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REVIEW ARTICLE
Ahead of print publication  

Cardiothoracic surgery practice at a tertiary center during the COVID-19 pandemic


 Department of CTVS, All India Institute of Medical Sciences, New Delhi, India

Date of Submission23-Mar-2020
Date of Decision25-Apr-2020
Date of Acceptance25-Apr-2020
Date of Web Publication06-May-2020

Correspondence Address:
Milind Hote,
Professor, Department of Cardiothoracic and Vascular Surgery, CT Centre, AIIMS, New Delhi - 110 029, India

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpcs.jpcs_35_20

  Abstract 

A COVID-19 pandemic has been declared by the WHO since January 2020. In this crisis, cardiac surgeons have to ensure that essential cardiac surgery is available while ensuring that inadvertent COVID-19 does not spread among patients or to the surgical team.

Keywords: COVID-19, guidelines, modification, surgery



How to cite this URL:
Hote M, Gupta SS. Cardiothoracic surgery practice at a tertiary center during the COVID-19 pandemic. J Pract Cardiovasc Sci [Epub ahead of print] [cited 2020 Aug 13]. Available from: http://www.j-pcs.org/preprintarticle.asp?id=283854

With the declaration of the COVID-19 pandemic, medical practice has changed and Cardiac Surgical practice has also changed.[1],[2],[3],[4],[5] Due to the lockdown and restricted travel, allocation of nursing staff and residents to COVID care and quarantine of any inadvertently exposed staff, there is shortage of staff in surgical units. Wards, beds, and ventilation equipped intensive care units (ICUs) are being kept reserved for potential escalation of the COVID-19 crisis. Blood banks cannot also provide full support as voluntary and patient-related donors are limited due to fear of hospital visit-related infections and also travel restrictions. In spite of this, cardiac surgical care has to continue for critical cardiac problems without compromising patient and health personal safety.[6],[7],[8],[9],[10],[11],[12],[13]

Elective surgery needs to be delayed because of the above and because resources have been shifted to the care of COVID-19 patients. We need to decide on:





  1. Types of patients which are to be deferred
  2. Patients which must be operated open
  3. The preparation of the surgical team and the ICU and the operation theatre for the patient in the COVID-19 setting.


The principals on which we are working currently are as follows:

The Department is presently operating only about 2%–4% of its normal surgical case load.

The guiding principles are:





  1. Possibility of COVID-positive patient being inadvertently operated in our operation theater (OT) (no detection/false hiding of COVID status/tested but coming false negative). In such a scenario, all the OT staff and ICU staff who come in contact with such a patient will be at jeopardy with the resulting health risk, quarantine difficulties, and departmental “temporary loss” of a large number of staff at one go
  2. The availability of personal protective equipment (PPE), in terms of quantity, is currently not adequate. The rationale is to preserve the meagre stock to be used only when really and absolutely necessary.
  3. The problem of “isolating” a positive patient once operated
  4. The known high risk of mortality if patient is operated and is COVID positive.


The general guiding principle is thus SAFETY, of all

Since the lockdown was implemented, the outpatient departments were shut down, and all routine admissions were stopped as per the directives from the administration and health ministry.

Subsequent to that, the working wisdom has been to do only the real genuine emergency cases which are of the following nature –





  1. Type A aortic dissection
  2. Coronary artery disease (CAD) spectrum - Severe unstable angina/severe left main disease angioplasty complications, acute coronary syndrome with mechanical complications
  3. Stuck prosthetic valves, not thrombolysis responsive, class 1V
  4. Obstructed total anomalous pulmonary venous return, refractory spells, cardiac tamponade patients
  5. Some other congenital heart problems, which if delayed, may deteriorate beyond a point to cause lifelong morbidity (Transposition of great arteries (TGA) with regressing ventricle).



  Protocol for Preoperative Management Top






  • These patients undergo mandatory clinical screening by the department of infectious diseases (IDs) before admission, whereby the patients with or without symptoms will be considered as COVID-19-positive unless proven otherwise by swab test
  • Two cubicles in step down ward [Figure 1] have been allocated to admit all new patients. A single nursing staff with proper PPE is allocated in each cubicle. Senior resident on duty has to wear appropriate PPE (N95 mask, face shield and gloves) before interacting with the isolated patients. Covid-19 swabs will be taken on Day 0 and Day 5 by the Emergency ID team. Blood sampling is done with adequate precautions. The blood bank is informed beforehand about sending of these samples. If positive, surgery not be done on these patients. If COVID-negative/cleared for surgery by ID team, they may be taken up for surgery
  • Precautions outlined during perioperative period - Anesthesia induction to be done with minimum staff, with full PPE gear
  • Operating team should be small and don full PPE. It has to be kept in mind that sternotomy and airway manipulation will generate aerosol
  • There have to be designated PPE donning and doffing areas for all personnel; the staff disposing of the discarded PPE should be fully conversant with the correct procedure and perform its task without errors
  • Postoperative convalescence - After the emergency surgery, all patients are shifted only to a different fully dedicated ICU [Figure 2] where senior residents and nursing staff on duty are to be provided with PPE and rotated in three shifts per day along with a separate donning and doffing area. A patient is shifted out of that ICU only after the day 5 COVID sample report is available. Patients with negative report will safely join those in regular ICU where already left over patients before lockdown are still recuperating.
Figure 1: Step down ward.

