key: cord-0867016-0iigvock
authors: Deora, Harsh; Dange, Preetham; Shashidhar, Abhinith; Tyagi, Gaurav; Srinivas, Dwarakanath
title: Management of Neurosurgical Cases in a Tertiary Care Referral Hospital During the COVID-19 Pandemic: Lessons From a Middle-Income Country
date: 2020-12-29
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.12.111
sha: 46d499c0c3ce2bc99c1bb520c5497d9474834db2
doc_id: 867016
cord_uid: 0iigvock

Background/Introduction COVID-19 pandemic has been at its peak for the past 6months and has affected more than 215 countries around the world. India is now the 2nd most-affected nation with more than 48,00,000 cases and 79,000 deaths. Despite this, and the fact that it is a lower-middle-income nation the number of deaths is almost 1/3rd of the USA and ½ of Brazil. There has, however, been no experience published from non-COVID designated hospitals where the aim is to manage non-infected cases with neurosurgical ailments while keeping the number of infected cases to a minimum. Methods We analyzed the number of neurosurgical cases (non-trauma) done in the past 5 months (March- July 2020) in our institute which is the largest neurosurgical center by volume in southern India and compared the same to the concurrent 5 months in 2019 and 5 months preceding the pandemic. We also reviewed the total number of cases infected with COVID-19 managed during this time. Results We operated a total of 630 cases(non-trauma) in these 5 months and had 9 COVID-19 infected cases operated during this time. There was a 57% (p=0.002) reduction in the number of cases operated as compared to the same 5 months in the preceding year. We employed a dual strategy of Rapid Antigen testing and surgery for cases needing emergency intervention and Reverse Transcriptase-Polymerase chain reaction test for elective cases. The hospital was divided into three zones (red, orange, and green) depending on infectivity level with minimal interaction. Separate teams were designated for each zone and thus we were able to effectively manage even infected cases despite the absence of pulmonology/medical specialists. Conclusion We present a patient management protocol for non-COVID designated hospitals in high volume centers with the constraints of a lower-middle-income nation and demonstrate its effectiveness. Strict zoning targeted testing and effective triage can help in management during the pandemic.

nation the number of deaths is almost 1/3rd of the USA and ½ of Brazil. There has, however, been no experience published from non-COVID designated hospitals where the aim is to manage non-infected cases with neurosurgical ailments while keeping the number of infected cases to a minimum.

We analyzed the number of neurosurgical cases (non-trauma) done in the past 5 months (March-July 2020) in our institute which is the largest neurosurgical center by volume in southern India and compared the same to the concurrent 5 months in 2019 and 5 months preceding the pandemic. We also reviewed the total number of cases infected with COVID-19 managed during this time.

We operated a total of 630 cases(non-trauma) in these 5 months and had 9 COVID-19 infected cases operated during this time. There was a 57% (p=0.002) reduction in the number of cases operated as compared to the same 5 months in the preceding year. We employed a dual strategy of Rapid Antigen testing and surgery for cases needing emergency intervention and Reverse Transcriptase-Polymerase chain reaction test for elective cases. The hospital was divided into three zones (red, orange, and green) depending on infectivity level with minimal interaction. Separate teams were designated for each zone and thus we were able to effectively manage even infected cases despite the absence of pulmonology/medical specialists.

J o u r n a l P r e -p r o o f INTRODUCTION COVID-19 is a rapidly evolving situation where the possibilities are endless and certainties are limited. As of 14th September 2020, this virus has affected over 215 countries with more than 29 million cases and around 928,000 deaths [1] . The only certainty is that these numbers will continue to rise and infect more individuals. India is a lower-middle-income country by current world bank classification, [2] which means its Gross National income per capita is between 1036$ to 4045$. This has an implication on the number of tests per capita with India doing only 32.13 tests per thousand people as compared to 253.47 tests per thousand in the United States [3] . Despite this, the total number of deaths in India is nearly one-third of that in the United States (68,000 vs 191,000) which could be attributed to the strict lockdown undertaken by the Union Government in India [1] . While the lockdown has been effective in reducing the total number of cases, it has undeniably reduced the number of neurosurgical caseloads even in the busiest of centers. Our center is a tertiary care hospital in South India that had a footfall of 224265 cases in 2017-18 with around 8900 surgeries per year of which more than 4000 cases were major elective procedures [4] . The management of neurosurgical cases during this raging pandemic with the dual goals of providing the best neurosurgical care with minimum risk of infections under resource constraints poses a considerable challenge.

