key: cord-0860104-4zxktm0r authors: Engelman, Daniel T.; Lother, Sylvain; George, Isaac; Funk, Duane J.; Ailawadi, Gorav; Atluri, Pavan; Grant, Michael C.; Haft, Jonathan W.; Hassan, Ansar; Legare, Jean-Francois; Whitman, Glenn; Arora, Rakesh C. title: Adult Cardiac Surgery and the COVID-19 Pandemic: Aggressive Infection Mitigation Strategies are Necessary in the Operating Room and Surgical Recovery date: 2020-04-27 journal: Ann Thorac Surg DOI: 10.1016/j.athoracsur.2020.04.007 sha: c8842ff3fd8acdc0427375712cb1de31e6e5d05b doc_id: 860104 cord_uid: 4zxktm0r Abstract The COVID-19 pandemic necessitates aggressive infection mitigation strategies to reduce the risk to patients and healthcare providers. This document is intended to provide a framework for the adult cardiac surgeon to consider in this rapidly changing environment. Pre, intra, and post-operative detailed protective measures are outlined. These are guidance recommendations during a pandemic surge to be utilized for ALL patients while local COVID-19 disease burden remains elevated. Vascular Surgery published tiered patient triage guidance. 3 Other suggestions from the ACS to enhance safety for healthcare workers 4 in the context of COVID-19 include the following: 1. Consider non-operative management whenever it is clinically appropriate for the patient. 2. Complete testing as close as possible to the planned operative date (preferably <48 hours) to lessen the risk that a patient becomes positive while waiting for surgery. 3. Avoid emergency surgical procedures during off hours, when possible, due to limited team staffing and the potential lack of optimal specialty specific expertise. 4 . Perform aerosol generating procedures (AGPs) 5 in confirmed or suspected COVID-19 patients while practicing enhanced droplet/contact precautions, including an N95 mask, eye protection, gown and gloves, or a powered air-purifying respirator (PAPR). Examples of known and possible AGPs include: a. Intubation, extubation, bag mask ventilation, non-invasive ventilation (CPAP and BiPAP), airway suctioning, nebulizer therapies, bronchoscopy, chest tube insertion, thoracotomies and pleural procedures. b. Electrocautery of blood or any other body fluids 6 c. Endoscopy 5. Defer non-urgent cardiovascular testing. 6. It will be challenging to distinguish COVID-19 from other respiratory infections, therefore, interventions will need to be applied broadly and not limited to patients with confirmed While helpful, these guidelines do not provide the granular guidance needed to address important aspects of the surgical management of cardiac surgical patients. In particular, there will remain a certain volume of patients that will still require urgent and emergent operations during this pandemic. At time of writing this manuscript, SARS-CoV-2, the novel coronavirus associated with COVID-19 disease, has been associated with at least a 3.4% mortality in the United States in those patients with a confirmed diagnosis. 8 The virus is well equipped with several virologic, epidemiologic, and clinical features that have contributed to its ability to rapidly spread through a global population. Specifically, a substantial number of asymptomatic or pre-symptomatic infections, with or without mild symptoms, are key to its effective dissemination throughout populations, including to healthcare providers. 9 At times of documented or suspected community spread of COVID-19, it is reasonable suspect that ALL patients could be carriers of the virus. As such, ALL patients should be considered COVID-19 suspects, regardless of testing availability or results, and all patients should be treated equally with precautions similar to those used in COVID-19 confirmed cases. This approach is similar to the concept of universal precautions. This level of safety may not be required if community transmission and the burden of cases is low in specific areas. However, to minimize infectious risk to healthcare providers of patients undergoing cardiac surgery in the pre, intra, and post-operative period, additional detailed protective strategies are suggested. These are guidance recommendations during a pandemic surge for ALL patients until the supply chain for personal protective equipment (PPE) is restored and local COVID-19 disease burden is substantially reduced. 1. Patients should be transferred directly to the operating room (OR), without stopping in the pre-op or post-anesthesia care unit (PACU) areas, to minimize exposure to other patients, staff, and other environments. 2. "COVID-19 precautions" signs should be posted on all doors to the OR suite to inform staff of potential risks and minimize exposure. 3. The operating room should remain positive pressure, but the surrounding rooms (i.e. anteroom(s)) must maintain a strict negative pressure ventilation system at > −2.5 Pa at ≥12 air changes per hour. 10 4. All OR staff are required to practice enhanced droplet and contact precautions (EDCP) in the operating room at all times. This includes the use of N95 respirator, eye protection, gown and gloves. Given the possibility of false negative testing (10 -30 %) 11 the American Society of Anesthesiology (ASA) recommends that all anesthesia professionals should utilize PPE appropriate for AGPs for all patients, during all diagnostic, therapeutic, and surgical procedures, when working near the airway. 12 We would broaden this recommendation to include all OR personnel. 5 . If N95 masks are to be reused, (though not optimal) the ASA and CDC recommend a 5-day period of drying 13 or preferably decontamination using ultraviolet germicidal irradiation, vaporous hydrogen peroxide, or moist heat by autoclaving. 14,15 6. If a PAPR is utilized as an alternative to a N95 respirator and eye protection, practitioners should be cautioned that these devices may reduce the clarity of surgical loupes and positioning of headlights. 12. Intraoperative staffing for the surgical case should be minimized to the minimal number needed to safely and efficiently complete the procedure. 13. Staff relief for breaks should be provided only as necessary to preserve PPE and decrease the number of staff exposed and re-entries. 14. Smoke evacuation electrosurgical devices should be used to minimize staff exposure to surgical smoke. 