Expert physicians weigh-in on resuming elective surgery during COVID-19 pandemic
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A group of expert physicians published a guidance document with recommendations for reducing pathogen transfer during reintroduction of elective orthopedic surgical procedures during the COVID-19 pandemic.
“The document was created with input from 80 experts (surgeons, anesthesiologists, infectious disease specialists and scientists) from around the world to produce a document that can be used as a roadmap that provides guidance in dealing with challenges that we will face when elective surgeries are resumed,” Javad Parvizi, MD, FRCS, James Edwards Professor of Orthopedic Surgery at the Sidney Kimmel Medical College and of Rothman Institute at Thomas Jefferson University Hospital, told Healio Orthopedics. “The document provides recommendations that will help reduce the risk of transmission of SARS-CoV-2, and for that matter other pathogens, during surgical procedures. The guidelines are intended to keep patients, health care staff and the society safe while allowing us to deliver care to patients who have been selflessly waiting to have their surgical problem assessed.”
General recommendations
As part of the general recommendations, the workgroup recommends resuming elective surgery when lockdown in the region has been lifted and a mandate allowing return to elective surgery has been issued by local, state, provincial or governmental authorities.
The hospital or surgical facility should have the capacity to admit patients without COVID-19 to an area of the hospital separated from patients with COVID-19 before resuming elective surgery, according to the document, as well as have an adequate supply of effective personal protective equipment, real-time polymerase chain reaction-testing kits for COVID-19 and be able to perform surgery safely with low risk of COVID-19 transmission. The workgroup recommends the delay of elective surgery among patients with active COVID-19 until they have recovered from the infection, and to schedule patients with substantial comorbidities and risk factors for surgery after healthier patients have been treated and experience with screening, prevention and treatment protocols has been identified.
From preoperative to postoperative care
The workgroup also made recommendations for the preoperative, intraoperative and postoperative care of patients. Some of the preoperative recommendations include screening all patients undergoing elective surgery for symptoms of COVID-19 during the pandemic and mandatory testing of patients in high-prevalence areas.
Regarding intraoperative measures, the workgroup recommends surgeons and the entire surgical team wear a mask and a face shield with neck cover wraps and extension that can be placed inside the gown during surgery on patients who have not been tested for COVID-19 in areas where COVID-19 is highly prevalent. Regular protective equipment may be worn among patients who have been tested for COVID-19 within 3 days before surgery and quarantined for 14 days prior to elective surgery, according to the document. The workgroup also recommended the operative staff:
- limit the number of people in the operating room;
- reduce door opening in the operating room;
- cautiously use electrocautery and judiciously use suction to remove smoke;
- keep the power setting to low as possible when high-power tools are being used, or consider using a Gigli saw, sharp osteotomes and manual reaming whenever possible; and
- keep equipment in the room to a minimum, including navigation consoles, X-ray machines and robots.
During postoperative care, the workgroup recommends patients have a minimized length of stay after surgery and patients should be discharged home with instructions on how to perform self-directed physical therapy. Whenever possible, postoperative rounds by the surgeon may be done through telemedicine, the workgroup noted. They also recommended that most follow-up may be done through telemedicine and to limit postoperative office visits to patients who are having issues or complications.
“We realize that the situation is evolving on a daily basis and that some of the recommendations in the present report may need to be altered as new evidence emerges,” the authors wrote. “In addition, we are aware that the infection-prevention measures described in the present report will highly depend on the prevalence of COVID-19 in the affected areas and the ability to implement the recommended diagnostic tests to properly rule out COVID-19 prior to surgery. We will continue to monitor the literature and update this document as needed.” – by Casey Tingle
Disclosures: Parvizi reports he is a paid consultant for 3M, Corentec, Ethicon, Heraeus NCI, Stryker, Tenor, TissueGene and Zimmer Biomet; has stock or stock options in Alphaeon, Ceribell, Corentec, Hip Innovation Technology, Intellijoint, Joint Purification Systems, MDValuate, MicroGenDx, Parvizi Surgical Innovations, Physician Recommended Nutriceuticals and PRN-Veterinary; receives IP royalties from Corentec; receives publishing royalties, financial or material support from DataTrace, Elsevier, Jaypee Publishers, SLACK Incorporated and Wolters Kluwer Health – Lippincott Williams & Wilkins; is a board or committee member for Eastern Orthopaedic Association and Muller Foundation; and is on the editorial or governing board for the Journal of Bone and Joint Surgery. Please see the study for all other authors’ relevant financial disclosures.
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