Bengaluru is the third most populous city in India with more than 20 million residents and it reported its first confirmed case on 9th March 2020 [6] . This was close to the first case reported in India on January 30th, 2020, and much later than the first case in Wuhan in late December 2020 [6] . We were able to utilize this time to make substantial preparations to face the pandemic. Being a high-volume center, one of our main concerns was crowd management and maintaining adequate social distancing and segregation in the space constraints that we had. A series of departmental protocols were put in place and measures were taken, including the postponement of elective surgeries, altered conventional outpatient service into J o u r n a l P r e -p r o o f telemedicine outpatient service, strict control of elective-emergency admissions, prevention of intermixing of cases and health care staff, improvements in operation and treatment processes, allocation of designated areas for holding and operating Covid patients and strict ward management. The objective of this report is to outline these measures and the impact that COVID-19 had on the neurosurgical management of cases at our institute.

We collected data for all neurosurgical cases operated during the 5 months of the pandemic (1st March 2020 to 31st July 2020) excluding trauma and compared the same to the number of cases operated during the same 5 months in 2019 and 5 months in the winter of 2019. For segregation of cases, the hospital was divided into three zones -Red, Orange, and Green with restricted transfer between each zone. After initial symptom screening, the patients were kept in the Orange Zone. Rapid antigen test (RAT) was employed for cases that required immediate surgery on an emergency basis. Such cases were operated using full personal protective equipment. RT-PCR was used as the definitive test before transferring a case to the green zone for elective surgery. The Red zone was utilized for Rapid Antigen and RT-PCR positive cases who needed emergency surgery.

For category wise comparision with the past 5months and one year back Mann Whitney U test was used to compare the number of cases. A Nonparametric test was used as the number of observations was less than 30 in each category of surgeries considering it as nonnormal distribution. For the comparision of total cases wih the two time periods standard t tests which a type of parametric method; they can be used when the samples satisfy the conditions of normality, equal variance, and independence.

Compared to last year there was a 57% (p=0.002)reduction in the number of surgeries done during the 5 months of the pandemic (Table 1) , with a total of 630 cases operated over this duration as compared to 1448 cases in 5 months in 2019. When compared to the preceding 5 J o u r n a l P r e -p r o o f months there was a 56% (p=0.009) reduction in the number of cases operated (Table 1) . A total of 9 cases of confirmed COVID-19 positive cases were operated on during this period with no transmission to health care workers involved during the surgery (Table 2) . A 3 tier management of patient inflow considering the emergent nature of the condition and rapidity of testing is thus demonstrated to be an effective management model (Fig 1) , for high volume resource-constrained hospitals. The most significant reduction was seen among neoplasm cases (p=0.015 & p=0.028) emphasizing the fact that many patients with neoplasms (benign and malignant) were delayed due the the pandemic.

In the pre-COVID 19 periods, neurosurgery patients were admitted through outpatient clinics and from emergency departments. All patients underwent thorough clinical evaluation, neuroimaging, along with routine investigations, and were operated on in one of the 7 elective or 3 emergency theatres. In the year 2018-2019, we operated more than 5700 cases (with more than 3000 elective cases) with 9 operative theatres (7 elective and 2 emergencies).

Since then we have opened 2 more theatres that were dedicated to operating COVID-19 positive cases with neurosurgical emergencies.

In the initial phase of the pandemic:

During the initial COVID-19 period ( Figure 1 ) when the number of positive cases was still low and an initial lockdown was in place, the admission was restricted to either from the emergency ward or a specially created holding ward where patients were admitted for RT-PCR testing before surgery. The Emergency area was remodeled and a special isolation ward was created where suspect patients were admitted for testing. An additional special triage area along with a testing kiosk was also created where all patients who came to the Casualty were screened before being assigned to either the general triage area or the isolation ward.

