key: cord-0917242-sm7h513o
authors: Lang, Shih-Shan; Gajjar, Avi A.; Tucker, Alexander; Storm, Phillip B.; Rahman, Raphia K.; Madsen, Peter J.; O’Brien, Aidan; Chiotos, Kathleen; Kilbaugh, Todd J.; Huh, Jimmy W.
title: Urgent neurosurgical interventions in the COVID-19 positive pediatric population
date: 2021-10-27
journal: World Neurosurg
DOI: 10.1016/j.wneu.2021.10.155
sha: c8bc321393f559d28b119d3e4d75d791b90646fa
doc_id: 917242
cord_uid: sm7h513o

Background Urgent neurosurgical interventions in pediatric patients with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) are rare. These cases pose an additional stressor on a potentially vulnerable dysregulated inflammatory response which may put the child at risk for further clinical deterioration. Our aim was to describe the perioperative course of SARS-CoV-2 positive pediatric patients who required an urgent neurosurgical intervention. Methods We retrospectively analyzed pediatric patients ≤18 years of age admitted to a quaternary children’s hospital with a positive PCR for SARS-CoV-2 virus from March 2020 to October 2021. Clinical characteristics, anesthetic and neurosurgical operative details, surgical outcomes, and non-neurological symptoms were collected and analyzed. Results Eight SARS-CoV-2 positive patients were identified with a mean age of 8.83 years (median 8.5 years; range 0.58 -18 years). 6 of the 8 patients were male. All children had mild disease or were asymptomatic with regards to COVID symptoms. The anesthetic and surgical courses for these patients were overall uncomplicated. All patients were admitted to a specialized isolation unit in the pediatric intensive care unit (PICU) for cardiopulmonary and neurologic monitoring. Increased protective personal equipment (PPE) during anesthesia and the operation did not impede a successful neurosurgical operation. Conclusions SARS-CoV-2 positive pediatric patients with minimal COVID-related symptoms who require urgent neurosurgical interventions face unique challenges regarding their anesthetic status, operative delays due to SARS-CoV-2 PCR testing and additional PPE requirements. Despite these clinical challenges, the patients in our study had no adverse post-operative consequences and no healthcare professionals involved contracted the virus.

Coronavirus disease 2019 is caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and has caused the ongoing worldwide pandemic. The burden of severe disease and mortality is greatest in older adults (>60 years), and also associated with underlying comorbid medical conditions including cardiovascular disease, obesity, poorly controlled diabetes, and immunocompromised conditions. 1-3 Acute respiratory failure is the most common complication of COVID-19 in adults. In contrast, children generally experience a mild illness which infrequently leads to hospital admissions and medical interventions. [4] [5] [6] To date, as of October 2021, over 6 million children in the United States alone have tested positive for COVID-19. 3, 7 In the pediatric population, the most common symptoms are fever, cough, runny nose, diarrhea, sore throat, and vomiting. 4, 8 However, it is increasingly recognized that this virus can lead to neurological manifestations such as encephalopathy, central nervous system inflammation and stroke. 9, 10 Pediatric patients with COVID-19 are particularly susceptible to developing a systemic inflammatory syndrome, termed "multisystem inflammatory syndrome in children" (MIS-C), which can result in cardiovascular, respiratory, gastrointestinal, mucocutaneous, hematologic and neurologic compromise. 11 Although rare, some children have developed intracranial hypertension that resolved with supportive medical care. 12 Thus, there is a risk that patients with COVID-19 could have neurologic symptoms due to the virus which may confound the perioperative neurologic assessment of pediatric neurosurgical patients. Furthermore, it is unknown whether general anesthesia and neurosurgical intervention puts infected children at greater risk of developing neurologic and/or cardiorespiratory complications from SARS-CoV-2, highlighting the need for additional data in this population.

