Speaker: Prof Dr Ashok Gupta, Reconstructive Plastic Surgeon, Bombay Hospital Institute of Medical Sciences, Mumbai

March 12, 2022

11am-12 noon

• The Covid pandemic has resulted in feelings of fear, anger and helplessness among surgeons. It has had an extensive effect on surgeons and patients requiring surgical care.
• It is essential to act thoughtfully and support the hospital surgical care system as well as to protect the benefits of the patients and at the same time conserving the hospital resources and protecting the hospital staff. 
• Surgical care requires an interaction between the patient and the surgeon, which cannot be replaced by the telehealth system, which can be implemented effectively in many other specialties of medicine.
• The pandemic has posed several challenges. The financial effects of the surgical shutdown have been far-reaching. Many private surgical practices were forced to shut down or relocate as they could not withstand the financial challenges. Some surgeons have retired early or have left the surgical specialty. These problems influence the surgical workforce during a time when there is likely to be a greater need for surgical care.
• To adapt to a new normal, prepare for a rapidly changing situation, postpone elective operations immediately, develop dedicated operating suites, duration of the surgery, need for ICU care after surgery, need for ventilator during or after surgery, blood loss during surgery, number of surgeons and nurses needed in the OR and whether surgery is being performed in the lower risk group or higher risk group. 
• The first fundamental for the surgeon is “is it worth the risk?”
• CovidSurg Collaborative, a global study published in October 2020 has shown that for every person who undergoes surgery during the pandemic, there is one in four chance that they will die and a 50/50 chance that they will suffer severe pulmonary complications. CovidSurg has expanded participation doubling the number of hospitals and tripling the number of countries. 733 hospitals across 73 countries and more than 24,000 patients were enrolled.
• Surgeons need guidance on how to deliver surgical services safely and effectively during Covid-19 pandemic. The aim was to identify the key domains that should be considered on developing pandemic preparedness for surgical services.
• Surgeons did not have any information about how Covid affects surgical patients.
• The current study tracked more than 1100 patients who underwent surgery. About 75% had emergency surgeries and 25% had elective surgeries.
• The Lancet shows that patients testing positive for the virus seven days before and up to 30 days after surgery are at high risk.
• In a study in the publication “Surgeon voices in Covid-19 era”, one in four patients infected with the virus before or after surgery died. One in every two patients contracted serious pulmonary complications such as pneumonia, ARDS or unexpected postoperative ventilation. The type of anesthesia used (general, regional, sedation or local) did not alter the outcome. This reminds us that Covid is not only a lung disease, it touches almost all other systems of the body. The biggest shock from this study is that the patient may survive the surgery, but still has a higher risk of developing serious complications or even death compared to before the pandemic.
• Impact of SARS-CoV-2 on postoperative pulmonary complications and mortality needs to be established to enable surgeons to make evidence-based decisions.
• The American College of Surgeons (ACS) has developed triage guidelines for Covid-19, which state that the hospitals and outpatient surgery centers should consider their patients’ needs and logistics capability to fulfil in real time.
• The need for a procedure should be established by a surgeon with expertise in the relevant surgical specialty to determine damages to be sustained by delay in undertaking the surgery.
• Feasibility of procedure be determined by administrative personnel accepting the hospital facility, safety and well-being.
• The risk to the patient should include an aggregate assessment of the real risk of proceeding and the real risk of delay.
• Covid-19 is a clear risk for all. Surgical procedures should be considered not based solely on Covid-associated risks but rather on an assimilation of all available medical and logistical information.
• Covid-19 free zones are a very vital recommended criteria to minimise risk of accidental exposure and must be established within the hospitals to protect patients, opting to undergo elective surgery during the pandemic.
• Hospitals should prepare detailed specific pandemic preparedness plans addressing the identified domains.
• Specific guidance should be updated continuously to reflect emerging evidence during the Covid pandemic.
• A backlog of procedures after the end of the pandemic is inevitable. Hospitals should plan to report effectively to ensure that patients for elective surgery have the best possible outcomes after the pandemic is over.
• The ACS’s Elective Surgery Acuity Scale (ESAS) balances the needs of the patient or impact of a surgical procedure with available resources.
• Planning for resuming surgeries should take into account the perspectives of multiple stakeholders, including surgery, anesthesia, nursing and facility administration.
• Elective procedures should be delayed until the patient is no longer infectious and has recovered fully.
• The impact of SARS-CoV-2 on postoperative recovery must be understood to inform clinical decision making during and after Covid-19.
• An international, multicenter, cohort study at 235 hospitals in 24 countries reported 30-day high mortality and pulmonary complication rates in patients with preoperative/perioperative infection.
• The American Society of Plastic Surgeons reported that most members stopped performing elective surgeries for an average of 28.1 weeks in 2020 due to Covid-19. For more than 2 years, Covid-19 has largely confined people to their homes and has significantly impacted nearly every aspect of lives.
• Now injectable procedures like botox, fillers continue to be the most sought-after treatments in 2020-21.
• Safety issues in the OR using N95 masks, face shields, eye protection and double layers of PPE are common practices but add to the hazard for performing long duration surgeries.
• Sometimes patients are so sick that the emergency surgery is performed in the ICU, which is not as sterile as the OR.
• Universal use of smoke evacuators to suction away the smoke plumes generated by electrocautery has been encouraged to minimize the risk of exposure to aerosolized tissue.
• Precautions should be taken for surgical cases of minimally invasive procedures that require the creation of pneumoperitoneum must be safely managed or avoided if possible.
• A patient is always informed about the risks before a surgery. 
• Preoperative patients could test negative for Covid even though they are infected (incubation period 2-14 days or the test could be false negative.
• Patients may not be infected, but could contract the virus while at the hospital or within the 30 days postoperatively.
• No system is fool proof. 
• Transportation to and from the rooms and the elevator, postoperative room can transmit infection.
• Patients should quarantine for 30 days and not have any contact with anyone even for a minor procedure.
• We have to understand the limitations cause by post-Covid recovery.
• The risk of pulmonary complications almost double if the surgery is for more than four hours.
• Interspecialty and multispecialty assessment of patients is required.
• Consent should be well documented before undertaking any procedure, particularly during the Covid era.
• The surgeon must carefully assess the risk-benefit ratio of a surgery.

Participants

Dr KK Kalra

Dr Ashok Gupta

Prof Arun Jamkar

Dr Anita Chakravarti

Ms Ira Gupta

Dr S Sharma

Moderator

Mr Saurabh Aggarwal