The hospital was divided into three zones: A Red Zone -for all COVID-19 positive patients, Orange Zone for emergency patients and those who were RAT negative, and a Green Zone for all RT-PCR negative patients.

The screening protocol included a detailed questionnaire ( Figure 1 ) and a score assigned to each patient, based on which the patients were admitted as detailed above. Also, every J o u r n a l P r e -p r o o f patient attendant had to undergo thermal screening, screening questionnaire, and use protective measures including hand sanitization and face masks which were provided free of cost to them by the hospital.

In the later phase when the cases increased exponentially:

As the RAT became widely available, the strategy outlined above changed. All symptomatic patients and patients for emergency surgery were screened with RAT. As the turnover time for RAT at our institute is less than 30 minutes, it served as a very useful tool especially for triaging. The main disadvantage though was the sensitivity rate which was around 50%. Also, all patients with an expected stay of more than 24 hours in the hospital were screened with RAT.

Personal protective measures: In the emergency/casualty area, all patients were evaluated by neurosurgery residents and nursing teams using protective measures like N95 masks or P100 respirators, face shields, hand gloves, and impervious gown. All healthcare workers in the emergency area were mandated to be in PPE gear.

Depending on the emergent nature of the illness (i.e. aneurysm rupture or signs of herniation), the patients were either subjected to throat nasopharyngeal swab for Rapid Antigen or nasal and oral swab for RTPCR for SARS COVID 19. Depending on the results the patients were operated on in the dedicated theatres as follows. Additionally, all patients being operated on in the Orange and Red Zones underwent a Chest CT.

Red Zone OT (2 dedicated theatres): All RAT positive and RT-PCR positive cases.

• Orange Zone OT (3 Dedicated theatres) -All RAT negative patients.

All COVID-19 patients operated at our institute were managed in the designated Red-Zone ward till he/she was fit for discharge.

Personnel precautions:

All cases in orange and red zones were operated with the operating team in full PPE and N-95 or P-100 respirators. Additional transparent face shields were worn during craniotomy along with copious irrigation. The central air conditioning was switched off during the procedure.

Health care personnel precautions:

All health care personnel with inadvertent exposure were assessed for risk and quarantined for 5 days followed by an RT-PCR test. A separate team consisting of consultants and residents were designated to the red zone who were not allowed to intermingle with doctors working in other zones and a standard protocol was followed while in that area (Fig 2) .

Doctors working in the orange and red zones were to follow a strict work cycle of 1 week of work followed by a 1-week cooling period to reduce the risk of transmission among the health care workers.

Cases seen in the Outpatient department were evaluated by neurosurgery consultant and resident teams using protective measures like N95 respirators, face shields, and hand gloves while taking adequate precautions to prevent crowding. If considered for admission depending on the nature of disease and need for surgery (Fig 3) , they were shifted to the holding ward and an RT-PCR test was performed on them. If negative these cases were shifted to the green zone to be operated in the 4 dedicated green zone theatres. Cases here were operated using face shields during craniotomy and N-95 masks with protective eye-gear throughout. After surgery, all patients were shifted to the postoperative ward, having shared cubicles with a restricted number of visitors/caregivers. They were all strictly observed for the development of any symptoms related to COVID 19.

Any patient who was RT-PCR positive and did not require emergent surgery was deferred until he became RT-PCR negative. Such patients were discharged to the designated COVID-19 hospitals for appropriate care.

During the initial stringent lockdown, the OPD was closed. To minimize inconvenience to patients, telephone calls were made to patients for follow-up. Also, a dedicated number was set up to which the patients could call and fix up an appointment for telephonic consultation.

During the telephonic consultation, relevant clinical details were sorted and if it was felt that the patients required a further evaluation, either a video telemedicine appointment was done J o u r n a l P r e -p r o o f or the patients were asked to come to OPD either at our institute or the nearest neurosurgical center.

