The coronavirus disease 2019 (COVID-19) pandemic has recently put global health services under escalating pressure. For patients who are known to be COVID-19 positive or at high suspicion for COVID-19 infection, although non-operative treatment is preferred for stable cardiovascular diseases to reduce the exposure, emergent cardiac surgery is still necessary when the primary concern is life-threatening and there is no alternative option.
Optimized infection-control workflow, standard prevention, and hierarchical protection [Table 1] help effectively minimize the risk of virus spreading and cross-infection in China. Here, we describe in detail a protocol of perioperative management for COVID-19 patients undergoing emergent cardiac surgery which has been widely adopted in China.
Table 1 -
Standard prevention and hierarchical protection for caregivers during coronavirus disease 2019 pandemic.
||Ordinary clinics or wards
||Wear disposable work caps, medical-surgical masks, disposable surgical masks (replace every 4 h or when wet feeling or when contamination), and disposable latex gloves when handling blood or body fluids
||Fever outpatient clinic
||Wear disposable work caps, goggles or protective screens, medical protective masks (N95 or KN95), protective clothing or disposable impermeable isolation clothing, disposable latex gloves, and disposable shoe covers
||Isolation area of fever outpatient clinic, isolation ward (including operation room and intensive care unit), and related laboratories
||Wear disposable work caps, comprehensive breathing protectors or electric air filter respirator (positive pressure headgear), medical protective mask (N95), protective clothing, disposable latex gloves, and disposable boots
Identifying COVID-19 infection while evaluating primary cardiovascular disease
For local patients, you should know his/her detailed epidemiological history, temperature, and respiratory symptoms and routinely acquire his/her complete blood cell count and chest computed tomography (CT) scan before admission. For suspected cases, the COVID-19 nucleic acid test should be done.
For a patient who is confirmed or at high suspicion for COVID-19 infection, a referral is only permitted when the treatment is not available in the local hospitals and the primary cardiovascular disease is life-threatening. Before the referral, a remote consultation should be organized to communicate and develop a treatment plan. The transportation should be carried out in a dedicated vehicle of negative pressure with staff fully protected.
For a patient who is confirmed or at high suspicion for COVID-19 infection, he/she should be first admitted into the buffer zone of the emergency department.
Hierarchical management of cardiac surgery
Upon arriving, a multidisciplinary team, including cardiovascular surgeons, anesthesiologists, cardiologists, and infectious disease specialists, should be called together to evaluate the patient. Discussion includes the triage of COVID infection, the urgency of cardiovascular disease, and possible non-surgical option. Emergent surgery should be reserved only for patients who have an absolute life-threatening disease and no alternative option, such as acute Stanford Type A aortic dissection, acute coronary syndrome refractory to medication and percutaneous coronary intervention, infectious endocarditis complicated by hemodynamic instability or embolism, unstable cardiac tumor with recurrent embolic events, and cardiac trauma.
Once emergent surgery is indicated, the patient should be admitted to an isolation ward (single-person isolation room, if possible). Isolation wards need to have isolation signs and restricted personnel access. Both family visit and accompany are strictly prohibited. Considering the status of critically ill patients with cardiovascular disease, patients should be bedridden and wear masks.
Diagnosis and evaluation should be immediately initiated on the patient's cardiovascular concern and if possible, testing should be done at the bedside. Any bedside test including echocardiography should be carried out strictly following Class III prevention. When entering or leaving an isolation ward, the relevant requirements of the “Technical Specifications for Hospital Isolation” and the “Procedures for Putting on and Taking off Protective Equipment for Medical Staff” should be followed. Before and after contact with patients, the requirements of the “Standard for hand hygiene for healthcare workers” WS/T313-2009 (published by National Health Commission of the People's Republic of China, 2009) should be followed in a timely and correct manner. Isolation wards are cleaned in accordance with “the Regulations of Air Purification Management in Hospital.”
Before the surgery, the surgical team should meet the staff from anesthesia department, operating room, respiratory department, infectious disease department, and medical office to discuss the surgical plan, and then notify associated personnel and make arrangement for medical supply.
Management in Cardiac Surgery Operating Rooms
- (1) It is recommended that surgery be carried out in an infection-customized room with negative pressure, an air purification system, and an air disinfection facility. Turn off the air-conditioning system. All medical staff need to take a temperature measurement.
- (2) Hang a “COVID-19” sign outside the operating room.
- (1) Medical supply should be prepared in advance, including disposable instruments, medication, and equipment.
- (2) It is recommended that the operating room be equipped with intercom and video surveillance facilities.
- (3) Move unnecessary items out of the operating room. Items that cannot be moved should be covered with a protective case to minimize the contamination.
- (4) Quick-drying hand disinfectants are preferred for surgical staff's hand disinfection. Other hand disinfectants can be used for allergic staff, including chlorine, ethanol, hydrogen peroxide, and other hand disinfectants. Chlorhexidine cannot effectively inactivate novel coronavirus and is not recommended.
