Covid-19 and Surgery Justin J Koenig DO FACOS - PowerPoint Presentation

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Covid-19 and Surgery

Justin J Koenig DO FACOS

Trauma/Acute care Surgeon

Beacon Medical Group

01APR2020

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Objective

Provide and understanding of where we are in terms of surgical care today

ACS Committee on Trauma Response

Define the term “Aerosol Generating Procedure”

Explain how surgical care may evolve in the next weeks to months

Discuss the latest recommendations of the ACS and their response on COVID-19

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Today

Trauma Surgery Services at Both Elkhart General and Memorial Hospital are operational with full capacity

Emergent procedures ARE being performed

Elective, Non-Emergent Surgery is no longer being performed, and is being rescheduled

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In the coming Days-Weeks

Trauma Services will continue to operate at full capacity

Emergent, non-elective procedures will continue to be performed based on the availability of supplies, staff, PPE and ventilators

OR capabilities have the possibility of being limited further based on our capacity

Cases are triaged daily and being performed when able

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MHSB Definition of an “Emergency surgery”

“Surgeries should be limited to life/limb threatening emergencies. If a patient could normally be scheduled in the future or discharged to come back for the surgery, we should postpone. If they would normally have the procedure emergently/unscheduled, it should be done. That leaves some gray areas that will come up, but we need to do the best we can to preserve resources and treat emergencies now.” -30MAR2020-

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Why?

Re-deployment of staff

Appropriate use of PPE

Utilization of resources

Avoidance of “AGPs”

Protection of Patients and staff

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Guidance from Committee on trauma

PPE fit testing for all Trauma Team members

When possible, restructure trauma teams and stagger cohorts

Redundancy of backup schedules

Droplet Precautions for all Trauma Patients

Minimize personnel at bedside for trauma activations when possible

Restrictive transfusion strategies for blood products

Distancing COVID-19 patients from non-

Covid

Patients despite trauma

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COVID-19 Guidelines for triage of Emergency General Surgery Patients

American College of Surgeons

Updated march 25, 2020

https://www.facs.org/covid-19/clinical-guidance/elective-case/emergency-surgery

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AGP: “Aerosol-Generating Procedure”

Any procedure that can lead to aerosolizing of body fluids, which increases the likelihood of droplet transmission

Examples

:

ET intubation

, tracheostomy,

GI endoscopy, evacuation

of

pneumoperitoneum

and aspiration of body fluids during

laparoscopy, electrocautery

Recommendations

Minimize OR staff Exposure whenever possible during these procedures

Use smoke evacuators for electrocautery

N95, face shields at a minimum, with consideration for PAPR use in OR for suspected COVID patients

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ACS COVID-19 Guidelines

Guiding principles

“There is no substitute for sound surgical judgment”

Provide timely surgical care for urgent/emergent surgical conditions, while optimizing patient care resources

and preserving the health of caregivers

Procedures should be performed if delaying the procedure will:

Prolong the hospitalization

Increase the likelihood of a later hospital admission

Cause harm to the patient

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ACS COVID-19 Guidelines

Guiding Principles

Multidisciplinary shared decisions regarding surgical scheduling should be made in the context of available resources

This concept is

variable, and rapidly evolving

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Alternative management strategies

Pneumoperitoneum

, Intestinal Ischemia, intestinal obstruction

Proceed with emergent surgery

Small bowel obstruction secondary to adhesions

Follow usual practice of non-operative management

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Alternative management strategies

Acute

hemorrhoidal

thrombosis/necrosis

Non-operative management when possible

OP management with local anesthesia

Surgical procedures only for refractory cases

Perianal/perirectal abscess

OP I and D with local anesthesia for perianal abscesses

OR drainage of perirectal abscesses/IR drainage if OR is unavailable

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Alternative management strategies

Soft tissue infections

I and D with local Anesthesia if superficial to the Muscle

OR debridement if abscess has intramuscular extension

Emergent Debridement of Necrotizing Soft

T

issue Infections

Acute pancreatitis with necrosis

“Step-Up” Approach

Avoid Endoscopy, laparoscopy or Operative drainage whenever possible

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Alternative management strategies

Uncomplicated appendicitis

Weigh IV/PO

Abx

vs short-Stay/OP Surgery

30-50% Failure rate, recurrence with

Abx

Complicated appendicitis

IR drainage of Abscess

IV

Abx

with transition to PO and discharge

Surgery if failed Non-operative management

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Alternative management strategies

Symptomatic

cholelithiasis

/Chronic

Cholecystitis

Manage pain

Delay surgery and perform electively

Lap

Chole

when non-operative management Fails

Choledocholithiasis

If no cholangitis, manage expectantly

ERCP with

sphincterotomy

and delayed elective cholecystectomy

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Alternative management strategies

Acute

cholecystitis

Laparoscopic Cholecystectomy

If OR unavailable, IV

Abx

Percutaneous

Cholecystostomy

Tube

Ascending cholangitis

Attempt

Abx

and Fluid resuscitation

ERCP with

sphincterotomy

Sepsis

Failed

Abx

Therapy

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Alternative management strategies

Diverticulitis

Uncomplicated: IV

Abx

with transition to PO

Abx

Complicated:

Hinchey 3 or 4: surgery

Hinchey 1 or 2: Percutaneous drainage and IV

Abx

Phlegmon

: IV

Abx

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Sages Recommendations regarding surgical response to Covid-19 crisis

Updated March 30, 2020

ALL elective surgical and endo cases should be postponed at the current time

Imminently life threatening, malignancy that could progress, active/urgent symptoms

2. For URGENT procedures: consider viral contamination with laparoscopy,

“There

is very little evidence regarding the relative risks of Minimally Invasive Surgery (MIS) versus the conventional open approach, specific to COVID-19. (1) We will therefore continue to monitor emerging evidence and support novel research to address these issues

.”

3. ENHANCED PPE for endoscopy or airway procedures (Droplet/Airborne)

4. Telework from home when possible, minimize patient encounters, cease educational sessions

NON-URGENT in person clinic/office visits should be cancelled or postponed

Manage wound care, triage active symptoms

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Sages Recommendations regarding surgical response to Covid-19 crisis

Follow all CDC guidelines and Notifications

we all may be called upon to assist with management in a crisis

Be safe, protect patients, staff, families, minimize travel

Be OVER-prepared, we are the example

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References

American College of Surgeons

https://

www.facs.org/covid-19

https://

www.facs.org/covid-19/clinical-guidance/maintaining-access

Society of American Gastrointestinal and Endoscopic Surgeons

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

/

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Recommendations

Understand that this is a fluid Situation,

Capabilities will change by the day

Supply issues may continue to be in flux

Be flexible

Be a steward of resources

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Domande?

“If you’re going through HELL…Keep Going”

-Winston Churchill