|
 
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| REVIEW ARTICLE |
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| Year : 2020 | Volume
: 4
| Issue : 5 | Page : 10-13 |
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How the COVID-19 Pandemic Affected the Care of the Surgical Patients in the Intensive Care Unit
Mohammed Bawazeer1, Thamer Nouh2, Ahmed Alburakan2, Wail Tashkandi3
1 Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
2 Department of Surgery, King Khaled University Hospital, King Saud University, Riyadh, Saudi Arabia
3 Department of Surgery, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| Date of Submission | 07-Sep-2020 |
| Date of Decision | 14-Sep-2020 |
| Date of Acceptance | 28-Sep-2020 |
| Date of Web Publication | 7-Dec-2020 |
Correspondence Address:
Mohammed Bawazeer
Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Centre, PO Box 3354, Riyadh 11211
Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/sccj.sccj_48_20
The World Health Organization has announced COVID-19 as a pandemic in late 2019. It spread around the world, and the first case in Saudi Arabia was discovered in February of 2020. All types of patients have been affected including the surgical patients. In this review, we describe how the care of the surgical patients affected by the pandemic. The types of the surgical patients during the pandemic are described. These patients could be non-COVID patients or COVID patients requiring surgery. We describe as well how we take care of these patients if they require a surgical intervention. This review is part of the collaborative initiatives of the Saudi critical care trials group.
Keywords: COVID-19, critical care, elective surgery, emergency surgery, pandemic, surgery
How to cite this article:
Bawazeer M, Nouh T, Alburakan A, Tashkandi W. How the COVID-19 Pandemic Affected the Care of the Surgical Patients in the Intensive Care Unit. Saudi Crit Care J 2020;4, Suppl S1:10-3 |
How to cite this URL:
Bawazeer M, Nouh T, Alburakan A, Tashkandi W. How the COVID-19 Pandemic Affected the Care of the Surgical Patients in the Intensive Care Unit. Saudi Crit Care J [serial online] 2020 [cited 2023 Mar 29];4, Suppl S1:10-3. Available from: https://www.sccj-sa.org/text.asp?2020/4/5/10/302584 |
| Introduction | |  |
Surgical patients have been negatively affected during the coronavirus infection disease (COVID)-19 pandemic. Cancellation of elective cases and utilization of intensive care unit (ICU) beds to accommodate the surge negatively impacted surgical patients. On the other hand, the continued care of emergency and urgent cases with concerns of transmitting the infection to these patients are also other factors.[1] In this mini-review, we describe how the surgical patients are being affected and how we take care of surgical patients during the pandemic. The surgical critical chapter of the Saudi Critical Care Society in collaboration with the Saudi Critical Care Trials Group presents this review.[2],[3]
| Bed Capacity and Staffing | | |
In preparation for COVID-19 pandemic, many organizations around the world instituted mandates and guidelines that served to increase bed capacity available to care for a possible surge in COVID-19-related admissions.[4],[5] In Saudi Arabia, the Ministry of Health (MOH) instituted such mandates in order increase effective bed capacity available to care for COVID-19 patients. In effect, a substantial number of surgical beds across Saudi hospitals were reallocated to care for COVID-19 admissions. In one Saudi academic center, surgical ward bed capacity was reduced from 212 beds to 72 beds, a 66% reduction. The same hospital had a 23-bed ICU that cared for surgical and medical patients and that was reduced to 15 beds while allocating resources to establish fully-fledged ICUs dedicated to COVID-19 admissions with a 72-bed capacity. In another Saudi center, the surgical ICU beds have been amalgamated with the transplant ICU in one physical location given the lower number of surgery being done during the pandemic and to allocate more beds to the COVID-positive patients.
Bed reallocations to care for COVID-19 patients meant a tremendous workload increase on the medical and intensive care staff. This was offset by reallocating staff from other specialties, especially anesthesia and surgical specialties to care for COVID admissions. One time while covering COVID ICU during the height of the crisis, the ICU team consisted of general surgery and orthopedics residents, a cardiac surgery registrar, and critical care surgeon. On top of that, surgical and anesthesia staff exposure, and sometimes infection, with COVID-19 was not an uncommon event. For those reasons, surgical and anesthesia staff available to care for non-COVID-19 surgical patients were greatly reduced.