Operative interventions on COVID-19 positive pediatric patients pose a particular set of challenges. Few studies on anesthetic and perioperative management of pediatric patients with SARS-CoV-2 have been described compared to adults, and as such guidelines describing optimal care are less refined. Anesthesiologists, in particular, are likely to be at increased risk of contracting COVID-19 during airway management, due to the close proximity of the patient's airway and exposure to aerosolized viral particles during airway management, including positive-pressure ventilation via mask, endotracheal intubation, extubation, or care of a tracheostomy tube. 13, 14 A systematic review from the 2003 SARS coronavirus outbreak demonstrated that compared to healthcare workers who did not perform airway or ventilator J o u r n a l P r e -p r o o f management, those who performed tracheal intubation had a 6.6-fold increased odds of contracting the virus. 15 Once the induction of anesthesia has begun and throughout the operative course, there is a risk present to all staff in the operating room. 16 Furthermore, the pediatric patient infected with COVID-19 who needs general endotracheal anesthesia and a surgical procedure can be at risk for further stress that may exacerbate an already vulnerable dysregulated inflammatory response, putting a child at risk for further clinical deterioration. At our institution, while elective surgeries were postponed in children with SARS-CoV-2, there were emergent or urgent conditions in our pediatric neurosurgical population that required general endotracheal anesthesia and surgical intervention to prevent life-threatening neurologic deterioration. To our knowledge, there has been only one specific case report in the literature of a pediatric patient infected with COVID-19

undergoing an urgent neurosurgical intervention. 17 To our knowledge, we report the first case series of pediatric patients who were COVID-19 positive and required urgent neurosurgical interventions.

This retrospective observational study was conducted in pediatric patients ≤18 years of age at a quaternary children's hospital over a 20-month time period (March 2020 -October 2021). The protocol was approved by the Committee for the Protection of Human Subjects Institutional Review Board (IRB). Throughout the study period, all patients underwent SARS-CoV-2 PCR testing from a nasopharyngeal or anterior nares source upon admission. SARS-CoV-2 PCR was obtained within 72 hours prior to surgery from March 2020 until present time. All cases were evaluated by the attending pediatric neurosurgeon and division chief and classified as emergent, urgent, or elective, similar to the recommendations of the Brazilian Society of Pediatric Neurosurgery (SBNPed) and an Italy pediatric hospital. [18] [19] [20] Cases requiring immediate surgical intervention from time of admission without waiting until the next day were deemed emergent.

These included hydrocephalus with altered mental status, infections, and brain or spine injury/trauma with severe neurological compromise from baseline including lethargy/obtundation. Neurosurgical procedures were considered urgent if there was risk of imminent neurological decline without surgical correction during that hospital admission, including CSF leak, hydrocephalus, shunt malfunctions, open myelomeningocele, brain, or spine J o u r n a l P r e -p r o o f tumors at risk for intracranial hypertension or neurological compromise, and intracerebral hemorrhage from hemorrhagic vascular malformations. Procedures were deemed elective if not considered a neurosurgical urgency or emergency and were re-scheduled after discussion with parents and hospital administration. Our classification system was similar to other studies and was used to stratify surgical cases based upon clinical status and the time frame in which they could be rescheduled (Table 1) . [18] [19] [20] Inpatient and outpatient records, radiologic studies, and operative reports were analyzed.

Patient data, including demographic characteristics, clinical presentation and course, laboratory and imaging results, underlying neurosurgical pathology, medications administered, and followup data were abstracted from the electronic medical record. If available, arterial blood gas carbon dioxide levels, oxygen saturations, blood pressures, intracranial pressures, mechanical ventilation parameters and medications were reviewed.

Formal N95 fitting, and PPE training sessions were administered to ensure the health and safety of the multi-disciplinary team. The decision to use a PAPR versus N95 mask by the attending pediatric neurosurgeon was decided based upon N95 fit test and complexity of surgery.

The pediatric anesthesia care team used an N95 mask or PAPR during intubation and mechanical ventilation.

