key: cord-0971508-wxioxlq9 authors: De, Soumen Das; Chang Liang, Zhen; Eu-Jin Cheah, Andre; Puhaindran, Mark Edward; Lee, Ellen Yutan; Tang Lim, Aymeric Yu; Sze Chong, Alphonsus Khin title: EMERGENCY HAND & RECONSTRUCTIVE MICROSURGERY IN THE COVID-19 POSITIVE PATIENT date: 2020-07-29 journal: J Hand Surg Am DOI: 10.1016/j.jhsa.2020.07.013 sha: 85f8ed371a321ca01b9be24d51d7815dcae74c29 doc_id: 971508 cord_uid: wxioxlq9 Abstract The case spectrum in hand surgery is one of extremes – purely elective day surgery cases under local anesthesia to mangling limb injuries that require immediate, and frequently, lengthy, surgery. Despite the cancellation of most elective orthopedic and plastic surgical procedures, hand surgeons around the world continue to see a steady stream of limb-threatening cases such as severe trauma and infections that require emergent surgical care. With the increase in community-spread, an increasing number of COVID-19 infected patients may be asymptomatic or have mild, non-specific or atypical symptoms. Some of them may already have an ongoing, severe infection. The time-sensitive nature of some of these cases means that hand surgeons may need to operate urgently on patients who may be suspected of COVID-19 infections, often before confirmatory test results are available. General guidelines for peri-operative care of the COVID-19 positive patient have been published. However, our practices differ from general orthopedic and plastic surgery, primarily because of the focus on trauma. This article discusses the peri-operative and technical considerations that are essential to manage the COVID-19 patient requiring emergency care, without compromising clinical outcomes and while ensuring safety of the attending staff. tendon injuries and ligament injuries also need to be addressed early. Infections tend to occur 48 in the elderly with compromised immunity (e.g. diabetes, chronic steroid treatment), 49 comorbid illnesses (e.g. renal impairment) and decreased physiologic reserves (e.g. heart disease). There is evidence that the elderly with pre-existing conditions have the highest risk 51 of mortality from COVID-19 6,7 . High-energy trauma tends to occur in young, physically fit 52 males engaged in manual work or who are injured in motor vehicle accidents. These patients 53 are less likely to succumb to COVID-19 8 , but there are two issues that are important to 54 recognize. First, there may be a subset of young and fit individuals more prone to a severe 55 form of acute lung injury (ALI) secondary to COVID infection, possibly due to an over-56 active immune response 9 . These patients may appear well initially but may deteriorate 57 rapidly. The second issue is pertinent to our local context. Many of the patients with severe The COVID-19 pandemic has compelled us to reexamine our manpower distribution and 83 routine workflows. We have re-organized our department into two self-reliant teams, each 84 comprising 2 or 3 attending surgeons, 2 senior residents or fellows and 2 junior doctors, that 85 remain physically segregated while continuing to manage patients in the outpatient clinics 86 and operating room (OR). The daily emergency admissions remain high and it is taxing for 87 the entire team to be on call for several days at a stretch. Therefore, each team takes 24-hour 88 emergency calls on alternate days. An attending, senior resident / fellow and junior doctor 89 from that team is responsible for any emergency in that 24-hour period. To illustrate this, more members of a team is exposed to COVID and must be quarantined for 14 days. Third, 97 this model allows senior surgeons to work together on complex surgical procedures to 98 maximize efficiency, facilitate intra-operative decision-making and take breaks during long 99 procedures. As much as possible, however, we advocate minimizing the number of medical staff in the OR and the most senior surgeon must be in attendance for difficult cases 5 . Our 101 model allows us to keep post-call days free of most scheduled activity, so that the team can 102 manage patients from a busy call the day before. To conserve resources, we employed a calibrated approach to "non-essential" work, 104 tailored to the severity of the COVID-19 situation locally. In the earlier phases, we cancelled 105 elective, complex surgery requiring inpatient hospitalization (e.g. brachial plexus 106 reconstruction) and continued with ambulatory cases under local