The doctors enquired about the patient's identity through the government identity card. The doctors then introduced themselves, with their qualification, registration number, and specialization. The duration of the telemedicine consultation was fixed. The patient history and questions were kept precise and prepared before the telemedicine consultation. A properly filled proforma for the first or follow-up consultation helped in the documentation and to conduct the telemedicine session effectively. The previous treatment details/admission discharge slips were collected before the consultation. The presence of the patient was essential during the telemedicine consultation. The patient had the right to choose in-person consultation at any stage. Doctors also had the professional discretion to choose the mode of consultation (in-person/text/audio/video). Doctors needed to arrive at diagnosis/provisional diagnosis before prescribing medication. They also avoided prescribing

Schedule-X and drugs listed under the Narcotic Drugs and Psychotropic Substance Act,1985 [7] .

We adhered to the selection of cases depending on the severity of the condition and urgency of care needed (Table 3) . All procedures which could be deferred E.g.: Epilepsy, deep Brain Stimulations were deferred. Preference was given to patients with significant raised intracranial pressure, progressive neurological deficits, aneurysms, etc. In cases such as lowgrade glioma, where a period of interval monitoring with MRI is a reasonable management option was also offered to cases. In the event of a 3-6 months delay, we considered adding a 3-month interval scan to ensure no tumor progression [9] . Patients with certain diseases that are known to follow a benign course with a good level of evidence like cervical spondylotic 

Comparing the number of cases to a similar period during the previous year, the maximum reduction was seen in functional neurosurgical cases like epilepsy surgery and movement disorders as these cases are being managed with medications as of now. Despite this, 3 cases of battery replacement were done for two patients with subthalamic nucleus-DBS for Parkinson's disease (PD) and one with globus pallidus interna-DBS for generalized dystonia presenting with acute worsening of symptoms due to battery exhaustion [11] . Apart from these, there was a tremendous reduction in cases presenting with neural tube defects (94%) and craniosynostosis (73%). We have previously shown the prevalence of these defects is less in the southern part of our country when compared to other areas, and perhaps due to the restriction of travel, these cases were being managed locally [12] . Cranioplasty and pain reliving procedures like trigeminal neuralgia were reduced by almost 80% as they were either deferred or managed medically. In addition, pituitary surgeries were also reduced by 72% perhaps due to the unprecedented fear among cases and increased risk of infection associated with them [13] . There was little reduction in aneurysm surgery (17%) when compared to the summer months. However, the reduction seemed more (37%) when compared to winter months during which the prevalence of aneurysmal subarachnoid hemorrhages is more [14] .

We also completely stopped cases dine with Intra-operative MRI (IOMRI) guidance as it would entail increased exposure of the patient to the MRI suite. Our MRI suite is hybrid and thus has a high footfall of cases undergoing routine MRI. Apart from these, there was no considerable difference in the number and composition of cases in summer and winters;

attributing the sudden decrease in the number of cases to the pandemic.

A total of nine COVID-19 positive cases were managed during this time, 7 of which were life-threatening emergencies, and 2 cases (pituitary and craniopharyngioma) presented with rapidly deteriorating vision. 8/9 of these cases were discharged at mRS<2 signifying that proper case selection can lead to gratifying results even in these cases. One case of craniopharyngioma acquired COVID-19 infection from another case (unknown source) after surgery. He later succumbed to the same due to severe ARDS.

We were able to successfully run the Gamma-Knife facility during this time without interruption and do 42 cases in 5months (70% reduction) and no infections (Table 1) . This meant that every case was pre-tested with RT-PCR within the prior 2 days of receiving treatment along with one relative. Any patient suffering from cough, fever, loss of smell, or history/contact to the COVID affected area were either tested twice one week apart or were rescheduled as most of these cases are not emergencies. Radiosurgery is a multidisciplinary team that involves a neurosurgeon, radiation oncologist, medical physicist, nursing staff, and radio-technicians. To minimize the chances of unnecessary exposure, only one team leader fixed the frame for the patient. While minimally symptomatic patients such as growing vestibular schwannoma or residual nonfunctional pituitary adenoma were given a lower priority, single or oligometastatic lesion of the brain with favorable outcomes was prioritized urgently. As the intubation and elective ventilation were considered high-risk procedures concerning coronavirus, we refrained from pediatric patients and the ones in need of anesthesia during GKRS. We considered the frame localizer, frame engaging unit over the gamma couch as infected material and sterilized the same after every procedure, air conditioning was avoided. The staff was encouraged to use the no-touch technique and frequent alcohol use for disinfection. All surfaces were repeatedly cleaned with alcohol-based solutions including computer apparatus, keyboards, and mouse. A single operator was asked to handle data entry, image definition, target and organs at risk delineation, treatment J o u r n a l P r e -p r o o f planning, and approval. Steroids were used judiciously in post-treatment cases with not more than a 7-day course in lesions presenting with edema. Using these precautions, we were able to achieve a zero-infection rate while maintaining the standard of care without affecting our workload.