Pre-screening for COVID risk was conducted by the pediatric anesthesia care team during pre-anesthesia evaluation. During admission, all patients received 24-hour preoperative screening, with components including symptom history, body temperature, oxygen saturation, and SARS-CoV-2 PCR. SARS-CoV-2 PCR was obtained within 72 hours prior to surgery from March 2020 until present time.

In similarity to other pediatric institutions, neurosurgical activity at our hospital was Eight children met inclusion criteria of needing an urgent neurosurgical operation with a positive SARS-CoV-2 PCR and were included in this study ( Table 2 ). All patients underwent surgery within 2 days of admission. Six out of 8 patients in this cohort were male (75 %), with a mean age of 8.83 years (median 8.5 years; range: 0.58 -18 years).

All of the patients were admitted to a specialized isolation unit with negative-pressure rooms and dedicated staff in our pediatric intensive care unit (PICU). Negative-pressure operating rooms were also used in order to minimize exposure through an isolated and restricted area by trained personnel wearing PPE. Consistent protocolized handwashing before and after donning or doffing the PPE was utilized. The pediatric anesthesiologist wore disposable skull caps, goggles, face shield and N95 or PAPR/CAPR (powered air-purifying respirator/controlled air-purifying respirator), scrubs or surgical gowns, disposable biological-proof protective suits in the outer layer, disposable gloves and disposable shoe covers. All patients over the age of 9 months (with special consideration to certain populations younger than 9 months) were given the option of a pre-medication with an anxiolytic medication (midazolam) prior to transport to the operating room per protocol to minimize fear and anxiety. In this report, all of the patients received midazolam without any clinical deterioration. This also has the potential benefit of minimizing the SARS-CoV-2-infected child from crying or coughing to reduce the risk of aerosolization of SARS-CoV-2 viral particles. The endotracheal intubation was performed with a video laryngoscope by the most experienced anesthesiology personnel to maximize distance from the child's face and first attempt success. A clear, transparent plastic drape between the anesthesiologist and patient was also utilized. Only essential personnel were in the room during induction of anesthesia, which excluded the neurosurgical and surgical nursing team. A cuffed orotracheal tube was placed to minimize air leak and complete muscle relaxation with IV neuromuscular blockade was used in order to prevent coughing and decrease the risk of virus particle aerosolization. Our specialized pediatric anesthetic protocol was developed with a multiinstitutional collaboration and was consistent with other pediatric anesthesia protocols. 13, 14 After intubation and mechanical ventilator support, the pediatric neurosurgical team and the surgical nursing team entered the operating room with their proper PPE with the attending J o u r n a l P r e -p r o o f pediatric neurosurgeon present for the entire duration of the critical portion of the case in order to minimize operation time. To minimize airborne transmission, the entrance of the surgical team was staggered until post-intubation. In addition to the attending pediatric neurosurgeon and anesthesiologist, other individuals present in the operating room included a neurosurgery resident or fellow, anesthesiology resident or fellow or certified registered nurse anesthetist (CRNA), nurse, and scrub technician.

The surgical team also wore disposable skull caps, eye protection and N95 or PAPR/CAPR, scrubs, surgical gowns, disposable gloves and disposable shoe covers. The pediatric neurosurgical team did not exit the room until the case was completed. All procedures were performed in negative-pressure operating rooms. To prevent aerosol generation, the use of aerosol-generating instruments including electrocautery, powered drills, insufflators, and lasers were limited if possible. Non-power tools were employed for burr holes. A smoke evacuator was used in conjunction to Bovie electrocautery.

