Since December 2019, the outbreak of coronavirus disease 2019 (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread to most countries worldwide. It is predicted that the pandemic may become a new normal in medical institutions.1 The major concern is how to prevent and control the transmission of SARS-CoV-2 as well as conduct non-COVID-19 surgeries at the same time. Within hospitals, it was necessary to reorganize clinical areas and establish new workflows to minimize nosocomial infection.
Although our medical center in Beijing, China was outside the epicenter of the pandemic, we nevertheless faced the dilemma of managing routine clinical practice while preventing and treating COVID-19 early in the pandemic. This study describes our experience of managing neurosurgical workflows during the pandemic, including information about our COVID-19 screening protocol, clinical caseload and workflows, and nosocomial infection.
MATERIALS AND METHODS
We retrospectively reviewed the clinical data of patients who underwent neurosurgical procedures at Beijing Tiantan Hospital, China between January 21, 2020 and July 31, 2020. All patients were screened for COVID-19 before admission by a consultant team in a dedicated COVID-19 screening clinic involving experts from pulmonology, infectious diseases, radiology, neurosurgery, and anesthesiology. A 3-level system of COVID-19 risk was established according to patients’ medical conditions and results of triage. A low-risk level referred to patients in whom COVID-19 was ruled out, and in whom surgery could be elective, limited or emergent. A moderate-risk level referred to patients in whom COVID-19 was not completely excluded, but in whom life-saving emergency surgery was required. A high-risk level referred to patients with confirmed or suspected COVID-19 status.
The screening assessment included inquiry of epidemiologic history, check of body temperature, investigation of symptoms, and performance of a complete blood count and chest computerized tomography scan. Before February 24, reverse transcription-polymerase chain reaction (RT-PCR) was not routinely available for all patients, and only performed in those identified as moderate-risk and high-risk by screening. After February 24, in accordance with the requirements of the Beijing Centers for Disease Control and Prevention, 2 RT-PCR tests of were conducted at intervals of 24 to 48 hours in our institution.
In China, the COVID screening epidemiologic inquiry included travel history to any epicenter of COVID-19, history of close contact with confirmed cases or cluster cases with fever or other respiratory symptoms. The symptom inquiry included fever, weakness, dry cough, shortness of breath, nasal congestion, runny nose, sore throat, impaired sense of smell, and diarrhea. Two consecutive negative results on the RT-PCR tests and absence of symptoms were required for patients to be considered COVID-19 negative.
Level-1 to level-3 personal protection was applied to low-to-high risk surgery as follows: level-1 protection—scrubs, disposable cap, surgical mask, gloves, and isolation gown; level-2 protection—scrubs, disposable cap, N95 mask, protective coverall, gloves, goggles or face shield, and boot covers, and; level-3 protection—scrubs, disposable cap, N95 mask, protective coverall, double-layer gloves, goggles or face shield, boot covers, and isolation gown.
A transitional unit was established for patients in whom COVID-19 had not been ruled out. The transitional unit included a transition ward and an isolated area in the intensive care unit where patients were managed in single rooms. Given the early stage of the pandemic, the majority of patients presenting for emergency surgeries were considered to be either “unknown” or “suspected” for COVID-19.2 Patients who did not complete RT-PCR tests were admitted to the transitional unit for further evaluation and treatment (Fig. 1).
A negative-pressure operation room (OR) and isolation OR were designated for patients with COVID-19 infection or those under investigation. Surgeries for moderate-risk patients were performed in the isolation OR, and surgeries for high-risk patients in the negative-pressure OR. The negative-pressure OR and isolation OR were located in the outpatient operation theater suite, far away from inpatient facilities. These ORs had isolated ventilation and sewage disposal systems.
