key: cord-0863616-mmlb5ra6
authors: Bonano, John C.; Huddleston, James I.
title: Perioperative Medical and Surgical COVID-19 Issues: Keeping Surgeons, OR Teams, and Patients Safe
date: 2021-01-23
journal: J Arthroplasty
DOI: 10.1016/j.arth.2021.01.047
sha: ff08c92cc7130c9fb35d99ec531a21fc22e2965a
doc_id: 863616
cord_uid: mmlb5ra6

COVID-19 has infected over 22 million people in the United States (US) and has had a devastating impact on the US economy and health care system. In order to help slow the spread of the virus and save hospital resources, non-essential businesses were forced to close and elective surgeries have been postponed. As we reach the peak of the pandemic and the COVID-19 vaccine gets distributed, health care systems must develop plans to safely resume elective surgeries. An effective institutional strategy not only includes clear perioperative testing protocols, but also education regarding clinical manifestations and exposure control to help keep surgeons, operating room teams, and patients safe.

As of January 10, 2021, there have been over 22 million Coronavirus Disease 2019 18 (COVID-19) cases and 370,000 deaths in the United States (US). [1] While its' impact on our 19 patients and their families has been devastating, the pandemic has also had a much broader 20 impact on our health care system. California hospitals are operating near capacity and struggling 21 to meet the demands for intensive care unit (ICU) beds and ventilators. [2] On March 19, 2020, 22

California ordered the first stay-at-home order in the US in an attempt to slow the spread of the 23 regional stay-at-home orders affecting 98% of the population in California. [2] In addition, to 25 help preserve hospital resources, the Centers for Medicare and Medicaid Services, [5] the 26 Surgeon General, and the American College of Surgeons [6] recommended against continuing 27 elective surgeries. As a result, 35 states mandated that all elective surgeries be cancelled. [7] 28 While these memorandums may help save hospital beds in the midst of a surge in COVID-19 29 cases, there are broader implications that must also be considered. With nonessential businesses 30 closed, over 16 million Americans have been forced to file for unemployment. [8] In addition, 31 those health care systems relying heavily on elective surgeries for revenue have been forced to 32 furlough employees and withhold surgeon salaries. [9, 10] In response, the Coronavirus Aid, 33

Relief, and Economic Security Act (CARES) was passed by the US Congress to provide $100 34 billion to hospitals and $350 billion to small businesses including private orthopaedic 35 practices. [11] [12] [13] While this has helped to lessen some of the financial burden, hospital systems, 36 like the Mayo Clinic, project up to $900 million in losses. The SARS-CoV-2 virus triggers an innate and adaptive immune response, involving the 56 production of IgM or IgG antibodies that bind to viral antigens.

[18] The innate immune cell 57 response results in the production of inflammatory cytokines, and detection of these cytokines 58 has been correlated with increased viral loads. [17] In contrast, increased IgG/IgM levels have 59 been shown to correlate with decreased viral loads and good clinical outcomes. [ For patients already admitted to the hospital that are indicated to undergo surgery, similar 111 standardized testing protocols must be developed to minimize transmission of COVID-19. If an 112 admitted patient has had a previous negative COVID test within three midnights and does not 113 report any new respiratory symptoms, they may proceed to the operating room as scheduled with 114 emergent surgery is indicated, a rapid COVID-19 test should be ordered, and the patient is 116 allowed to proceed with surgery before the test results. In this case, the patient is treated as a 117 "person under investigation" and full COVID precautions are taken including the use of an N95 118 mask, face shield, and waiting 20 minutes before entering the room after intubation. For non-119 urgent surgeries, routine COVID tests are ordered and should be resulted prior to proceeding 120 with surgery. If positive, one must consider the risks and benefits of delaying surgery versus 121 potential transmission if deciding to proceed with the procedure in a COVID+ patient. 122 123

In addition to perioperative patient testing protocols, testing for the medical staff is also 125 of critical importance. Healthcare workers on the frontlines have the highest potential exposure 126 to COVID+ patients. Their health and safety are vital to not only maintaining the capacity to 127 provide care during the current surge in COVID cases, but also for those patients who have other 128 urgent medical problems, not related to COVID. At our institution we define an exposure as a 129 close interaction with a COVID+ patient within 6 feet for over 15 minutes. If asymptomatic, we 130 recommend testing at 2-5 days after the exposure and again at 14 days after the exposure, given 131 the established incubation period of the virus. While waiting for the results, staff are allowed to 132 continue to work with appropriate PPE and social distancing. If symptomatic, staff should 133 undergo the same testing protocol but are not allowed to return to work until after the first 134 negative test result. If a healthcare worker tests positive and is asymptomatic, they are allowed 135 to return to work in 10 days. If symptomatic with a positive test result, staff must be afebrile for 136 three consecutive days with improving symptoms before returning to work at a minimum of 10 who have recently traveled or been in mass gatherings. 139

While detailed perioperative testing protocols can help minimize the transmission of the 142 virus, there is still the potential for COVID+ patients to undergo surgery undetected, due to 143 potential false negative tests and the long incubation period before seroconversion and symptom 144 development. The following case describes an example of this scenario and highlights potential 145 perioperative factors contributing to COVID transmission. 146

A 66 year old male with a past medical history of reactive airway disease underwent an 147 uncomplicated right total knee arthroplasty in July, 2020. He had a COVID negative test 2 days 148 prior to his scheduled operation. He was discharged home on postoperative day two, where he 149 lived with his wife, and had home health nursing and physical therapy visit him two times per 150

week. On postoperative day 13, he called our clinical advice service to report difficulty 151 breathing and a productive cough. He was advised to go to the local emergency department 152 where he and his wife were both diagnosed with COVID, requiring admission. He did not 153 require an ICU bed and was discharged home after 6 hospital days without complication on 154 home oxygen. At his 6 week follow up, his clinical symptoms had improved but he was still 155 using oxygen by nasal canula on an as-needed basis. At 3 months, he was no longer requiring 156 oxygen but reported feeling tired with dyspnea on exertion. 157 Despite following our standard preoperative COVID testing protocol and having a 158 negative COVID test 2 days prior to surgery, this patient unfortunately contracted the virus in the 159 perioperative setting. While it is possible that he had a false negative test, the high sensitivity for 160 he was exposed to the virus in the community or the preoperative area, after his initial test was 162 obtained. In addition, there is the potential for noncompliance with PPE and social distancing 163 guidelines that may have increased his risk of exposure. Factors pertaining to the inpatient 164 hospital system that may have contributed to exposure include protocols to limit visitors, social 165 distancing, COVID+ patient isolation, cleaning/disinfection, hand hygiene, PPE availability, and 166 potential exposure from the healthcare staff. Outpatient factors include exposure in the 167 community or home environment from his home health visits. 168

This is a rare case that not only highlights that COVID is a potential cause of readmission 169 after total joint arthroplasty, but it also shows that COVID+ patients exist in the operating room 170 and hospital despite strict preoperative testing protocols. In order to minimize healthcare staff 171 exposure and transmission, it is vital to continue to practice proper use of PPE, social distancing, 172 and minimizing in-person patient interaction. 

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