All equipment and instruments normally kept in the operating rooms were removed and only the equipment and instruments needed for the ongoing case were stocked (including sutures). A staff of nurses waited outside the operating room and utilized walkie-talkies in order to decrease door opening and closing and one nurse was designated to obtain new equipment or instruments when needed. Our pediatric neurosurgical protocol was consistent with specialized protocols that have been performed in Wuhan city, China and other institutions. 16, 21, 22 Post-operative PICU course Upon exiting the operating room, all outer clothing was properly discarded, and the room including the anesthesia machine underwent a thorough disinfection and sterilization. To minimize contamination, the multi-disciplinary team changed into new scrubs after each COVID-19 case. The COVID infected pediatric patient was transported back to the negative pressure specialized COVID unit in our PICU through an isolated and restricted area by anesthesia and neurosurgical personnel wearing PPE. All PICU personnel specially trained for COVID and wearing proper PPE took care of these children. In addition to PICU and neurosurgery personnel, pediatric infectious disease and infection control were closely involved to help monitor the patient and to help minimize exposure risk. Visitor policies limited patient visitors to only two parents with no siblings allowed. None of the healthcare personnel involved were infected with COVID-19.

There were 16 neurosurgical operations/procedures performed in 8 patients with the most common being cerebrospinal fluid diversions (external ventricular drain placement n=5, shunt revision/placement n=4). The next most common surgery was revision of a wound for CSF leakage (n=3) ( Table 2 ). All patients except 1 were immediately extubated in the operating room and remained at neurological baseline. One patient required prolonged intubation and mechanical ventilation due to poor neurological status secondary to her intracranial hemorrhage and was extubated without difficulty once her mental status improved.

A 7-month-old male with a history of an occipital encephalocele resection and hydrocephalus status post ETV presented with a persistent pseudomeningocele at the ETV site with CSF leakage. Head CT showed a hygroma and persistently enlarged ventricles. He tested positive for SARS-CoV-2 from routine admission screening but was asymptomatic. He underwent a wound revision of the ETV incision. Four days later, he required placement of an EVD due to repeat CSF leakage from the ETV incision. He then underwent placement of a VP shunt, however CSF cultures obtained during this operation were positive for Streptococcus agalactiae and consequently he back to the operating room for a VP shunt removal, EVD placement, and a second wound revision of ETV incision. Overall, he was intubated and extubated 6 times (including anesthesia for imaging) and did not experience any viral symptoms or neurologic sequelae during his month-long hospitalization. On hospital day 30, she underwent bilateral ventriculoperitoneal shunt (VPS) placement due to EVD weaning failure and lack of communication between the right temporal cyst and lateral ventricles. During the last two operations she was successfully extubated in the operating room.

She did not experience any viral symptoms during her hospitalization and was discharged to inpatient rehabilitation 2 months after admission.

A 15-month-old male with a prior history of a ventriculo-atrial (VA) shunt from posthemorrhagic hydrocephalus, history of prematurity of birth and prior jejunal perforation with ileostomy presented with symptoms of vomiting and obtundation. He had symptoms of fever 2 days prior to admission with recent exposure to a COVID-19 positive contact and tested positive for SARS-CoV-2 on the day of admission. Head CT revealed increased ventricular size from baseline and due to bradycardia, and obtundation, he emergently underwent a VA shunt removal (for distal malfunction) and EVD placement. Due to aspiration pneumonitis from intubation and respiratory symptoms from COVID-19, he developed tachypnea and a desaturation episode to 72% on pulse oximetry after extubation, and required non-invasive bilevel positive airway pressure (BiPAP) ventilation in the PICU. Chest X-ray demonstrated atelectasis superimposed on chronic lung disease of prematurity. Two days later, a new VA shunt was placed. He was discharged on post-operative day 2 after shunt placement and re-presented with fever on postoperative day 8; all work-up including CSF was negative and was eventually discharged home without further neurologic or respiratory sequelae. was identified on culture, which was ultimately determined to be a contaminant. She was placed on broad spectrum antibiotics and went to the operating room for a wound washout and closure for the leaking incision. The patient was discharged on post-operative day 6 with no respiratory symptoms, ongoing fever or neurologic sequelae.

