SAGES Recommendations Regarding Surgical Response to COVID-19 Crisis

Dear SAGES Community-

Note: these recommendations are subject to change.

SAGES is committed to the protection and care of patients, their surgeons and staff, and all who are served by the medical community at large. Through this prism, the following recommendations are made in light of the COVID-19 pandemic.

1. All elective surgical and endoscopic cases should be postponed at the current time. There are different levels of urgency related to patient needs, and judgment is required to discern between these. However, with the numbers of COVID-19 patients requiring care expected to escalate over the next few weeks, the surgical care of patients should be limited to those whose needs are imminently life threatening, with malignancy that could progress or with active symptoms that could require urgent care. All others should be delayed until after the peak of the pandemic is seen. This minimizes risk to both patient and health care team, as well as minimizes utilization of necessary resources, such as beds, ventilators, personal protective equipment (PPE), and unexposed health care providers and patients.

2. For procedures deemed urgent and necessary, it is strongly recommended that consideration be given to the possibility of viral contamination during laparoscopy. Such risk should be individually weighted against the benefit of laparoscopy for a patient’s health and recovery. While it is unknown whether coronavirus shares these properties, it has been established that other viruses can be released during laparoscopy with carbon dioxide. Erring on the side of safety would warrant treating the coronavirus as exhibiting a similar property. For laparoscopic procedures, use of devices to filter released CO2 for aerosolized particles should be strongly considered.(1,2)

3. With early information from Italy, China and previous SARS experience, there may be risk of viral exposure to procedurialists from endoscopy and airway procedures. When these procedures are necessary, enhanced PPE should be considered, following CDC guidelines for droplet or airborne precautions. (3,4)

4. All non-essential hospital or office staff should be allowed to stay home and telework. All in person educational sessions should be canceled. The minimum number of providers necessary should enter patient rooms during rounds and other encounters, and adherence to hand washing, antiseptic foaming and appropriate use of PPE should be strictly enforced. Where necessary, in person surgical consultation should be performed by decision makers only.

5. All non-urgent in person clinic/office visits should be canceled or postponed, unless needed to triage active symptoms or manage wound care. All patient visits should be handled remotely when possible, and in person only when absolutely necessary. Access to clinics should be maintained where possible, however, to avoid patients seeking care in the ED. Only a minimum of required support personnel should be present for these visits, and PPE should again be appropriately utilized. Consideration should be given to redeploying OR resources for intensive care needs.

6. Follow and stay up to date with all CDC guidelines and notifications. Our patients will be asking us the difficult questions. Stay as informed as you can: https://www.cdc.gov/coronavirus/2019-ncov/whats-new-all.html and https://www.cdc.gov/coronavirus/2019-nCoV/index.html

7. It is likely that a prolonged epidemic will result in demand outweighing the availability of critical care providers. Physicians from other specialties, including us, may be called upon to help manage these patient in a full scale crisis.

8. Register your center for CovidSurg, a global collaborative research effort seeking to report on the comprehensive experience and outcomes of COVID-19 surgical patients and providers. With more centers included, better knowledge can be gained to improve the safety, quality, and outcomes during this pandemic. The study protocol, registration, and details are available online at: globalsurg.org/covidsurg/.

9. Be safe. Protect yourself, your patients, your staff, and your families. Don’t go to unnecessary gatherings, don’t go to public places such as restaurants and stores, and minimize trips for food and supplies. Help neighbors, friends, and strangers. The consequences of over preparation do not begin to approach the consequences of under preparation. We’re all in this together. 

REFERENCES:

1. Surgical smoke and infection control.

Alp E, Bijl D, Bleichrodt RP, Hansson B, Voss A. J Hosp Infect. 2006 Jan;62(1):1-5. Epub 2005 Jul 5.

2. Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery. Kwak HD, Kim SH, Seo YS, Song KJ. Occup Environ Med. 2016 Dec;73(12):857-863. doi: 10.1136/oemed2016-103724. Epub 2016 Aug 2.

3. Coronavirus (COVID-19) outbreak: what the department of endoscopy should know.

Repici A, Maselli R, Colombo M, Gabbiadini R, Spadaccini M, Anderloni A, Carrara S, Fugazza A, Di Leo M, Galtieri PA, Pellegatta G, Ferrara EC, Azzolini E, Lagioia M. Gastrointest Endosc. 2020 Mar 13. pii: S0016- 5107(20)30245-5. doi: 10.1016/j.gie.2020.03.019. [Epub ahead of print]

4. Perioperative Considerations for the 2019 Novel Coronavirus (COVID-19).

Liana Zucco, Nadav Levy, Desire Ketchandji, Mike Aziz, Satya Krishna Ramachandran, Anesthesia Patient Safety Foundation, https://www.apsf.org/news-updates/perioperative-considerations-for-the-2019-novel-coronavirus-covid-19/, 2020 Feb 12

Other helpful links:

GI society recommendations:
https://www.asge.org/home/joint-gi-society-message-covid-19

Primers on ventilator management:
http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf

Critical care and COVID-19:
https://jamanetwork.com/journals/jama/fullarticle/2762996

Source : https://www.sages.org/category/covid-19/