key: cord-0923709-gz9om6nu authors: Brat, Gabriel A.; Hersey, Sean; Chhabra, Karan; Gupta, Alok; Scott, John title: Protecting Surgical Teams During the COVID-19 Outbreak: A Narrative Review and Clinical Considerations date: 2020-04-17 journal: Ann Surg DOI: 10.1097/sla.0000000000003926 sha: d2d617c1c7d76eac73fbd2b56042d7d9a40148c5 doc_id: 923709 cord_uid: gz9om6nu nan essentially all tissues and fluids tested and even surgical smoke from the use of electrocautery. 7, 8 Given these inherent risks, we outline key considerations for protecting surgical teams below. Without detailed planning and protocols, transporting a patient with COVID-19 puts clinicians and patients at high risk of viral transmission. Frequent, structured communication in the form of huddles plays an integral role in mitigating this risk. A recent article described the value of bringing together stakeholders to plan safe patient transport and the process of getting the patient onto the operating room table. 9 Huddles should include surgeons, the anesthesia team, intensive care unit (ICU) attendings and nurses, respiratory therapists, operating room (OR) nursing staff, environmental services, security, and members of infection control. To standardize this process, hospitals have developed transport protocols for the operative team 10, 11 and are performing transport simulations to prepare for high numbers of potential patients. Open communication between the surgical team and peri-operative staff allows the group to transfer high-risk patients from wards to the OR and back with reduced risk to the team. SARS-CoV-2 can survive for days on multiple operating room surfaces, including plastic and stainless steel. 6 Though under ordinary conditions, operating rooms use positive pressure airflow, this runs the risk of contaminating adjacent ORs and hallways--thus, operating rooms with negative pressure capabilities are recommended. 12 When negative pressure rooms are unavailable, it is important to allow sufficient time between cases for complete room air exchange--usually on the order of 30 minutes. This time interval is based on the number of air changes per hour as described by the CDC. 13 Items such as hospital charts, pagers, and cell phones must be left outside the OR with contingencies to respond to time sensitive pages. Additionally, anything that was in contact with the patient, such as the ward bed, should also be considered contaminated. If possible, a dedicated runner should be posted outside of the OR to obtain supplies such as suture, surgical staplers, and energy devices as needed. 9 This eliminates the need for excessive movement into and out of the room by the circulating nurse, and also minimizes consumption of personal Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. protective equipment with every entry and exit of the room. All single-use equipment (even unopened) in the room is thrown away at the end of the case, and thus only what is currently needed and absolutely required for the case should be brought in. Standard surgical personal protective equipment (PPE) includes a face shield, mask, waterproof gown, double gloves, and shoe covers. There is some disagreement, however, about the type of respiratory protection--N95 respirator, powered air purifying respirator (PAPR), or standard surgical mask--that should be used for surgical procedures on patients with COVID-19. Currently, we are not aware of any data to suggest that either the N95 or PAPR are better to protect against COVID-19. PAPRs are generally used when HCWs cannot achieve a proper fit with an N95; guidelines and mask specifications suggest equivalence for aerosolized agents. 14 A surgical mask is capable of blocking gross inhalation of droplets, while a well-fitted N95 respirator is additionally capable of filtering aerosols. This is of particular interest to surgeons as aerosols have been identified from multiple surgical procedures, including those that use electrocautery and high-speed tools, 15, 16 and smoke from electrocautery has been shown to harbor intact bacterial and virus particles. 7, 8, [17] [18] [19] As such, surgery can be considered an -aerosol generating procedure‖ (AGP), 20 especially with the use of electrocautery and/or laparoscopy. The Centers for Disease Control in both the US 20 and in China, 21 as well as the Association of Spanish Surgeons, 22 specifically recommend use of N95 respirators (preferably without valves) for surgeries with AGPs on COVID-19 patients. Australia's Department of Health encourages N95 use for -high-level contact‖ with infected patients. 23 A recent guideline in the Chinese Journal of Surgery presented recommendations for emergency surgery in COVID-19 patients that specifically include the use of N95 masks for anesthesia and surgical teams. 24 However, the World Health Organization (WHO) recently published PPE guidance for healthcare workers that did not specify that surgical procedures required N95 respirators. 25 Some groups may erroneously interpret the absence of laparoscopy or electrocautery on the list to imply that most surgical procedures are not aerosol-generating. The meta-analysis cited by the WHO guidance specifically noted that there were nearly no surgical cases included in its Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. analysis--and only open thoracotomy was extracted as a data element. 26 In a time when there is limited information about transmission of COVID-19, aggressive protection 4 with complete PPE for AGPs (which includes N95 masks) is in line with guidance from multiple national organizations as well as the limited data available from previous research. It is unclear if laparoscopy increases surgeon risk of exposure to aerosolized viral particles. Carbon dioxide insufflation, energy devices, and high-speed surgical equipment generate significant aerosols. Though aerosols may be contained in the abdomen during laparoscopy, when expelled under pressure-such as with release of pneumoperitoneum-they may spread widely. 