The first COVID-19-positive patient at Beijing Tiantan Hospital was diagnosed on January 21, and we began screening for COVID-19 at the preoperative visit and evaluation. From January 21 to July 31, 2020, 4025 patients underwent neurosurgical procedures, including 768 emergent surgeries and 3257 nonemergent surgeries. Of these, 3722 patients were low-risk for COVID-19, 303 were moderate-risk, and none were high-risk. In addition, 1419 patients underwent neurointerventional procedures, including 114 emergent and 1305 nonemergent interventions. Of these, there were 1339 low-risk patients, 80 moderate-risk patients, and no high-risk patients. A total of 895 neurosurgical and neurointerventional patients were admitted to the transitional unit, and none of these patients were diagnosed with COVID-19.
During the study period, 45 patients were diagnosed with COVID-19 in our hospital and subsequently transferred to the COVID-19 designated hospital. There were no COVID-19 nosocomial infections among patients or health care workers.
As the largest neurosurgery center in China, our institution has been performing surgeries during the pandemic. Many suspected and confirmed COVID-19 cases were tested at our institution during the pandemic in Beijing. Due to the introduction of strict infection prevention and control policies to contain the outbreak during our emergency response to the pandemic, no health care worker or surgical patient in our institution became infected with COVID-19. As the pandemic is likely to become a normalized global health issue, we believe that infection prevention and control should be maintained to reduce the risk of rebound in COVID-19 infections. The World Health Organization also recommends screening all individuals at their first point of contact with health care systems.3
Multiple case series have reported concerns about ischemic and hemorrhagic stroke in patients with COVID-19.4,5 Older adults are at high risk of becoming critically ill with a higher D-dimer.6,7 Hypertensive patients with COVID-19 might also be vulnerable to hemorrhagic stroke; SARS-CoV-2 uses angiotensin converting enzyme II as a cellular entry receptor.8 Therefore, patients with COVID-19 have a greater chance of requiring endovascular treatment, which can be complicated by perioperative stroke during acute infection leading to greater challenges for neuroanesthesiologists.9 To minimize the time to treatment, we minimized the time required to screen for COVID-19 by establishing an efficient triage system including a consultation team of experts, performing simultaneous computerized tomography scans of the brain and chest, and promptly informing the OR team about the suspected cases.
Consensus guidelines from the Society for Neuroscience in Neuroanesthesiology and Critical Care (SNACC) provides recommendations for the perioperative management of acute ischemic stroke patients.2 Conscious sedation and general anesthesia are 2 common options for emergency endovascular thrombectomy, and each has its own pros and cons. However, it has been reported that 5% to 10% of patients undergoing conscious sedation require conversion to general anesthesia due to agitation or body movement.10,11 The SNACC guidance cautions that emergent conversion from conscious sedation to general anesthesia is undesirable in the COVID-19 pandemic given the risk of producing aerosol contamination in an uncontrolled situation.2 General anesthesia has the advantage of immobilization and controlled access to the airway, whilst also preventing pulmonary aspiration, but can be associated with hemodynamic fluctuation and lung injury.12 In our institution, we preferred to perform general anesthesia with endotracheal intubation during the pandemic instead of using a laryngeal mask airway. To prevent coughing and risk of aerosol spread, we used rapid sequence induction and intravenous administration of lidocaine, opioids, and dexmedetomidine during the intervention. Any personal protective equipment component that became heavily soiled by blood or body fluids during procedures was replaced immediately.13 Of note, it is very difficult for anesthesiologists using level-3 protection to manage an airway, and the risk of a difficult airway is increased. Therefore, we prepared a difficult airway kit, including the availability of a videolaryngoscope, which was available in the room.
General recommendations for the perioperative management of patients during the COVID-19 pandemic have already been published.9,14 For neurosurgical procedures requiring dissection of the nasopharyngeal mucosa, such as the transsphenoidal excision of pituitary tumors, the risk of aerosolizing the virus is very high when powered instruments are used in the nasal cavity.15,16 Recently, published guidance recommends suspending non-urgent surgery in patients with COVID-19 until the infection is cleared.17 Craniotomy may also be considered as an alternative to transnasal surgery.9 Emergent transnasal surgery for patients with COVID-19 must be conducted in negative-pressure ORs by health care workers using level-3 PPE, and the patient transferred to the transitional unit postoperatively.