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Figure 2: Intensive care unit for CTVS patients.

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Nursing in-charge of the ward ensures the availability of 10 PPE kits at all times.





  • Any patient who has been operated in CTVS department previously and now has any symptom suggestive of postoperative complication, can have telephonic consultation with our post MCh senior residents and get appropriate advice. If his/her coming to hospital is deemed necessary, they are advised to come ONLY to AIIMS Emergency and not directly to CTVS wards. In emergency ward, they are appropriately evaluated, triaged as per their COVID status and admitted in the appropriate area
  • All healthcare personnel are instructed to be very vigilant about any symptoms as are seen with COVID infection and if they are symptomatic, the clinical algorithm to be followed fully by them (Reporting to emergency COVID screening area, getting appropriate advice and triage as per symptom severity and report positivity).


Till now, we are yet to operate on a preoperatively confirmed COVID-positive patient. In the patients that have been operated (about 12 since March 25, 2020), the COVID tests done postoperatively have been negative.

We anticipate that if the COVID case load increases suddenly and some proportion of these patients fall very sick, so as to be requiring ECMO support, the CTVS department has to be very well prepared for such an eventuality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Zheng YY, Ma YT, Zhang JY, Xie X. COVID-19 and the cardiovascular system. Nat Rev Cardiol 2020;17:259-60.  Back to cited text no. 1
    
2.
Adams JG, Walls RM. Supporting the health care workforce during the COVID-19 Global Epidemic. JAMA 2020;323:1439-40.  Back to cited text no. 2
    
3.
Matt P, Maisano F. Cardiac surgery and the COVID-19 outbreak: What does it mean? Available from: https://www.pcronline.com/News/Whats-new-on-PCRonline/2020/Cardiac-Surgery-and-the-COVID-19-outbreak-what-does-it-mean. [Last accessed on 2020 Apr 25].  Back to cited text no. 3
    
4.
Ong SW, Tan YK, Chia PY, Lee TH, Ng OT, Wong MS, et al. Air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from a symptomatic patient. JAMA 2020;323:1610-1612. doi:10.1001/jama.2020.3227.  Back to cited text no. 4
    
5.
Bilkhu R, Viviano A, Saftic I, Billè A. COVID-19: Chest drains with air leak – The silent 'super spreader'?. CTSNet 2020. doi:10.25373/ctsnet.12089130.  Back to cited text no. 5
    
6.
Johns Hopkins University & Medicine. COVID-19 Map; Published 2020. Available from: https://coronavirus.jhu.edu/map.html. [Last accessed on 2020 Apr 02].  Back to cited text no. 6
    
7.
Chen W, Huang Y. To protect healthcare workers better, to save more lives. Anesth Analg 2020. doi: 10.1213/ANE.0000000000004834. [Epub ahead of print].  Back to cited text no. 7
    
8.
van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med 2020;382:1564-7.  Back to cited text no. 8
    
9.
Meng L, Qiu H, Wan L, Ai Y, Xue Z, Guo Q, et al. Intubation and ventilation amid the COVID-19 outbreak: Wuhan's experience. Anesthesiology 2020. doi:https://doi.org/10.1097/ALN.0000000000003296.  Back to cited text no. 9
    
10.
Wilder-Smith A, Chiew CJ, Lee VJ. Can we contain the COVID-19 outbreak with the same measures as for SARS? Lancet Infect Dis 2020. pii: S1473-3099(20)30129-8. doi: 10.1016/S1473-3099(20)30129-8. [Epub ahead of print].  Back to cited text no. 10
    
11.
Mavioǧlu Levent H, Ünal Utku E, Aşkın G, Küçüker Alp Ş, Özatik Ali M. Perioperative planning for cardiovascular operations in the COVID-19 pandemic. Turk Gogus Kalp Dama 2020; https://doi.org/10.5606/tgkdc.dergisi.2020.09294.  Back to cited text no. 11
    
12.
Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare. Available from: https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html. [Last accessed on 2020 Apr 04].  Back to cited text no. 12
    
13.
Mavioglu HL, Unal EU. Cardiovascular surgery in the COVID-19 pandemic. J Card Surg 2020. doi: 10.1111/jocs.14559. [Epub ahead of print].  Back to cited text no. 13
    


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