves diminish tactile sensation and make it less reliable during neurosurgical procedures. Wearing this extensive amount of PPE for a prolonged period during a neurosurgical operation may make the surgeon fatigued and dehydrated due to excessive sweating. Communication among the health care providers may become difficult, given the muffled voices and hearing that results from multiple layers of PPE . Additional measures, including the use of hand gestures, may be required for communication during the surgery. 7 An example of health care personnel wearing proper PPE is provided in Figure 1 . Other personnel, including anesthesiologists, surgical technologists, and circulating nurses in the OR, should also be equipped with proper PPE. Personnel entering and leaving the OR should be rigorously restricted. A buffering area outside the OR should be used for the delivery of surgical supplies operated by a designated team. This team also should be fully protected and be ready to enter the OR should an emergency arise. All equipment used during the procedure should be thoroughly sterilized or properly disposed of to prevent viral spread. Health care providers involved should perform immediate self-cleaning before leaving the procedure area, preferably showering the whole body and changing into a new surgical outfit. On February 6, 2020, a patient presented to the emergency department with headache followed by a loss of consciousness at a local hospital in Guangzhou. Computed tomography (CT) scan of the head revealed subarachnoid hemorrhage and left frontal lobe hematoma (Figure 2A) . The patient was then transferred to our facility for neurosurgical consultation and treatment. Upon arrival, the patient was unconscious, body temperature 38.9 C (102 F), pulse 61 bpm, respiratory rate 17 bpm, and blood pressure 179/120 mm Hg. Neurologic examination showed bilateral pupil diameter 2.5 mm, sluggish pupillary light reflex, 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 to the emergency department. Given the travel history and high body temperature, we 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 445 446 447 448 449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 suspected that the patient contracted the SARS-Cov-2 virus during the trip to Hubei province. The COVID-19 task force of our hospital was consulted, and a suspected diagnosis of COVID-19 was made. Specimens were collected for testing. A nasopharyngeal swab sample was sent for reverse-transcription polymerase chain reaction Q6 testing for SARS-CoV-2 virus. CT angiography of the head (Figure 2B and C) and thoracic CT were obtained, with all health care personnel in enhanced PPE. CT angiography of the head revealed an anterior communicating artery aneurysm. Thoracic CT showed bilateral lower lobe inflammatory changes and suspected right upperlobe exudative change ( Figure 3A) . Definitive aneurysm repair procedure was deemed necessary and urgent by the neurosurgery team; the COVID-19 emergency surgery protocol was then activated. A negative-pressure OR was requested, and the anesthesiology team was informed of the situation and the planned surgical treatment. An isolation room was reserved for the patient for immediate postoperative care. The patient was transitioned to the OR through the designated route. All participating health care personnel was wearing enhanced PPE, as mentioned previously (Figure 4) . The patient underwent a modified pterional craniotomy for hematoma evacuation with anterior communicating artery aneurysm clipping, and placement of intracranial pressure monitor. After surgery, the patient was transported to an isolation room for recovery and postoperative care, as well as COVID-19 treatment. The nasopharyngeal testing of COVID-19 returned to be negative. However, due to the high false-negative rate (30%) of the testing and the patient's symptoms and CT findings, a decision was made by the COVID-19 task force to treat the patient as a patient under investigation for 14 days. The patient did well and eventually was discharged home at 14 days postoperatively with intact neurologic function. Two-month postoperative CT of the head ( Figure 2D ) was obtained, which showed resolved hematoma, stable aneurysm clip, and no hydrocephalus. A thoracic CT also was obtained and showed improvement from previous hospital admission images ( Figure 3B ). Although not without challenges, with proper protection following the aforementioned guidance, emergent and urgent neurosurgical surgeries and procedures can be safely performed for the benefit of critical patients during the COVID-19 pandemic. 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696 697 698 699 700 701 702 703 704 705 706 707 708 709 710 711 712 713 714 715 716 717 718 719 720 721 722 723 724 725 726 727 728 729 730 731 732 733 734 735 736 737 738 739 740 Centers for Medicare & Medicaid Services. Adult Elective Surgery and Procedures Recommendations. Available at Centers for Disease Control and Prevention. How COVID-19 Spreads Restore the spreading route of a super-spreader Conversion of operating theatre from positive to negative pressure environment Ebola: personal protective equipment (PPE) donning and doffing procedures Centers for Disease Control and Prevention. Sequence for putting on personal protective equipment (PPE). Available at Perioperative care provider's considerations in managing patients with the COVID-19 infections Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.