key: cord-1002638-9q8k1qws
authors: Sharma, Ravi; Garg, Kanwaljeet; Katiyar, Varidh; Alam, Intekhab; Tandon, Vivek; Raheja, Amol; Mishra, Shashwat; V, Pavana; Suri, Ashish; Chandra, P Sarat; Kale, Shashank S.
title: Analysis of neurosurgical cases before and during the COVID-19 pandemic from a tertiary care centre in India
date: 2021-06-12
journal: World Neurosurg
DOI: 10.1016/j.wneu.2021.06.019
sha: 3abc6ba70ca3f843187435a8b66d401ec7799e76
doc_id: 1002638
cord_uid: 9q8k1qws

Objective We present the unique administrative issues as well as specific patient and surgeon related challenges and solutions implemented while treating neurosurgical cases during the COVID pandemic vis-à-vis the pre COVID times at our tertiary care center. Methods This is a retrospective study comparing the outcome of the neurosurgical patients treated from the beginning of lockdown in India on 25 March 2020 to 30 November 2020 with that of same period in the previous year, 2019. Results We had a total of 687 admissions under neurosurgery this year during the study period as compared to 2550 admissions in 2019. The total number of surgeries done under neurosurgery also showed a similar trend with only 654 surgeries in 2020 compared to 3165 surgeries in 2019. During COVID-19 times, a total of 474 patients were operated including both trauma and non-trauma cases. Out of the 50 COVID-19 suspect/ indeterminate patients who were operated upon, 5 patients turned out to be positive for COVID-19. Significant differences were seen in the mortality (p<0.01) and morbidity (p<0.01) among trauma patients on comparing COVID and pre-COVID periods. Similarly, a significant difference was observed in the mortality (p<0.001) and morbidity (p<0.001) in non-trauma patients. Conclusions A higher mortality and morbidity during the COVID times is primarily attributable to poorer baseline clinical status. Our experience in this COVID period might not only help us in tackling subsequent waves but also help other institutions in developing world to be better prepared for the same.

The severe acute respiratory disease syndrome-coronavirus 2 (SARS-CoV-2) also known as coronavirus 3 infectious disease-19 (COVID-19) has exacted a great, adverse effects on the global health-care system in 4 general, and has thus posed very difficult challenges for optimal healthcare delivery in the fragile health-5 systems of many developing countries like India. An increasing proportion of healthcare resources had to 6 be compulsively dedicated to treating COVID-19 patients as the pandemic intensified in our nation. Akin 7 to other medical specialties, a paradigm shift was inevitable in the neurosurgical discipline, with 8 channelization of hospital resources and manpower to emergency care at the cost of outpatient and 9 inpatient services. 1- 9 We, being a tertiary care referral center, run a very busy neurosurgical service. We 10 were catering to about 130,000 patients on an outpatient basis and performing around 6000 surgeries on 11 an annual basis, before the pandemic began. 10 We had to curtail elective surgical procedures and 12 outpatient services due to the nationwide lockdown. Performing surgery on admitted patients was fraught 13

with clinical and administrative challenges. In this study we attempt to highlight the unique administrative 14 issues faced as well as specific patient and surgeon related issues in such a big neurosurgical service in a 15 developing country. We also highlight the solutions implemented by us, while treating over 200 cases 16 surgically during this pandemic phase, which we believe will be helpful in future as well. 19 and pre COVID-19 and data related to demographic profile, diagnosis (cranial or spinal, trauma or 26 non-trauma), management (type of intervention-surgery or conservative, type of procedure) and 27 outcomes (in-hospital mortality, complications, hospital stay) etc. was compared between the two groups. 28

Mean year of experience for the operating surgeon was calculated according to the number of years spent 29 as a specialist neurosurgeon. 30