anesthesia (LA). We further 107 reduced such surgery because of a greater demand for manpower elsewhere. We have also 108 concentrated our 24-hour emergency microsurgery service to a single hospital rather than 109 spread resources more thinly across several affiliated institutions. purifying respirator (PAPR) should be used when an aerosol-generating procedure, such as 117 drilling/sawing is anticipated 5, 14 . This is reasonable for short procedures but is extremely 118 taxing for operations that extend beyond 3-4 hours. It is also impossible to use the operating 119 microscope with a full PAPR setup. We use high-magnification loupes (3.5 to 4x) with PAPR 120 suits for procedures involving medium-sized vessels (e.g. radial artery repair). For procedures 121 mandating the operating microscope (e.g. digital artery repairs), the surgeon will have to 122 remove the PAPR and wear goggles or a face shield instead. It is important that all parts of 123 the surgery that potentially generate aerosols should be completed before transitioning to the 124 operating microscope (Figure 1) . In this context, the surgeon must consider the patient's needs and do what they can while protecting themself. For example, we should not perform 126 non-critical arterial repairs in a viable digit because the risks do not justify the benefits. More 127 critical problems such as single finger replantation may create an ethical dilemma 15 . Finally, 128 we are relying increasingly on small, purpose-built lead-lined procedure rooms to perform 129 semi-urgent procedures such as fracture fixation, so that main OR resources are not taxed. 196 Open wounds with underlying non-critical injuries (e.g. nerve, tendon, bone) should be 197 thoroughly cleaned under an appropriate block and sterile dressings applied. These procedures may be performed in the emergency room (ER) and further tests to ascertain the 199 patient's COVID status should be obtained 5 The patient was isolated post-operatively until the swab results were known. He tested 308 negative for COVID and was subsequently discharged from inpatient care 5 days later. Novel Coronavirus and Orthopaedic 314 Surgery: Early Experiences from Singapore Clinical characteristics of 24 asymptomatic infections with 319 COVID-19 screened among close contacts in Nanjing COVID-19: a new challenge for human beings Surgical Considerations in Patients 324 with COVID-19 Clinical features of COVID-19 in elderly patients: A 326 comparison with young and middle-aged patients Comorbidity and its impact on 1590 patients with 329 Covid-19 in China: A Nationwide Analysis Predictors of mortality for patients with COVID-19 332 pneumonia caused by SARSCoV-2: A prospective cohort study Clinical features of patients infected with 2019 novel 335 coronavirus in Wuhan Latest Advances in Wide Awake Hand Surgery COVID-19 Resources for Members | The British Society for Surgery of the Hand Regional Anesthesia for Postoperative Pain Control Continuous peripheral nerve blocks: A review of the published evidence Twelve simple maneuvers to optimize digital replantation and 372 revascularization Revascularization and Replantation in the Hand: Ectopic 375 Banking and Replantation Ectopic banking of amputated parts: A clinical review Replantation of Cryopreserved Fingers: An "organ 380 Banking Development and Validation of a Prognostic Risk-Adjusted Scoring System for Operative Upper-Extremity Infections Quantifying the Effect of 386 Diabetes on Surgical Hand and Forearm Infections Factors Affecting Mortality in Hong Kong Patients With 392 Upper Limb Necrotising Fasciitis. Hong Kong Med J = Xianggang yi xue za zhi Factors 395 Associated with Mortality and Amputation Caused by Necrotizing Soft Tissue 396 Infections of the Upper Extremity: A Retrospective Cohort Study Bedside Procedures in Hand Surgery Pulmonary fibrosis and COVID-19: the potential 401 role for antifibrotic therapy Considerations in Flap Selection for Soft Tissue Defects of the 404 Thromboinflammation and the hypercoagulability of COVID-406 Digital Ischemia in COVID-19 Patients: Case Report CNN As the primary author of the Work, I have full authority to act on behalf of the other authors in any matter arising from this Release, including but not limited to, review and approval of the edited Work. south-korea-a-growing-number-of-covid-19-patients-test-positive-after-recover. 416 Accessed June 13, 2020. 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