- (1) The medical staff who transfer patients should have Class III protection as required.
- (2) The surgical transfer process requires a dedicated passage and a special elevator. Avoid the busy period and route.
Management of the operating room during the operation
- (1) Use disposable instruments, equipment, and medical supply as possible.
- (2) Minimize the number of people involved in the surgery, and strictly perform personal disinfection before surgery. Dedicated personnel in the operating room are responsible for the delivery of the material inside and outside the operating room. Indoor personnel are not allowed to leave the operating room during surgery, and outdoor personnel can only enter after wearing protective equipment. Prepare in advance surgical supplies and consumables to reduce the exchange of personnel and equipment into and out of the room.
- (3) All participants should have Class III protection. After scrubbing (for ease of scrubbing, we prefer to cut two-third of both sleeves of the protective clothing, and seal the end with tape), surgeons and scrub nurses should wear disposable sterile surgical gowns and two pairs of gloves. If the operation time is expected to exceed 4 h, a diaper should be made available to operation room personnel before entering the room. Any medical staff with broken skin should not be allowed to participate in the operation.
- (4) Strictly follow the principles of aseptic and safe manipulation to avoid occupational exposure. If language communication is affected by protective equipment, alternative communication methods should be chosen in advance. During the operation, attention should be paid to avoid the injury of sharps and the contamination of patients’ blood and body fluids.
- (5) The surgeon fills in the Infectious Disease Report Form after the procedure.
Management of operating room after the operation
- (1) Medical staff in the operating room should notify intensive care unit (ICU) medical staff in advance and transfer patients via the dedicated route.
- (2) Disposal of instruments: reusable instruments should be double-packed and labeled with “COVID-19,” and recycled and disinfected by the supply center separately.
Terminal management in the operating room
- (1) Perform air disinfection according to the requirements of infectious disease management. Clean and disinfect the exhaust fan unit, as well as the surface of all equipment.
- (2) Surgical sheets and other fabrics should be disposed of as infectious waste.
- (3) The pathological tissue should be placed in a double-layered yellow medical waste bag, sealed in layers, and transported to the pathology department with clear notification. All medical waste should be treated following the medical waste disposal process.
- (4) Medical staff should follow the workflow and remove surgical gown correctly at the designated place. Outer and inner protective equipment should be removed in the operation room (contaminated area) and the buffer zone respectively.
- (5) For a hybrid operating room, radiation protection and protective equipment disinfection should be implemented.
- (6) Quality control should be done to confirm the effect of disinfection on the surface, air, and handlers of objects.
Management of occupational exposure of personnel
- (1) Isolation is required in the event of exposure or suspected close contact. Put under medical observation for 14 days and then receive the COVID-19 nucleic acid test.
- (2) Mask slip-off: Immediately change the gloves or take off the outer gloves to adjust the mask; then back up and remove protective equipment strictly following the specifications, and take personal hygiene (take a bath, change clothes and clean the mouth, nasal cavity and external ear canals).
- (3) Damaged protective equipment: Leave the contaminated area immediately, remove protective equipment in accordance with specifications, and conduct personal hygiene disposal (take a bath, change clothes and clean mouth, nasal cavity, and external auditory canals); assess the exposure and determine whether the medical observation is required.
- (4) Syncope: Medical staff in the same area should assist the syncope one to leave the polluted area as soon as possible, remove his/her outer gloves and apply hand sanitizing, and then remove the protective equipment of the syncope one, assess the condition and treat syncope immediately. Take personal hygiene when he/she is sober. Assess the exposure and determine whether a medical observation is required. If a further rescue is needed, prompt brain protection and cardiopulmonary resuscitation should be carried out in an open place or another operating room.
All medical staff at the operating table and anesthesiologists should wear positive pressure breathing hoods. Take into consideration the use of a magnifying lens, the surgery site, the disturbing sight, tolerant duration of wearing protective equipment, as well as emergencies (including attrition and accidental exposure).
After surgery, the patient is transferred to the single-room isolation unit with negative pressure in ICU. Medical staff should strictly take Class III protection while taking care of suspected or confirmed cases during non-invasive ventilation, tracheal intubation, tracheotomy, cardiopulmonary resuscitation, and bronchoscopy. Take protective measures against droplet, contact, and air contamination. Disinfection equipment, appliances, air conditioners, waste, and waste gas should be handled following operating room requirements.
If the patient status is stable and there is no pneumonia, fever, obvious abnormalities in blood tests including complete blood count, or ground-glass opacity in the chest CT, consider transferring the patient out of the ICU to the recovery ward.
Before leaving the hospital, the patient should not only meet the standard of post-operative recovery but also meet the criteria of clinical recovery from COVID-19 pneumonia.
This protocol is meant to provide advice for the surgical team and to serve the best interests of patients. It should not be considered as rigid guidelines. Nor is the information intended to impede the development of consensus regarding institutional and local guidelines. There is also a great deal of uncertainty around this evolving pandemic and a large amount of regional variability.
Conflicts of interest
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