All the admissions in both the groups were categorized based on etiology (trauma and non-trauma), 32 management strategy (surgical and non-surgical) and pathological diagnosis (neoplastic, vascular, 33 infectious, hydrocephalus, peripheral nerve, spine pathologies). Patients with age less than 18 were 34 J o u r n a l P r e -p r o o f considered in pediatric age group. The outcome was assessed in terms of morbidity (operative or non-1 operative complications) and mortality. For the purpose of this study morbidity was defined as any 2 adverse event which prolonged the hospital stay or added significantly to the post discharge medical care 3 needed or resulted in a temporary or permanent neurological deficit. The data collected was entered in 4

Microsoft Excel and statistical analysis was done using IBM SPSS Statistical package version 20. Chi-5 square test was used to compare the categorical data. A p value of less than 0.05 was considered as 6 significant. Graphical representation in the form of flowcharts was prepared using Microsoft Office 7

Powerpoint 2016 and 'R studio'. was reduced to about a third (69 out of 173) and similarly, only one-third (3 out of 9) operating rooms 22 (OR) were functional, during the pandemic. 23

Most of the patients were tested for COVID-19 before surgery but in certain emergent scenarios patients 24 were taken up for surgery with adequate precautions before the results were available and a total of 50 25 such COVID-19 suspect/ indeterminate patients were operated upon. Out of these 50 patients, 5 patients 26 The distribution of etiologies among the admitted patients was different between 2019 and 2020 as has 7 been summarized in figure 2. The management strategies were also changed during this time period. For 8 benign etiology like vestibular schwannoma, where the patient presented with emergent manifestations of 9 hydrocephalus, it was observed that a cerebrospinal fluid diversion procedure was preferably performed 10 initially to tide-over the crisis during the upstroke of COVID-19 cases in our state. Definitive surgery was 11 deferred for a later date in such cases, which is not our usual protocol. Patients during this period were 12 admitted mainly through the emergency department during the initial period, while during the first un- which is around 1.3 billion, it is by far the largest lockdown in the human history. 11 Though there is 7 uniformity of guidelines across the world irrespective of financial status of countries. However, the lower-8 middle income countries have significantly poor hospital beds, ICU beds, ventilator and doctor to 9 population ratios. This deficiency has put significantly more strain on the healthcare system during 10 COVID times. With already limited resources being diverted for COVID management, the non COVID 11 routine and emergent services are directly affected. Thus, the challenges and solutions for lower-middle 12 income countries are different both qualitatively and quantitatively. Therefore, this lockdown was bound 13

to impact an already strained health infrastructure of India. Impact on the field of neurosurgery can be 14 gauged from the fact that our center which is otherwise extremely busy in terms of volume of patient 15 flow, had to significantly curtail all elective admissions and outpatient services. Compared to 2019, 16 around 73% drop in surgical procedures and a drastic 97% drop in the outpatient services was observed 17 during the study period. However, we were determined as well as prepared to treat the neurosurgical cases 18 as needed. The total number of surgeries done, in fact, increased even in the face of increasing number of 19 cases of COVID-19 as shown by figure 3. We had to quickly adapt to the changing times and find 20 solutions to unprecedented challenges that we were facing. (Table 2 ). Further, we had to be prepared for incoming neurotrauma patients though they were 2 expected to be less than the usual number. 14 This was achieved by halting all new admissions and 3 expediting the discharge of already admitted patients. Additional procurement of ventilators was done 4 from trauma center as well as new purchases were made for these extremely sick transferred cases. On 5 similar grounds, the trauma emergency bay was recreated at the suspended outpatient clinics appointment 6 area to tide over the crisis. Conversion of existing infrastructure into an infectious disease hospital, 7

occasionally is the only option for many hospitals. However, this is not without collateral damage to non 8 COVID19 patients who were earlier meant to be treated at these facilities. Therefore, development of new 9