In summary, the current outbreak of COVID-19 has been rapidly expanding across the globe. Special concerns regarding perioperative management of neuroscience patients, and personal protection, are still needed even in areas where the pandemic is waning. On the basis of our single-center experience, developing a full screening protocol for COVID-19, establishing a risk level guide, and using a transitional unit are effective measure for ensuring the safety of patients and health care workers.
The authors thank Professor Fenghua Li, MD, and Professor Reza Gorji, MD (Department of Anesthesiology, SUNY Upstate Medical University, Syracuse, NY), for reviewing and providing helpful comments on the manuscript. The authors also thank Kaiying Zhang, MD (Department of Anesthesiology, The University of Texas Health Science Center at Houston, Houston, TX), for revising and editing the manuscript.
1. Bowdle A, Munoz-Price LS. Preventing infection of patients and healthcare workers should be the new normal in the era of novel coronavirus epidemics. Anesthesiology. 2020;132:1292–1295.
2. Sharma DRM, Han R, et al. Anesthetic management of endovascular treatment of acute ischemic stroke during COVID-19 pandemic
: consensus statement from Society for Neuroscience in Anesthesiology & Critical Care (SNACC). J Neurosurg Anesthesiol. 2020;32:193–201.
3. WHO. Clinical management of COVID-19 interim guidance. 2020. Available at: https://www.who.int/publications/i/item/clinical-management-of-covid-19
. Accessed June 1, 2020.
4. Oxley TJMJ, Majidi S, Kellner CP, et al. Large-vessel stroke as a presenting feature of Covid-19 in the young. N Engl J Med. 2020;382:e60.
5. Mao L, Jin H, Wang M, et al. Neurologic manifestations of hospitalized patients with Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol. 2020;77:1–9.
6. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet. 2020;395:497–506.
7. Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020;382:1708–1720.
8. Zhou P, Yang XL, Wang XG, et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature. 2020;579:270–273.
9. Flexman AM, Abcejo A, Avitisian R, et al. Neuroanesthesia practice during the COVID-19 pandemic
: recommendations from Society for Neuroscience in Anesthesiology & Critical Care (SNACC). J Neurosurg Anesthesiol. 2020;32:202–209.
10. Hindman BJ. Anesthetic management of emergency endovascular thrombectomy for acute ischemic stroke, part 1: patient characteristics, determinants of effectiveness, and effect of blood pressure on outcome. Anesth Analg. 2019;128:695–705.
11. Hindman BJ, Dexter F. Anesthetic management of emergency endovascular thrombectomy for acute ischemic stroke, part 2: integrating and applying observational reports and randomized clinical trials. Anesth Analg. 2019;128:706–717.
12. Zhang Y, Jia L, Fang F, et al. General anesthesia versus conscious sedation for intracranial mechanical thrombectomy: a systematic review and meta-analysis of randomized clinical trials. J Am Heart Assoc. 2019;8:e011754.
13. Peng PWH, Ho PL, Hota SS. Outbreak of a new coronavirus: what anaesthetists should know. Br J Anaesth. 2020;124:497–501.
14. Chen X, Liu Y, Gong Y, et al. Perioperative management of patients infected with the Novel Coronavirus: Recommendation from the Joint Task Force of the Chinese Society of Anesthesiology and the Chinese Association of Anesthesiologists. Anesthesiology. 2020;132:1307–1316.
15. Perdelli F, Spagnolo AM, Cristina ML, et al. Evaluation of contamination by blood aerosols produced during various healthcare procedures. J Hosp Infect. 2008;70:174–179.
16. Vukkadala N, Qian ZJ, Holsinger FC, et al. COVID-19 and the otolaryngologist: preliminary evidence-based review. Laryngoscope. 2020. doi: doi: 10.1002/lary.28672. [Epub ahead of print].
17. Givi B, Schiff BA, Chinn SB, et al. Safety recommendations for evaluation and surgery of the head and neck during the COVID-19 pandemic
. JAMA Otolaryngol Head Neck Surg. 2020. doi: doi: 10.1001/jamaoto.2020.0780. [Epub ahead of print].