6 15. Patients should preferably recover in a negative pressure isolation room when resources permit (in the PACU or ICU). If negative pressure isolation rooms are unavailable, consider early recovery in the OR prior to transfer to a single patient room. 16. After the patient has left the OR, the OR should be closed for an appropriate standoff period to achieve greater than 99.9% aerosol clearance. The amount of time that aerosols stay suspended in the air will depend on a number of factors including the size of the room, the number of air changes per hour, how long the patient was in the room, if the patient was coughing or sneezing, and if an AGP was performed. General guidance on clearance rates under differing ventilation conditions is available from the CDC. 18 17. Following the standoff period, the OR suite must be cleaned using routine procedures with EPA-approved hospital disinfectant 18. Surgeries should be performed by the most experienced available surgeons and assistants to limit exposure time in the OR. Junior residents and other learners should not be exposed unless absolutely necessary. 19 . Strong consideration to surgical approach and technique must be considered to optimize patient outcomes while minimizing exposure risk to providers. Use of laparoscopic or videoassisted thoracoscopic procedures should be avoided when possible due to risk of aerosolization from C0 2 insufflation systems with inadvertent lung injury. 24. TEE in an intubated, anesthetized patient has never been demonstrated to generate aerosols. However, many societies have classified TEE as an AGP. Clinicians should weigh the necessity of placing a TEE in each cardiac surgical patient against the theoretical concern of generating aerosols. If performed, all staff should wear a N95 mask. The most experienced echocardiographer should perform the examination, including probe insertion/removal. 20 There is accumulating evidence indicating that a substantial fraction of COVID-19 infected individuals are asymptomatic. 21,22,23 A study of skilled nursing facility residents infected with COVID-19 demonstrated that half were asymptomatic or pre-symptomatic at the time of contact tracing evaluation and testing. 24 In a population-based study in Iceland, 43% of the participants who tested positive reported having no symptoms. 25 In a study of 215 pregnant women admitted for delivery in New York City, 15% were COVID-19 positive 88% of whom were asymptomatic. 26 Virologic studies have demonstrated viral RNA and viable virus among persons with asymptomatic and pre-symptomatic infection. 22, 24, 27 If a high-fidelity, rapid point-of-care testing system is available, providers could consider screening preoperative patients immediately prior to surgery if time permits within a 24-hour window, particular in areas of high COVID-19 disease burden. Positive screening tests should lead to reconsideration of the risks and benefits of proceeding with surgery. These patients may be in the pre or early symptomatic phase of infection and are likely at heightened risk of adverse outcomes following surgery. In a retrospective cohort study of 34 patients who were unintentionally scheduled for elective surgeries during the incubation period of COVID-19, the mortality rate was 20%. 28 However, negative screening tests must be interpreted with caution, particularly in the setting of a) low pre-test probability; b) typically low viral titers in the asymptomatic phase and; c) the possibility of false negatives. If clinical suspicion for COVID-19 remains (due to exposure history, active symptoms, high prevalence of circulating community infections, or other clinical factors), repeat testing may be indicated during the postoperative course. Following viral infections, an IgM immune response occurs which then diminishes within a few weeks. The IgG and IgA immune response occurs simultaneously, producing more specific and longer acting immunity. Testing patients' serostatus could be an important tool to determine if patients have mounted prior immunity from natural infection, reducing the likelihood of current COVID-19 colonization. The prospect of testing providers for serologic immunity to COVID-19 is also promising if the presence of antibodies confers immunity to future infection, as providers with acquired immunity could be selected to care for COVID-19 suspected or confirmed patients. Unfortunately, serologic testing and capacity are currently limited and require further scientific evidence to support their use in screening healthcare workers. Important studies are underway to determine the pattern of antibody development following COVID-19 infection, whether antibodies confer immunity to future infections, if specific antibody titers determine the level of protection, and the duration of conferred immunity. Similar coronavirus outbreaks demonstrated that survivors developed robust immunity after natural infection. The 2003 SARS outbreak elicited an immunity that was protective for up to three years. 29 Until more data emerges supporting the widespread adoption of antibody testing, 30 strict infection prevention and control policies are required to enhance the safety of patients and providers. At the present time, we urge all health care organizations providing cardiac surgery in regional environments of widespread COVID-19 disease, to consider adopting these aggressive mitigation strategies a) to create a safe environment that protects our patients from acquiring or transmitting COVID-19, and b) to protect members of our surgical and postoperative provider teams. We all look forward to the near future when elective surgery can be resumed as the threat of this virus wanes and capacity permits, but until that time comes, and in an effort to hasten its arrival, the aforementioned protocols should become standard of care. Interim Guidance for Healthcare Facilities: Preparing for Community Transmission of COVID-19 in the United States Tiered Patient Triage Guidance Statement COVID-19: Elective Case Triage Guidelines for Surgical Care. ACS website Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review Awareness of surgical smoke hazards and enhancement of surgical smoke prevention among the gynecologists Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2). Science 2020. 10 Self-contamination during doffing of personal protective equipment by healthcare workers to prevent Ebola transmission -hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China. Resuscitation Evidence of SARS-CoV-2 Infection in Returning Travelers from Wuhan, China Infections in Residents of a Long-Term Care Skilled Nursing Facility Spread of SARS-CoV-2 in the Icelandic Population Universal Screening for SARS-CoV-2 in Women Admitted for Delivery SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients Clinical characteristics and outcomes of hospitalised patients with COVID-19 treated in Hubei (epicenter) and outside Hubei (non-epicenter): A Nationwide Analysis of China Duration of antibody responses after severe acute respiratory syndrome