Reductions in surgical bed capacity and staffing meant a reduction in operative case capacity of hospitals were inevitable.[5],[6] But that is not the whole story, as concerns over personal protective equipment (PPE) shortages and increased risk of COVID-19 infection in surgical patients were also worrisome. Furthermore, reports indicate a possible increase risk of adverse outcomes after elective surgery with perioperative COVID-19 infection.[7] Therefore, most governments and professional bodies including Saudi MOH, recommended cancellation of elective surgery, with some exceptions that will be discussed more in the next section. This action was important to free up bed capacity and ensure supplies of PPE, as well as to protect patients and health-care workers.
Overall, GlobalSurg–CovidSurg data projected the cancellation of more than 28.4 million operations in sixty countries over the 12-week peak pandemic period and the delay or cancellation of 2.3 million cancer cases.[5] This is a staggering number of operations, and once the pandemic is over, will require tremendous effort to overcome the negative impact it had on surgical patients.[8]
| Types of Surgical Patients during the Pandemic | | |
Non-COVID patients requiring surgery
Other than bed reallocation, the MOH has suggested case reallocation as well. The Saudi Patient Safety Centre requested the Saudi General Surgery Society (SGSS) to formulate a plan to be used as guidelines to be distributed in different health-care institutions.
Due to the diversity of our health-care systems, SGSS tried to prioritize the operative interventions based on the acuity of the cases and to reserve the expected shortage of resources during the pandemic peak. Attached is an example of the classification that is being recommended, and always as in any guidelines, especially in the surgical practice, the final decision of priority of intervention falls under the discretion of the attending surgeon [Table 1].[9] | Table 1: Saudi general surgery society categorization of patients according to their urgency, publication of the Saudi Patients Safety Centre
Click here to view |
Of course, life-threatening cases and emergency procedures have to be done immediately. Other cases can be done within 24 h such as appendectomies.
Some cases can be done within 1 week such as laparoscopic cholecystectomies for acute cholecystitis. Elective cases can be postponed within 1–3 months such as curative oncology interventions, nonobstructing hernias, laparoscopic cholecystectomies for chronic cholecystitis, and benign anal conditions and procedures done under local anesthesia.
The rest of the cases that can be postponed until the end of the pandemic or more resources are secured such as bariatric and cosmetic surgery. Those guidelines are dynamic, depend on the existing available resources of ICU and ward beds in addition to workforce.
PPerforming surgical operations, whether emergency or elective procedures, are following the recommendations of the MOH infection control guidelines in terms of swabbing patients or airborne precautions to maintain safety of patients and staff.[10]
Asymptomatic/unknown admitted with a surgical issue requiring surgery
At the beginning of the pandemic, there was some uncertainty about what to do with the surgical patients. COVIDSurg conducted a study on patients who were asymptomatic but tested positive 7 days before and 30 days after surgery. They included 1128 patients. The 30-day mortality of the cohort was 23.8%. Pulmonary complications occurred in 51.2%, with a mortality of 38%. Most of the patients who died in this cohort are from the patients who developed pulmonary complications. Based on these data, they recommended postponing elective surgery and promoting nonoperative management of some cases.[7]
While most institutions cancelled elective surgery, however, emergency cases need to be dealt with. Many hospitals mandate COVID-19 swab testing before having an emergency surgery. If time allows and/or the patient is considered to be high risk, computed tomography chest is performed before surgery.[11],[12]
Trauma and unstable patients may be faced during the pandemic, all these patients should be considered high risk, and the health-care workers (HCWs) should wear appropriate PPE.[13]
COVID-19 patients
There are many COVID-19 patients are that are admitted to the ICU because of pneumonia or they are tested positive and asymptomatic. These patients may require surgery, which could be COVID-related or non-COVID-related surgical issues.