infrastructure, or identification of a facility where less emergent patients (unlike trauma or cancer) are 10 treated, should be considered for treating COVID or any such similar disease outbreaks in future. to COVID-19 facility. Out of the remaining 7 ORs, 4 ORs could be made functional, 2 were converted 2 into donning and doffing areas for streamlining the movement of OR staff and reducing risk of cross-3 infection; while the 7 th OR which was an intraoperative magnetic resonance imaging (MRI) suite was not 4 utilized due to issues related to sterilization. Out of these four, initially two and then three ORs could be 5 utilized in parallel due to paucity of neuro-anesthesia team members, as 40% of their workforce was 6 shifted to COVID-19 hospital. The induction time also increased significantly during COVID-19 times by 7 around 40 minutes due to the additional COVID-19 related precautions. ORs were modified to have 8 negative pressure ventilation for COVID-19 suspected/indeterminate cases who required emergency 9 surgery and waiting for the COVID-19 test results as has been recommended by several authors. [19] [20] [21] The 10 various solutions implemented for infrastructure related challenges have been summarized in Figure 5A . As per the protocol of our institute level II PPEs (i.e. inner coverall suits, N95 masks, goggles/face-screen 2 and outer surgical gown) are to be used for any neurosurgical procedure. In the initial part of our 3 experience, we were unclear about risk for virus transmission through aerosol generating procedures 4 performed outside the sinonasal tract (e.g. high speed drilling during craniotomy). Further, despite the 5 high specificity of RT-PCR tests, the sensitivity in the field was affected by sampling errors. Hence full 6 PPE (level II/III) use was recommended for all procedures as a precautionary measure. Despite viral RNA 7 detection in a varying proportion of COVID infected patients, the risk of viral transmission to the surgeon 8 through aerosol generating procedures has been inexplicably low. 23 Thus, full PPEs for COVID negative 9 patients were abandoned eventually because the risk perception was not commensurate to the 10 inconvenience of PPE use in prolonged neurosurgical operations. We realized that the use of PPEs 11 reduced dexterity, comfort and visualization. Surgeons had difficulty in performing surgery for more than 12 3-4 hours at a stretch. Thus, many surgical procedures like excision of acoustic schwannoma, aneurysmal 13 clippings and long segment spinal fixations were performed by two teams. Each team had one attending 14 consultant and one resident and they worked in 3-4 hours long shifts. This was deemed necessary to also 15 decrease exposure of the team to a confined and potentially unsafe environment and ensure good patient 16

To improve comfort, engineering interventions with air conditioning helped in lowering of temperature 18 and more than six times air exchange per hour. Visualization was improved by use of endoscope or 19 exoscope wherever it was possible. In our morbidity and mortality meets, few cases were discussed 20 because of an unexpected turn of events. We realized operating in PPEs is fraught with challenges for 21 both the anesthesia and neurosurgical teams. Patients who had undergone RT-PCR testing preoperatively and were found negative were managed in 26

Non-COVID-19 ICU. Level II PPE was utilized by staff, which worked on an 8 hourly regular shift basis. 27

Staff was sensitized to keep a close watch for symptoms of influenza-like illness (ILI) and severe acute 28 respiratory infections (SARI). All suspected patients underwent repeat RT-PCR testing for COVID-19 as 29 per the advice of the Hospital infection control committee (HICC). 30

Patients who underwent surgical procedures before their RT-PCR report for COVID-19 could be made 31 available or patients who were admitted from casualty due to life threatening emergencies like an 32 extradural hematoma pending their COVID-19 report were managed in a separate ICU where patients 33 were allowed only on alternate beds to maintain distance. Staff in this ICU was instructed to wear Level 34 III PPE. Six Hourly shifts of HCWs in this ICU were utilized to maintain staff comfort and decrease 1 exposure. The increased number of shift duties required frequent travel for our staff, which was difficult 2 during the lockdown phase. 3 4 Surgical Outcomes during COVID-19 pandemic 5

