The global health crisis caused by the COVID-19 virus, has being marked by a rapid spread, numerous severe respiratory cases and an elevated mortality rate [1]. It has forced World Health Organization to declare global emergency and governments to apply confinement measures and stop the scheduled medical activities [2]. Recommendations have been developed for the management of patients with COVID-19 requiring endotracheal intubation and critical cares [3]. In addition of surgical emergencies and cesarean sections, certain surgical or diagnostic procedures cannot be postponed due to the risk of unacceptable morbidity. Therefore, Health Ministries have authorized the performance of these procedures in accordance with specific rules. Data on this type of perioperative management for COVID-19 negative patients are rare.
This observational study was carried out on all patients admitted for surgical and/or interventional emergencies, deemed impossible to postpone during the COVID-19 crisis. The research has been approved by our Institutional Review Board Informed written consent for the procedure was obtained from all patients. In agreement with the local TeamCOVID and the Surgical Committee, patient admission rules for non-COVID-19 related pathology were established, including:
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a distinct pathway for non-COVID-19 patients upon admission,
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clinical evaluation prior to hospitalization,
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systematic nasopharyngeal swab with SARS-cov2 PCR test and chest CT within the previous 48 h preceding the intervention,
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patient care in the operating unit with assumption of positive COVID-19, so with full personal protective equipment (PPE), using FFP2 or FFP3 facial masks, disposable head caps, long sleeve waterproof coats, protective goggles or full-face shield, gloves
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regional anesthesia whenever possible,
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if endotracheal intubation is required, the application of COVID-19 intubation rules: full PPE, patient protection field, nasal pre-oxygenation, intubation with a video-laryngoscope, rapid sequence anesthetic induction, by an experienced anesthesiologist, and a respiratory circuit in the manual position without insufflation, until the pilot balloon is inflated and high-efficiency particulate air filters are connected the anesthetic machine (Photo 1 ).
Photo 1.
(A and B): Systematic endotracheal intubation in our institution during this period COVID-19. Use of a MacGrath videolaryngoscope, Rapid Sequence Induction under a transparent sterile field, personal protective equipment (FFP2 mask, protective visor, gloves, gowns, lids).
Among forty consecutive patients, six (15%) were found to be positive at COVID-19 in the perioperative period. Patients expressing positive clinical symptoms, PCR and/or chest CT were older and all had arterial hypertension and more often diabetic and had coronary heart disease. Two patients died of COVID-19 and none in the COVID negative group. Four (10%) had a positive PCR test and/or an evocative chest CT upon admission. Two patients (5%), initially without symptoms and with negative PCR and a non-suggestive CT on admission, were tested positive in the post-operative period (Fig. 1 ). Of the other 34 remaining patients, 67.6% were surgical, 52.9% were under general anesthesia with endotracheal intubation. 32.4% of the patients were outpatients and their 2-week follow-up was unremarkable. No caregivers and anesthesiologists involved in patient care were diagnosed with COVID-19, in the 14 days following care.
Fig. 1.
Distribution pattern of patients in this study and their outcomes.
The results of this study illustrate a non-negligible number of patients (10%) admitted for emergency intervention may be infected with COVID-19, and, on the other hand, despite negative tests on admission, others (5%) may become positive postoperatively. This reflects the fragility of the nasopharyngeal PCR assays whose false negatives (30–40%), as well as the chronology of the sampling [4]. Indeed, negative PCR test and chest CT on admission of a patient could falsely insure the physician abdicating the airways and take a risk of contamination. Respecting the rules of individual protection and the circuits of COVID-19 and non-COVID-19 patients, no symptomatic cases of SARS-Cov2 infection have been reported among the caregivers and anesthesiologists, although few studies are available on their contamination in the operating theatre while 3.5 to 29% in frontline staff working in COVID-19 areas [5]. Mortality was also higher than expected for patients positive for SARS-Cov2 virus and is a strong argument for postponing, when possible the surgical/interventional procedure. The take-home message is that all surgical patients be treated as suspected of being COVID-19 positive and to respect guideline compliance in particular by anesthesiologists managing airways.
Authors contribution
Gilles Boccara: Study design, conduct of study, data analysis, and manuscript preparation.
David Cassagnol: Study design, relecturer, translation.
Laurent Bargues: Study design, conduct of study.
Thierry Guenoun: Study design, conduct of study.
Benjamin Aubier: Study design, conduct of study.
Ivan Goldstein: Study design, conduct of study.
Stéphane Romano: Conduct of study.
Dan Longrois: Study design, relecturer.
Financial disclosures
None.
Declaration of competing interest
None.
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