Surgery due to non-COVID-related issues
There are certain high-risk procedures that may increase the risk of transmission to HCW. Procedures such as bronchoscopy, endotracheal intubation, laparoscopy, open lung surgery, all endoscopic procedures, and tracheal surgery including tracheostomy are considered high risk.[12]
Therefore, certain precautions need to be taken into account. All personnel must wear appropriate PPE. Procedures should be performed in negative-pressure operating rooms (ORs). It has been recommended to have a specific transfer pathway between OR and the patient location. During induction, only personnel involved in the care at that moment should be present inside the room. Limit the number of door opening as much as possible. Extubated patients should be recovered in the OR for up to 1 h. Intubated patients should be transported to ICU with a dedicated COVID-19 ventilator. Temporary occlusion of the endotracheal tube is usually performed when switching between anesthesia and the transport ventilator.[12]
Surgery due to COVID-related issues
There are limited reports whether COVID-19 affects the gastrointestinal system or not. A recently published case series of four patients needed laparotomy due to gastrointestinal perforations. They were managed in the usual manner with either repair or resection and primary anastomosis. They did not mention in the final pathology report whether it was COVID-19 positive or negative. The pathophysiologic mechanism is perhaps related microthrombosis leading to intestinal ischemia.[14]
One of the coauthors managed a patient with colonic perforation that was managed with resection. The final pathology of the specimen is COVID positive (personal communication, unpublished report).[15] There are still some more data to confirm these findings.
| Conclusion | | |
The care of the surgical patients has been negatively affected by the pandemic. A recovery plan should be mandated to overcome the cancellations of surgery. A group of patients, whether COVID positive or negative, will present to us at some point during the pandemic. Certain precautions should be undertaken to promote the safety of patients and HCW.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | COVIDSurg Collaborative. Global guidance for surgical care during the COVID-19 pandemic. Br J Surg. 2020;15:10.1002/bjs.11646. doi:10/1002/bjs.11646. Epub ahead of print. PMID:32293715; PMICD: PMC7262310.  |
| 2. | Deeb AM, Al Qasim E, Afesh L, Abdukahil SA, Sadat M, Arabi YM. Building capacity in critical care research coordination in Saudi Arabia: The role of the Saudi critical care trials group. Saudi Crit Care J 2018;2:35-41. [Full text] |
| 3. | Arabi YM, Mandourah Y, Al-Hameed FM, Maghrabi K, ALshahrani MS, Sadat M. Moving the critical care research agenda forward in Saudi Arabia. Saudi Crit Care J 2019;3:1-2. [Full text] |
| 4. | Aletreby WT, Alharthy AM, Faqihi F, Mady AF, Ramadan OE, Huwait BM, et al. Dynamics of SARS-CoV-2 outbreak in the kingdom of Saudi Arabia: A predictive model. Saudi Crit Care J 2020;4:79-83. [Full text] |
| 5. | COVIDSurg Collaborative: Elective surgery cancellations due to the COVID-19 pandemic: Global predictive modelling to inform surgical recovery plans. Br J Surg. 2020 May 12:10.1002/bjs.11746. doi:10.1002/bjs.11746. Epub ahead of print. PMID:32395848; PMICD: PMC7272903. |
| 6. | Lancaster EM, Sosa JA, Sammann A, Pierce L, Shen W, Conte MC, et al. Rapid response of an academic surgical Department to the COVID-19 pandemic: Implications for patients, surgeons, and the community. J Am Coll Surg 2020;230:1064-73. |
| 7. | COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: An international cohort study. Lancet 2020;396:27-38. |
| 8. | Urbach DR, Martin D. Confronting the COVID-19 surgery crisis: Time for transformational change. CMAJ 2020;192:E585-6. |
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| 11. | Alhazzani W, Al-Suwaidan FA, Al Aseri ZA, Al Mutair A, Alghamdi G, Rabaan AA, et al. The Saudi critical care society clinical practice guidelines on the management of COVID-19 patients in the intensive care unit. Saudi Crit Care J 2020;4:27-44. [Full text] |
| 12. | Coccolini F, Perrone G, Chiarugi M, Di Marzo F, Ansaloni L, Scandroglio I, et al. Surgery in COVID-19 patients: Operational directives. World J Emerg Surg 2020;15:25. |
| 13. | Cheeyandira A. The effects of COVID-19 pandemic on the provision of urgent surgery: A perspective from the USA. J Surg Case Rep 2020;2020:rjaa109. |
| 14. | Gao Y, Xi H, Chen L. Emergency surgery in suspected COVID-19 patients with acute abdomen: Case series and perspectives. Ann Surg 2020;272:e38-9. |
| 15. | Personal communication with Dr. Thamer Nouh. Unpublished Report. |
[Table 1]
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