We do not believe that the higher mortality of non-trauma patients operated during the study period 6 (p<0.001) can be attributed to COVID-19 infection per se. It can be explained on the basis of the fact that 7

we have operated primarily emergency and semi-emergency cases during the study period. These patients 8

were consequently sicker preoperatively in comparison to the cases operated in 2019 when most surgeries 9

were elective. Other plausible reasons which are directly attributable to COVID-19 could be 10 compromised surgical finesse due to the PPE gears, limited availability of blood products, difficulty in 11 performing awake surgery and use of regular neuro-monitoring, and working in shifts wherein the change 12 in operating teams can lead to a bit of disorientation. However, the most plausible explanation seems to 13 be the difference in the baseline clinical status of the patients as only large tumors were operated during 14 the COVID time. Moreover, no degenerative spine surgeries were done. This is also proven by the fact 15 that there was no difference in mortality observed in trauma cases (operated or conservatively treated) and 16 non-trauma cases managed conservatively during the study period vis a vis 2019 patient cohort group 17 (p=0.26). This shows that optimal care could be delivered despite tremendous challenges involved. The 18 solutions related to surgical challenges have been summarized in figure 5B . 19 20

Cost of surgery at our public sector hospital ranges from 25-500 USD, depending upon the type of 22 procedure. Owing to the financial crunch caused by the pandemic many families lost their livelihoods and 23 due to logistic issues couldn't arrange for the surgical expenses. Twenty-five patients were treated free of 24 cost in the study period compared to 4 in 2019. After discharge, many patients were also provided with 25 temporary accommodation at one of our outsource health facilities for the time period until they could 26 arrange transport services, which was difficult due to lockdown. The total amount of money collected for 27 surgery during the study period was around INR 16 million which is around 60% percent less when 28 compared to records of last year. Despite this major shortfall, no disruption in the supply chain of 29 medicines or equipment was allowed. During the lockdown, patients and caregivers could not arrange for blood donors and our blood bank was 7 running short on supplies. Blood donation campaign organized by the resident doctor's association helped 8 us in saving many lives. Entry of caregivers had to be restricted in wards due to the risk of cross-9

infection. Regular counselling of relatives by healthcare workers (HCWs) and ICU residents (twice daily) 10 helped allay their anxiety and establish a proper communication mechanism. Audio or video calls were 11 also utilized for this purpose for limiting the chance of cross infection. The routine COVID-19 testing of 12 the caregivers themselves would have been ideal but was not feasible due to logistic issues. However, the 13 caregivers underwent temperature screening at all entrances to the neurosurgical block, were educated on 14 safe practices and were given surgical masks. Multiple blood donation campaigns were organized where 15 general public and personnel from police and para-military forces voluntarily donated the blood. This 16 helped us tremendously in managing the scarcity of blood products. 17

Three of our residents developed COVID-19 symptoms. One of the residents was posted in COVID-19 20 ward, while the rest acquired infection from their family members who were also doctors and working in 21 COVID-19 designated hospitals. We observed that use of proper PPE, stringent contact tracing and timely 22 diagnosis kept the incidence lower than hospitals in developed countries. 29 Regular counselling and 23 training of staff helped not only in allaying fears but also emphasized the importance of following good 24 practices. Various measures implemented to control infection among patients and healthcare workers 25 have been summarized in figure 5C . their teaching, online classes/webinars were organized along with video presentations by our faculty and 32 international faculty to teach surgical skills in line with other neurosurgical training institutes. 31, 32 We 33 further plan to organize simulation based training in OR to improve hand eye coordination using 34 endoscope and microscope modules. We are also buying an advanced simulator to improve training. 1

These solutions have been elucidated in figure 5D . We can plan hybrid workshops for the residents 2 providing them hand on training on various models to provide better training than online webinars. 3 4

Limitations 5

There was a predominance of elective procedures during 2019 while during the lockdown in 2020 most of 6 the patients were treated for emergency or semi-emergency conditions, therefore, the two groups are not 7 exactly comparable. Moreover, the sample size of patients during the study period is too small and 8 heterogenous, precluding a detailed comparative analysis. 9

Difficulty encountered with the use of PPEs could not be objectively assessed. Retrospective study design 10 and single center experience are yet other limitations of this study. 11 12

The challenges posed by the initial wave of COVID-19 in treating neurosurgical cases were tackled with 14 solutions feasible for a resource poor country. We have discussed these solutions that will not only help 15 us in tackling a second wave of this pandemic but also help other institutions in India as well as other 16 lower to middle income countries to be better prepared for the same. 

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