A 16-year-old male with a prior history of a VPS placed at age 2 for congenital hydrocephalus with the last revision at age 11 developed swelling and pain in his right neck along the course of his shunt. Radiographic imaging revealed a 1.7 cm disconnection of the VPS in the lower neck. He had no symptoms of SARS-CoV-2 infection on admission, but tested positive by PCR. The patient subsequently underwent a distal shunt revision and was discharged to home on post-operative day 1 with no respiratory symptoms, fever or neurologic sequelae. Chest X-ray was reassuring and these episodes did not recur after the first post-operative day.

However, he continued to experience headaches through post-operative day 3 and repeat head CT showed further reduction of the subdural hygroma suggesting that the headaches may be related to the viral syndrome instead of a shunt malfunction, highlighting the complexity of postoperative management of SARS-CoV-2 infected patients. He was discharged on post-operative day 3 with follow-up resolution of the headache.

There have been over 125 million worldwide cases of COVID-19 and our knowledge of the disease continuously evolves. 23 However, since originally discovered, most reports have been One recent study demonstrated that pediatric patients with non-severe COVID-19 had higher rates of peri-anesthetic respiratory complications such as laryngospasm, bronchospasm, hypoxemia or post-operative supplemental oxygen requirement than uninfected patients but no increased risk of non-respiratory complications or mortality. 24 While none of the patients in our series had laryngospasm or bronchospasm, one patient had transient post-operative hypoxia attributable to SARS-CoV-2, one patient had acute respiratory failure requiring non-invasive ventilation from SARS-CoV-2 infection superimposed on a history of bronchopulmonary dysplasia, and one patient remained intubated and mechanically ventilated for a prolonged period of time for neurologic concerns unrelated to SARS-CoV-2. There were no deaths.

A recent report of 4 pediatric patients with MIS-C described meningismus symptoms and intracranial hypertension based on an elevated opening pressure by lumbar puncture. None required neurosurgical intervention and all were successfully treated with pharmacological methods. 12 None of our cohort met criteria for MIS-C. This population warrants specific study, given that they experience a more severe clinical spectrum including a higher mortality rate, higher prevalence of cardiovascular dysfunction (including shock and myocardial dysfunction) and respiratory symptoms such as hypoxemia and pneumonia, and of relevance to pediatric neurosurgeons, a higher prevalence of neurologic sequelae. 11, 25, 26 One of the limitations of our report besides the small number of patients was that most patients were asymptomatic with respect to COVID-19 symptoms, so it is unclear if a higher prevalence of respiratory or other clinical complications would have been observed if the cohort were larger or had more severe symptoms of COVID-19. However, given that many children with SARS-CoV-2 are asymptomatic, our cohort reflects real-world practice likely to be encountered by pediatric anesthesiologists and neurosurgeons. While further studies are clearly needed, our experience supports that urgent pediatric neurosurgical operations should not be delayed as our growing familiarity with PPE and other safe practices facilitates care of these patients, even during urgent operations.

The relative successes of our minimally symptomatic infected pediatric patients in this small case series supports a relative resiliency to severe manifestations of COVID-19 in children, despite the stresses of general anesthesia and major neurosurgery. As our knowledge and understanding of the clinical manifestations of COVID-19 in the pediatric population expands, we may be able to determine more accurately the risk factors for poor outcomes among pediatric neurosurgery patients, as well as optimal protocols for peri-operative management. We hope that our report will help guide clinical care in order to help determine the optimal anesthetic and perioperative guidelines for COVID-19 infected pediatric patients that require urgent neurosurgical treatment. 

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Abbreviations: AVM = arteriovenous malformation; COVID-19 = coronavirus disease

= multisystem inflammatory syndrome in children

MRI = magnetic resonance imaging; OR = operating room

PAPR/CAPR = powered airpurifying respirator/controlled air-purifying respirator

PCA = posterior cerebral artery, PCR = polymerase chain reaction

PPE = personal protection equipment; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2; VPS = ventriculoperitoneal shunt