Our center is the biggest neurosurgical center in South India which caters only to neurological diseases with only visiting specialists employed in the field of general and respiratory medicine and thus is not an ideal set-up for the management of COVID-19 cases. . In addition to using standard precautions like minimal drilling and copious irrigation, certain low-cost but highly effective solutions were used like boxed intubation (Fig 4) 

Unfamiliar techniques are to be avoided. Endobronchial intubation should be checked with flexion of the neck if needed for surgery to avoid ventilator disconnections later. The conduct of awake intubation and awake surgeries are discouraged as they tend to generate more aerosols. However, if inevitable, every precaution should be taken to minimize aerosol generation [20] . Lower cranial nerve monitoring electrode placement should be done after intubation with a vasopressor ready in case of hypotension. After extubation, it should be ensured that the patient wears a face mask immediately and there should be strict adherence to doffing protocols. All disposable sensors used for neuro-monitoring must be discarded 

The senior author (DS) was a part of the consensus guidelines regarding the practice of Neurosurgery and Neurology from India [15] . These guidelines are applicable in the operating room while taking neurosurgery rounds and pre and post-operative management.

We tried to emulate the same at our hospital and a summary is presented below:

1. Pre-procedure briefing: Each member of the team should understand the sequence of anesthesia and surgery as this will ensure seamless teamwork with all the necessary drugs and equipment in place before the commencement of the operating procedure.

Negative pressure operating room preferred, however, high frequency of air change (25/hr) is equally effective.

Separate operating room(OR) with separate air duct flow for managing COVID-19 cases: Each OR should have its ventilation system with an integrated high-efficiency particulate air filter (HEPA)

Creating a set of new workflows e.g. coordination of staff, movement of surgical and anesthetic equipment, infection prevention practices, etc.

A comprehensive program for the use of PPE must be enforced.

Discard the canister of soda lime to eliminate the negligible risk of circuit contamination after surgery.

Following the disposal of single-use equipment, all instruments should be sent for decontamination and sterile re-processing.

All staff should then shower and change into a clean set of scrubs J o u r n a l P r e -p r o o f 9.

"High-touch" equipment e.g., anesthesia stations, laptops, cabinets, etc., should be covered with disposable plastic sheets.

Names of all participating staff members are recorded to facilitate contact tracing.

Since more time is required for decontamination, the turn-around time for surgery is naturally increased.

There is a dual priority of personal protection while ensuring patients' safety, timely management, and capacity building. Along with the glaring problem of infection, there is another threat of neurosurgery emergency building up. This wave may overwhelm the already stretched systems to the hilt. We need to flatten this curve while avoiding contagion.

These measures may guide neurosurgery practitioners to effectively manage patients ensuring the safety of caregivers and care seekers [27, 28] .

Ours 

The ongoing pandemic has exposed several loopholes in the worldwide health care system. A sizeable number of global fatalities have occurred, and the impact is being felt worldwide.

We have successfully managed neurosurgical cases despite not being a COVID-19 designated hospital and without the presence of pulmonologists or even medical specialists.

Effective steps were taken by us like zoning, triaging, and managing the workload with constraints to prevent neurological deterioration of elective cases waiting for surgery and presenting acutely, have proven effective. We present this model for high volume centers in middle-income nations where testing and non-availability of critical care beds is a reality. 

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