27, 28 Care should be taken to minimize the possibility of inadvertent release and filter the CO2 using existing technology. 24, 29 However, this risk may not be unique to laparoscopy. Viral and bacterial aerosols have been identified in surgical plumes in both laparoscopic and open procedures. 8, 15, 17, 18 However, the use of a smoke evacuation device is in line with pre-existing OR guidelines 30 Clinicians may actually be more likely to infect themselves when removing their PPE than when caring for a contagious patient. 31 To avoid self-contamination, everyone in the OR must be able to put on (don) and remove (doff) PPE correctly. Proper gowning and doffing procedures should be reviewed with surgeons, residents, and OR staff before each case to ensure proper technique. 32, 33 In addition, based on previous viral outbreaks, a -buddy system‖ has been recommended, in which providers assist with and oversee the doffing of a colleague. 34 In our experience, the combined use of video-based instruction and a colleague's oversight significantly improves anxiety among staff and may lead to less self-contamination during PPE removal. Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Though careful planning and appropriate PPE are essential, the most effective way to prevent viral exposure is to avoid performing non-essential surgical procedures. As recommended by the American College of Surgeons, 35 this limits the opportunities for patients and clinicians to become exposed, conserves personal protective equipment, and preserves health system capacity. Non-operative approaches (e.g. for appendicitis, diverticulitis, and cholecystitis) may be a safe alternative to surgery for some patients. Many patients, however, will require emergency operative intervention. Our evaluation of the literature has provided more questions than answers with regard to PPE choices and surgical technique. Recent clinical trials have focused on outpatient clinicians, 36 but no study has effectively evaluated how best to protect operating surgeons. As we better understand the epidemiology of transmission of these agents and methods of prevention, there is a need to study and re-evaluate the information above. Thus, the issues highlighted in this review should not be taken as official guidelines, mandates, or standard operating procedures. The global community is learning more about COVID-19 every day. Surgeons should seek guidance from their appropriate national, local, and hospital guidelines and regulations-many of which are likely to change over time as new information becomes available to the global community. By presenting our best understanding of the literature, we are hoping to promote the safety of surgical teams and, as a result, the patients who are relying on them for life-saving surgical care. Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. The public health burden of emergency general surgery in the United States: A 10-year analysis of the Nationwide Inpatient Sample Detection of SARS-CoV-2 in Different Types of Clinical Specimens Clinical Characteristics of Coronavirus Disease 2019 in China Protecting health-care workers from subclinical coronavirus infection Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a Symptomatic Patient Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1 Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery The presence of P22 bacteriophage in electrocautery aerosols ENCE_OF_P22_BACTERIOPHAGE_IN_ELECTROCAUTERY_AEROSOLS/links/00b7 d52a09d15f05f3000000.pdf Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited What we do when a COVID-19 patient needs an operation: operating room preparation and guidance UW Medicine COVID-19 Protocols Available from UCSF Health COVID-19 Clinical Resources | UCSF Health Hospital Epidemiology and Infection Prevention Available from Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients Performance of N95 respirators: filtration efficiency for airborne microbial and inert particles Identification of Aerosol Production during Surgical Procedures. 00229128 Health Protection Scotland Available from Is it time for a more systematic approach to the hazards of surgical smoke?: reconsidering the evidence Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited Can Efficient Smoke Evacuation Limit Aerosolization of Bacteria? Awareness of surgical smoke hazards and enhancement of surgical smoke prevention among the gynecologists Centers for Disease Control and Prevention For different groups of people: how to choose masks Available from Interim recommendations for the use of PPE during hospital care of people with COVID-19 Version 2 Available from Recommendations for general surgery clinical practice in novel coronavirus pneumonia situation World Health Organization. Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19): Interim Guidance Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited Preliminary study of electrocautery smoke particles produced in vitro and during laparoscopic procedures Characterization of smoke generated during the use of surgical knife in laparotomy surgeries Several suggestion of operation for colorectal cancer under the outbreak of Corona Virus Disease 19 in China Compliance with surgical smoke evacuation guidelines: implications for practice Protecting health care workers from SARS and other respiratory pathogens: organizational and individual factors that affect adherence to infection control guidelines COVID-19: Removal and disposal of Personal Protective Equipment (PPE). UK: NHS Available from The Buddy System Available from COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures. American College of Surgeons N95 Respirators vs Medical Masks for Preventing Influenza Among Health Care Personnel: A Randomized Clinical Trial Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited