Cardiac surgery outcomes in patients with coronavirus disease 2019 (COVID-19): A case-series report.

OBJECTIVE: The impact of coronavirus disease 2019 (COVID-19) on the postoperative course of patients after cardiac surgery is unknown. We experienced a major severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak in our cardiac surgery unit, with several patients who tested positive early after surgery. Here we describe the characteristics, postoperative course, and laboratory findings of these patients, along with the fate of the health care workers. We also discuss how we reorganize and reallocate hospital resources to resume the surgical activity without further positive patients. METHODS: After diagnosis of the first symptomatic patient, surgery was suspended. Nasopharyngeal swabs were performed in all patients and health care workers. Patients who were positive for SARS-CoV-2 were isolated and monitored throughout the in-hospital stay and followed up after discharged until death or clinical recovery. RESULTS: Twenty patients were found to be positive for SARS-CoV-2 sometime after cardiac surgery (mean age 69 ± 10.4 years; median European System for Cardiac Operative Risk Evaluation II score 3 [interquartile range, 5.1]); the median time from surgery to diagnosis was 15 days (interquartile range, 11). Among the patients, 18 had undergone cardiac surgery and 2 of them transcatheter aortic valve replacement. Overall mortality was 15%. Specific COVID-19-related symptoms were identified in 7 patients (35%). Among the 12 health care workers infected, 1 developed a bilateral mild-grade interstitial pneumonia. CONCLUSIONS: COVID-19 infection after cardiac surgery, regardless the time of the onset, is a serious condition. The systemic inflammatory state that follows extracorporeal circulation may mask the typical COVID-19 laboratory findings, making the diagnosis more difficult. A strict reorganization of the hospital resources is necessary to safely resume the cardiac surgical activity.

Laparoscopic vs open surgery during the COVID-19 pandemic: what are the risks?

INTRODUCTION: The initial intercollegiate surgical guidance from the UK during the COVID-19 pandemic resulted in significant changes to practice. Avoidance of laparoscopy was recommended, to reduce aerosol generation and risk of virus transmission. Evidence on the safety profile of laparoscopy during the pandemic is lacking. This study compares patient outcomes and risk to staff from laparoscopic and open gastrointestinal operations during the COVID-19 pandemic. METHODS: Single-centre retrospective study of gastrointestinal operations performed during the peak of the COVID-19 pandemic. Demographic, comorbidity, perioperative and survival data were collected from electronic medical records and supplemented with patient symptoms reported at telephone follow up. Outcomes assessed were: patient mortality, illness among staff, patient COVID-19 rates, length of hospital stay and postdischarge symptomatology. RESULTS: A total of 73 patients with median age of 56 years were included; 55 (75%) and 18 (25%) underwent laparoscopic and open surgery, respectively. All-cause mortality was 5% (4/73), was related to COVID-19 in all cases, with no mortality after laparoscopic surgery. A total of 14 staff members developed COVID-19 symptoms within 2 weeks, with no significant difference between laparoscopic and open surgery (10 vs 4; p=0.331). Median length of stay was shorter in the laparoscopic versus the open group (4.5 vs 9.9 days; p=0.011), and postdischarge symptomatology across 15 symptoms was similar between groups (p=0.135-0.814). CONCLUSIONS: With appropriate protective measures, laparoscopic surgery is safe for patients and staff during the COVID-19 pandemic. The laparoscopic approach maintains an advantage of shorter length of hospital stay compared with open surgery.

Protective Modifications in Ophthalmology Practice during COVID-19 Pandemic: Challenges and Lessons Learned.

Ophthalmology is a specialty which involves close contact with patients. Personal protective equipment (PPE) along with modifications in examination techniques and equipment are needed to avoid spread of coronavirus infectious disease (COVID-19) to health professionals. This communication aims to highlight and critically analyse the measures suggested to control this spread. We also highlighted our experience with protective gear modifications. As with any practice, triage is cornerstone. Use of disinfectants, good personal hygiene practices and PPE for patients and staff, must be adopted for safe ophthalmology practices. Key Words: COVID-19, Ophthalmology, Personal protective equipment (PPE).

Should We Postpone Elective Cardiovascular Procedures and Percutaneous Coronary Interventions During the COVID-19 Pandemic?

BACKGROUND: Prioritization among patients with coronary artery disease represents a difficult issue during the SARS-CoV-2 pandemic. We present our clinical practices and patients' outcomes after elective, emergent, and urgent cardiovascular surgery and percutaneous coronary interventions (PCI). We also investigated the rate of nosocomial infection of SARS-CoV-2 in health workers (HWs), including surgeons after cardiovascular procedures and percutaneous interventions (PCI). MATERIAL AND METHODS: We performed 186 cardiovascular operations and PCI between March 15 and October 15. According to the level of priority (LoP), we performed urgent and emergent coronary artery bypass grafting (CABG) and cardiac valve repair or replacement surgery in 44 patients. In one patient with acute chordae rupture with pulmonary edema, we performed mitral valve replacement. We performed the aortic arch repair in two patients with type-I aortic dissection in urgent situations. Therefore, in 47 patients we performed cardiac operations in urgent or emergent situations. Elective CABG (N = 28) and elective cardiac valve (N = 10) surgeries were performed (total: 38). While rescue PCI was urgently performed in 47 patients with ST-segment elevation myocardial infarction (STEMI), it was performed in elective or emergent situations in 40 patients with myocardial ischemia. Endovascular treatment was performed in four patients with deep venous thrombosis (DVT) and in four patients with chronic arterial occlusion, respectively. Surgical vascular repair and embolectomy were performed in patients with peripheral artery injury (N = 6) and acute arterial embolic events (N = 4), respectively. We performed thoracic computed tomography followed by reverse transcriptase-polymerase chain reaction (RT-PCR) test in patients with irregular diffuse reticular opacities with or without consolidation on chest X-ray. Blood coagulation disorders including d-dimer, thromboplastin time (TT), and partial thromboplastin time (aPTT) were measured prior to procedures. RESULTS: No mortality and morbidity was seen after percutaneous and surgical arterial or venous procedures. The total mortality rate was 4.1% (8 of 186 CAD patients or valve surgery) after urgent and emergent CABG (N = 4), an urgent valve replacement (N = 1), and PCI (N = 3). Low cardiac output syndrome (LOS) and major adverse cardiac cerebrovascular event (MACCE) were the mortality factors after cardiac surgery. The reasons for death after PCI were sudden cardiac arrest related to the dissection of the left main coronary artery during procedure and pneumonia due to COVID-19 (N = 2). Ground-glass opacities in combination with pulmonary consolidations were detected in seven patients. Interlobular septal and pleural thickening with patchy bronchiectasis in the bilateral lower lobe involvement was found after thoracic computed tomography in these patients. We confirmed in-hospital COVID-19 using a PCR test in two patients with STEMI prior to PCI. PT and aPTT increased, but fibrin degradation products did not in those two patients. We confirmed COVID-19 via phone call in six CABG patients and one PCI patient after discharge from the hospital. None of the patients diagnosed with COVID-19 died after being discharged from the hospital. CONCLUSION: Cardiovascular surgery and PCI can safely be performed with acceptable complications and mortality rates in elective situations, during the COVID-19 pandemic. Preoperative control of OR traffic, careful evaluation of the patient's history, consultation, and precautions taken by healthcare professionals are important, during and after procedures. Also important is wearing a mask and face shield and careful disinfection of equipment and space.

Risk of disease transmission from flexible nasoendoscopy during the coronavirus disease 2019 pandemic.

BACKGROUND: Concerns have emerged regarding infection transmission during flexible nasoendoscopy. METHODS: Information was gathered prospectively on flexible nasoendoscopy procedures performed between March and June 2020. Patients and healthcare workers were followed up to assess for coronavirus disease 2019 development. One-sided 97.5 per cent Poisson confidence intervals were calculated for upper limits of risk where zero events were observed. RESULTS: A total of 286 patients were recruited. The most common indication for flexible nasoendoscopy was investigation of 'red flag' symptoms (67 per cent). Forty-seven patients (16 per cent, 95 per cent confidence interval = 13-21 per cent) had suspicious findings on flexible nasoendoscopy requiring further investigation. Twenty patients (7.1 per cent, 95 per cent confidence interval = 4.4-11 per cent) had new cancer diagnoses. Zero coronavirus disease 2019 infections were recorded in the 273 patients. No. 27 endoscopists (the doctors and nurses who carried out the procedures) were followed up.The risk of developing coronavirus disease 2019 after flexible nasoendoscopy was determined to be 0-1.3 per cent. CONCLUSION: The risk of coronavirus disease 2019 transmission associated with performing flexible nasoendoscopy in asymptomatic patients, while using appropriate personal protective equipment, is very low. Additional data are required to confirm these findings in the setting of further disease surges.

Management of tracheostomy in COVID-19 patients: The Japanese experience.

OBJECTIVE: Involvement in the tracheostomy procedure for COVID-19 patients can lead to a feeling of fear in medical staff. To address concerns over infection, we gathered and analyzed experiences with tracheostomy in the COVID-19 patient population from all over Japan. METHODS: The data for health-care workers involved in tracheostomies for COVID-19-infected patients were gathered from academic medical centers or their affiliated hospitals from all over Japan. RESULTS: Tracheostomies have been performed in 35 COVID-19 patients with a total of 91 surgeons, 49 anesthesiologists, and 49 surgical staff members involved. Twenty-eight (80%) patients underwent surgery more than 22 days after the development of COVID-19-related symptoms (11: 22-28 days and 17: ≥29 days). Thirty (85.7%) patients underwent surgery ≥ 15 days after intubation (14: 15-21 days, 6: 22-28 days, and 10: ≥29 days). Among the total of 189 health-care workers involved in the tracheostomy procedures, 25 used a powered air-purifying respirator (PAPR) and 164 used a N95 mask and eye protection. As a result, no transmission to staff occurred during the 2 weeks of follow-up after surgery. CONCLUSION: No one involved in tracheostomy procedures were found to have been infected with COVID-19 in this Japanese study. The reason is thought to be that the timing of the surgery was quite late after the infections, and the surgery was performed using appropriate PPE and surgical procedure. The indications for and timing of tracheostomy for severe COVID-19 patients should be decided through multidisciplinary discussion.

Quantification of Aerosol Particle Concentrations During Endoscopic Sinonasal Surgery in the Operating Room.

BACKGROUND: Recent indirect evidence of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) transmission during endoscopic endonasal procedures has highlighted the dearth of knowledge surrounding aerosol generation with these procedures. As we adapt to function in the era of Coronavirus Disease 2019 (COVID-19) a better understanding of how surgical techniques generate potentially infectious aerosolized particles will enhance the safety of operating room (OR) staff and learners. OBJECTIVE: To provide greater understanding of possible SARS-CoV-2 exposure risk during endonasal surgeries by quantifying increases in airborne particle concentrations during endoscopic sinonasal surgery. METHODS: Aerosol concentrations were measured during live-patient endoscopic endonasal surgeries in ORs with an optical particle sizer. Measurements were taken throughout the procedure at six time points: 1) before patient entered the OR, 2) before pre-incision timeout during OR setup, 3) during cold instrumentation with suction, 4) during microdebrider use, 5) during drill use and, 6) at the end of the case prior to extubation. Measurements were taken at three different OR position: surgeon, circulating nurse, and anesthesia provider. RESULTS: Significant increases in airborne particle concentration were measured at the surgeon position with both the microdebrider (p = 0.001) and drill (p = 0.001), but not for cold instrumentation with suction (p = 0.340). Particle concentration did not significantly increase at the anesthesia position or the circulator position with any form of instrumentation. Overall, the surgeon position had a mean increase in particle concentration of 2445 particles/ft3 (95% CI 881 to 3955; p = 0.001) during drill use and 1825 particles/ft3 (95% CI 641 to 3009; p = 0.001) during microdebrider use. CONCLUSION: Drilling and microdebrider use during endonasal surgery in a standard operating room is associated with a significant increase in airborne particle concentrations. Fortunately, this increase in aerosol concentration is localized to the area of the operating surgeon, with no detectable increase in aerosol particles at other OR positions.

Head and neck cancer surgery during the COVID-19 pandemic: An international, multicenter, observational cohort study.

BACKGROUND: The aims of this study were to provide data on the safety of head and neck cancer surgery currently being undertaken during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: This international, observational cohort study comprised 1137 consecutive patients with head and neck cancer undergoing primary surgery with curative intent in 26 countries. Factors associated with severe pulmonary complications in COVID-19-positive patients and infections in the surgical team were determined by univariate analysis. RESULTS: Among the 1137 patients, the commonest sites were the oral cavity (38%) and the thyroid (21%). For oropharynx and larynx tumors, nonsurgical therapy was favored in most cases. There was evidence of surgical de-escalation of neck management and reconstruction. Overall 30-day mortality was 1.2%. Twenty-nine patients (3%) tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within 30 days of surgery; 13 of these patients (44.8%) developed severe respiratory complications, and 3.51 (10.3%) died. There were significant correlations with an advanced tumor stage and admission to critical care. Members of the surgical team tested positive within 30 days of surgery in 40 cases (3%). There were significant associations with operations in which the patients also tested positive for SARS-CoV-2 within 30 days, with a high community incidence of SARS-CoV-2, with screened patients, with oral tumor sites, and with tracheostomy. CONCLUSIONS: Head and neck cancer surgery in the COVID-19 era appears safe even when surgery is prolonged and complex. The overlap in COVID-19 between patients and members of the surgical team raises the suspicion of failures in cross-infection measures or the use of personal protective equipment. LAY SUMMARY: Head and neck surgery is safe for patients during the coronavirus disease 2019 pandemic even when it is lengthy and complex. This is significant because concerns over patient safety raised in many guidelines appear not to be reflected by outcomes, even for those who have other serious illnesses or require complex reconstructions. Patients subjected to suboptimal or nonstandard treatments should be carefully followed up to optimize their cancer outcomes. The overlap between patients and surgeons testing positive for severe acute respiratory syndrome coronavirus 2 is notable and emphasizes the need for fastidious cross-infection controls and effective personal protective equipment.

Short-term Outcomes for Patients and Providers After Elective Tracheostomy in COVID-19-Positive Patients.

BACKGROUND: Urgent guidance is needed on the safety for providers of percutaneous tracheostomy in patients diagnosed with COVID-19. The objective of the study was to demonstrate that percutaneous dilational tracheostomy (PDT) with a period of apnea in patients requiring prolonged mechanical ventilation due to COVID-19 is safe and can be performed for the usual indications in the intensive care unit. METHODS: This study involves an observational case series at a single-center medical intensive care unit at a level-1 trauma center in patients diagnosed with COVID-19 who were assessed for tracheostomy. Success of a modified technique included direct visualization of tracheal access by bronchoscopy and a blind dilation and tracheostomy insertion during a period of patient apnea to reduce aerosolization. Secondary outcomes include transmission rate of COVID-19 to providers and patient complications. RESULTS: From April 6th, 2020 to July 21st, 2020, 2030 patients were admitted to the hospital with COVID-19, 615 required intensive care unit care (30.3%), and 254 patients required mechanical ventilation (12.5%). The mortality rate for patients requiring mechanical ventilation was 29%. Eighteen patients were assessed for PDT, and 11 (61%) underwent the procedure. The majority had failed extubation at least once (72.7%), and the median duration of intubation before tracheostomy was 15 d (interquartile range 13-24). The median positive end-expiratory pressure at time of tracheostomy was 10.8. The median partial pressure of oxygen (PaO2)/FiO2 ratio on the day of tracheostomy was 142.8 (interquartile range 104.5-224.4). Two patients had bleeding complications. At 1-week follow-up, eight patients still required ventilator support (73%). At the most recent follow-up, eight patients (73%) have been liberated from the ventilator, one patient (9%) died as a result of respiratory/multiorgan failure, and two were discharged on the ventilator (18%). Average follow-up was 20 d. None of the surgeons performing PDT have symptoms of or have tested positive for COVID-19. CONCLUSIONS: and relevance: PDT for patients with COVID-19 is safe for health care workers and patients despite higher positive end-expiratory pressure requirements and should be performed for the same indications as other causes of respiratory failure.

Staff risks stratification in preparation for COVID-19 in a tertiary healthcare facility in Nigeria.

INTRODUCTION: this report is a documentation of a staff risk stratification programme, undertaken in University of Benin Teaching Hospital, with outcomes, and the actions taken to protect staff. METHODS: an adapted risk stratification tool was circulated to all staff through their respective heads of departments/units. Staff were expected to voluntary assess their health and risk status in the context of COVID-19, using the tool. A central multi-disciplinary screening committee assessed submissions and invited staff who required further evaluation for physical interviews. Respondents were categorized into three risk/exposure groups from lowest to highest - A, B, and C, based on their individual health assessments, occupational exposures, and information obtained from direct interviews. RESULTS: the committee received submissions from 746 staff, representing 19.4% (about a fifth) of the hospital's 3,840 staff. One hundred and twenty two of these were invited for physical interviews, of whom 88 (72.1%) were categorized as high risk (Category C): pregnancy (53.4%); bronchial asthma (19.3%); hypertension (11.4%); cancer (3.4%) and sickle cell disease (2.3%); fractures and pulmonary tuberculosis (1%, respectively). These staff were recommended for redeployment from areas of high risk exposure to COVID-19. CONCLUSION: a management-driven risk assessment of hospital staff in preparation for the COVID-19 pandemic revealed that a fifth of staff assessed themselves as being vulnerable to adverse outcomes from exposure. It is our hope that similar risk stratification programmes will become standard practice in healthcare facilities during disease outbreaks, especially in Africa.

Safety of patients and providers in lung cancer surgery during the COVID-19 pandemic.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has resulted in patient reluctance to seek care due to fear of contracting the virus, especially in New York City which was the epicentre during the surge. The primary objectives of this study are to evaluate the safety of patients who have undergone pulmonary resection for lung cancer as well as provider safety, using COVID-19 testing, symptoms and early patient outcomes. METHODS: Patients with confirmed or suspected pulmonary malignancy who underwent resection from 13 March to 4 May 2020 were retrospectively reviewed. RESULTS: Between 13 March and 4 May 2020, 2087 COVID-19 patients were admitted, with a median daily census of 299, to one of our Manhattan campuses (80% of hospital capacity). During this time, 21 patients (median age 72 years) out of 45 eligible surgical candidates underwent pulmonary resection-13 lobectomies, 6 segmentectomies and 2 pneumonectomies were performed by the same providers who were caring for COVID-19 patients. None of the patients developed major complications, 5 had minor complications, and the median length of hospital stay was 2 days. No previously COVID-19-negative patient (n = 20/21) or healthcare provider (n = 9: 3 surgeons, 3 surgical assistants, 3 anaesthesiologists) developed symptoms of or tested positive for COVID-19. CONCLUSIONS: Pulmonary resection for lung cancer is safe in selected patients, even when performed by providers who care for COVID-19 patients in a hospital with a large COVID-19 census. None of our patients or providers developed symptoms of COVID-19 and no patient experienced major morbidity or mortality.

A multi-institutional assessment of COVID-19-related risk in radiation oncology.

PURPOSE: The COVID-19 pandemic has presented challenges to delivering safe and timely care for cancer patients. The oncology community has undertaken substantial workflow adaptations to reduce transmission risk for patients and providers. While various control measureshave been proposed and implemented, little is known about their impact on safety of the radiation oncology workflow and potential for transmission. The objective of this study was to assess potential safety impacts of control measures employed during the COVID-19 pandemic. METHODS: A multi-institutional study was undertaken to assess the risks of pandemic-associated workflow adaptations using failure mode and effects analysis (FMEA). Failure modes were identified and scored using FMEA formalism. FMEA scores were used to identify highest-risk aspects of the radiation therapy process. The impact of control measures on overall risk was quantified. Agreement among institutions was evaluated. RESULTS: Thirty three failure modes and 22 control measures were identified. Control measures resulted in risk score reductions for 22 of the failure modes, with the largest reductions from screening of patients and staff, requiring use of masks, and regular cleaning of patient areas. The median risk score for all failure modes was reduced from 280 to 168. There was high institutional agreement for 90.3% of failure modes but only 47% of control measures. CONCLUSIONS: COVID-related risks are similar across oncology practices in this study. While control measures can reducerisk, their use varied. The effectiveness of control measures on risk may guide selection of the highest-impact workflow adaptions to ensure safe care in oncology.

Susceptibility of patients receiving chemotherapy for haematological malignancies to scabies.

BACKGROUND: Scabies is a contagious dermatosis. The risk factors for its transmission remain unclear. A scabies outbreak, involving patients who were receiving chemotherapy for haematological malignancies, occurred at our hospital. METHODS: The outbreak population was analysed to determine whether the incidence of scabies was higher among contact patients receiving chemotherapy for haematological malignancies. RESULTS: A patient with crusted scabies was the index case, and 18 of 78 contact healthcare workers (HCWs) and 22 of 135 contact patients were diagnosed with classical scabies. Ten of 17 contact patients with haematological malignancies and 12 of 118 contact patients with other diseases were infected with scabies. The incidence rate was significantly higher among the patients with haematological malignancies (P<0.001). The patients with haematological malignancies had a significantly lower mean minimum neutrophil count than those with other diseases (1159/µL vs 3761/µL, P=0.0012). Most haematological patients did not require special nursing assistance, suggesting that the higher incidence of scabies among these patients resulted from their immunodeficiency rather than greater skin-to-skin contact with infected HCWs. CONCLUSION: Our study suggests that patients receiving chemotherapy for haematological malignancies are more susceptible to scabies than patients with other diseases, and require stricter protection.

Preventing COVID-19 Transmission on Labor and Delivery: A Decision Analysis.

OBJECTIVE: The health care system has been struggling to find the optimal way to protect patients and staff from coronavirus disease 2019 (COVID-19). Our objective was to evaluate the impact of two strategies on transmission of COVID-19 to health care workers (HCW) on labor and delivery (L&D). STUDY DESIGN: We developed a decision analytic model comparing universal COVID-19 screening and universal PPE on L&D. Probabilities and costs were derived from the literature. We used individual models to evaluate different scenarios including spontaneous labor, induced labor, and planned cesarean delivery (CD). The primary outcome was the cost to prevent COVID-19 infection in one HCW. A cost-effectiveness threshold was set at $25,000 to prevent a single infection in an HCW. RESULTS: In the base case using a COVID-19 prevalence of 0.36% (the rate in the United States at the time), universal screening is the preferred strategy because while universal PPE is more effective at preventing COVID-19 transmission, it is also more costly, costing $4,175,229 and $3,413,251 to prevent one infection in the setting of spontaneous and induced labor, respectively. For planned CD, universal PPE is cost saving. The model is sensitive to variations in the prevalence of COVID-19 and the cost of PPE. Universal PPE becomes cost-effective at a COVID-19 prevalence of 34.3 and 29.5% and at a PPE cost of $512.62 and $463.20 for spontaneous and induced labor, respectively. At a higher cost-effectiveness threshold, the prevalence of COVID-19 can be lower for universal PPE to become cost-effective. CONCLUSION: Universal COVID-19 screening is generally the preferred option. However, in locations with high COVID-19 prevalence or where the local societal cost of one HCW being unavailable is the highest such as in rural areas, universal PPE may be cost-effective and preferred. This model may help to provide guidance regarding allocation of resources on L&D during these current and future pandemics. KEY POINTS: · Universal screening is the preferred strategy for labor.. · With high prevalence, universal PPE is cost-effective.. · For planned cesarean, universal PPE is cost saving..