Cardiac Surgery and Covid-19 Insight into Peri-Operative Management

Statistical Analysis

All the data was entered in Microsoft Excel and analyzed in STATA 12.0. The statistical analysis was descriptive. Cases were stratified into adult and pediatric cases and were further sub categorized. Percentages of different cases were derived [4].

Adults

• Type A aortic dissection.
• Coronary artery disease (CAD) spectrum-Severe unstable angina/severe left main disease angioplasty complications, acute coronary syndrome with mechanical complications.
• Stuck prosthetic valves, thrombolysis unresponsive, class IV.

Pediatrics

• Obstructed total anomalous pulmonary venous return, refractory spells, cardiac tamponade patients.
• Some other congenital heart problems, which if delayed, may deteriorate beyond a point to cause lifelong morbidity (Transposition of great arteries (TGA) with regressing ventricle).

Pre-operative consideration

• Emergency department- Every patient in requirement of an emergency surgery was tested for SARS COV-2 via RT-PCR test (30-50% false negative) in the emergency department and kept in emergency ward until the results of test came back [9, 10]. Along with that, they were screened for temperature, and history of contacts with COVID-19 patients and travel from hotspot areas, if any, was documented.
• If the patient turned out positive then he/she was treated for COVID-19 in the COVID dedicated hospital sections.
• If the patient tested negative, patient was shifted to COVID dedicated step down ward if the patient was stable and if the patient required more critical care, then to the ICU setting.
• If patient required critical care and the test results were still awaited, then the patient was shifted to dedicated CTVS COVID-19 ICU, equipped with ventilatory support, round the clock doctors and nursing staff with level-3 personal protective gear. If the patient tested negative, patient was shifted to CTVS NON-COVID ICU. If the patient tested positive, then patient was shifted to dedicated COVID section of our center.
• Two cubicles in step down ward had been allocated to admit all new patients. A single nursing staff with proper PPE was allocated in each cubicle. Senior resident on duty had to wear appropriate PPE (N95 mask, face shield and gloves) before interacting with the isolated patients. COVID-19 swabs were taken on Day 0 and Day 5 by the emergency ID team.
• Blood sampling was done with adequate precautions. The blood bank was informed beforehand about sending of these samples.
• If positive, surgery was postponed as per hospital/ department policy for 2-4 weeks (not be done on these patients) unless it was an emergency.
• If patient was declared COVID-negative/cleared for surgery by ID team, they were taken up for surgery.
• Consent was taken regarding any surgical procedure, unexpected delays, minimal visitor entry, teleconferencing as a mode of communication about patient status while in ICU and wards during treatment and also for follow ups post discharge.
• Thorough psychological counseling was done (Figure 3).

Click to enlarge

Figure3: Patient Triage Algorithm.

Intra-Operative Considerations

• Precautions outlined during peri-operative period include anesthesia induction to be done with minimum staff wearing full PPE gear.
• Operating team was limited in number to decrease resource utilization and exposure risk.
• Proper personal protective gear as per institution protocol was used.
• It was kept in mind that sternotomy and airway manipulation will generate aerosol.
• There were designated PPE donning and doffing areas for all personnel.
• The staff disposing off the discarded PPE was made fully conversant with the correct procedure and trained to perform the task without error.
• Due to COVID-19, limited number of operation rooms were functional, being reduced from normally 8 rooms to 2 rooms.
• After a week of utilization of the two operating rooms, the operating rooms were disinfected and other available operating rooms were used in a similar fashion.
• Post-surgery patients were shifted to non-Covid CTVS ICU for post-operative management.
• Currently COVID-19 positive patients are not being operated in our institution and once the patient is declared negative, the patient is taken up for surgery after patient is stabilized and optimized for surgery.

ICU Modifications in COVID-19 Times

• Avoid transferring confirmed cases to the non-Covid ICU.
• Transfer confirmed cases to dedicated COVID ICU with pressure and oxygen supply, emergency intubation cart.
• Disinfect high touch surfaces like anesthesia machine and anesthesia work area with an Environmental Protection Agency (EPA)-approved hospital disinfectant.
• Allow time for aerosols in isolation to be washed out [11].
• Surgical mask provided to awake and stable patients.
• Distance of 1 meter between patient beds.
• Daily assessment of temperature and respiratory symptoms.
• New onset fever or cough to be isolated and investigated.
• Avoid high flow oxygen, NIV, or nebulized medications.
• Postoperative rounds, medications and wound management to be performed under full PPE.
• No entry of attendants of the patient in the ICU in order to avoid any transfer of COVID-19 infection to susceptible patient and health care workers.
• Amidst pandemic there is a surge of sicker variety of patients, who require meticulous care and have a much difficult post-operative course and require a longer ICU stay.

Post-Operative Considerations

Immediate Post-Operative Period

• Patient receiving checklist cleared.
• Patient allowed entering the ICU.
• One person at head end and two other persons by the side of bed while shifting.
• One person for attaching monitors and any drugs, if required.
• Patient connected to ventilator.
• Optimization of inotropes and medications as per patient requirement.
• While attending a patient or performing a procedure level 2 PPE mandatory.
• Emphasis on fast tracking of the post-operative period via early extubation, early mobilization and early shifting of the patient to dedicated non-Covid ward wherever possible.
• Low threshold kept for COVID-19 testing in patients showing features of COVID-19 and repeated testing done in view of moderate sensitivity of test (50-70%) [12].
• All healthcare personnel vigilant about any symptoms of COVID infection and if symptomatic, the clinical algorithm followed fully by them (reporting to emergency COVID screening area, getting appropriate advice and triage as per symptom severity and report positivity).
• If a patient’s test result for COVID-19 comes as positive, patient immediately transferred to COVID dedicated CTVS ICU.
• Contact tracing done by the nodal officer; contacts stratified into high risk or low risk contacts based upon the type, time of exposure and the level of PPE kit donned by the exposed personnel.
• Once patient is stabilized then patient is shifted to non- Covid CTVS ward from where patient is discharged.

Modified Approach for Post-Operative Outpatient Follow Up

• Technology now allows people to connect anytime, anywhere, to anyone in the world, from almost any device.
• This has dramatically changed the face of medical practice and has come in as one of the forerunners in providing necessary facilities to patients, reducing resource consumption.
• It has provided a safe and easy method for the most important component in medical practice that is “communication” while eliminating the risk of transfer of infection.
• Patients are attached to telemedicine OPD as regular OPD services are suspended.
• Patients are provided with tele-OPD numbers and can call during fixed days and time periods.

• Patients interaction also done with the use of digital communication using video conferencing, image exchanges on messengers (inspection of post-operative wound etc.), soft copy exchange of reports and advised to visit emergency department if required.
• Late post-operative period. Patients discharged are advised the following: a) Fluid restriction if required. b) Follow diet restriction. c) Report immediately if: Fever more than 2 days
• Bleeding/ discharge from wound.
• Decreased urine output.
• Worsening of symptoms.
• Shortness of breath.
• Giddiness, intense headache. a) In case of emergency, contact the nearest hospital or emergency department of our institute. b) Daily bath and maintenance of personal hygiene. c) For patients with mechanical heart valves and on anticoagulation, always follow strictly:
• The correct dose of warfarin (blood thinner) to be taken as prescribed to prevent clot formation and dysfunction of valve.
• PT- INR range to be maintained as per the valve placed.
• Dose to be remembered by patient as well as patient bystander every time.
• Warfarin to be taken astutely at a fixed time every day.
• PT-INR blood testing to be fortnightly or as advised. Patients are explained in detail about symptoms of COVID -19 and taught as to how to approach the hospital in case of suspected COVID infection.