Perioperative preparation in thoracic day surgery: Battle against COVID‐19

Abstract

Since December 2019, there have been a series of unexplained cases of pneumonia reported in Wuhan, China. The Chinese government and researchers took rapid measures to control the epidemic and carried out etiological research.1 The novel severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) is behind the ongoing outbreak of coronavirus disease 2019 (COVID‐19).2, 3, 4, 5, 6, 7, 8 Enhanced recovery after surgery (ERAS), also known as fast track surgery (FTS), was originally proposed by Danish scholar Kehlet in 1997. Day surgery or outpatient surgery was originally reported by Nicoll in 1909. The successful implementation of the ERAS concept in thoracic surgery has made it possible for the treatment of some thoracic diseases to be completed in the day surgery department. At the same time, day surgery for thoracic diseases is a further concentrated embodiment of the implementation of the ERAS concept. To help surgeons around the world to better deal with COVID‐19, here, we summarize the management and clinical pathway for thoracic day surgery to prevent the COVID‐19 epidemic. Preoperative preparation for thoracic day surgery The day surgery center of West China Hospital is a hospital‐based surgical setting that has nine operating rooms, a post‐anesthesia care unit (PACU), 33 beds, and two nurse stations. It has strict criteria for both patients and surgeons. Patients have to visit appropriate specialist clinics to evaluate whether they qualify for thoracic day surgery. Day surgery is performed for thoracic diseases such as primary pneumothorax, benign tumors of the lung (hypomorphic tumor, etc), pure ground‐glass (GG) lung cancer nodules, benign mediastinal tumors (mediastinal cysts, nerve tumors, mature teratoma, etc), and palmar hyperhidrosis. In this scenario, patients must complete a thoracic specialist clinic evaluation and a COVID‐19 epidemic survey. This also applies to patients without a travel history to the epidemic area since 1 January 2020, and those without contact with a COVID‐19 positive patient, a temperature ≥37.3°C, or a cough within one month. The patient's companion should also be evaluated, and both should sign the consent form of COVID‐19 notification. Only one companion for each patient can stay in the hospital in order to reduce cross‐infection. All patients must have a chest computed tomography (CT) scan to exclude COVID‐19 infection or other lung conditions that may threaten anesthesia. After meeting the basic conditions detailed above, the patient should undergo COVID‐19 screening, blood novel coronavirus antibody detection/nucleic acid detection, pharyngeal swab, stool test, and high‐resolution thoracic CT if necessary. Patients should also meet the standard requirements for thoracic day surgery, including patient age (≤55 years), diameter of the pulmonary nodule on thoracic CT scan (≤3 cm) for early stage lung cancer or benign pulmonary nodule patient, and an ASA status of 1 or 2. Basic preoperational tests should be performed, including routine blood tests, coagulation function, electrolytes, hepatic function, renal function, blood type, 12‐lead electrocardiogram, pulmonary function, contrast CTs (cerebral and abdominal) in the outpatient department within 21 days, and spontaneous evaluation of anesthesia. Contrast cerebral and abdominal CTs are optional for benign diseases such as pneumothorax and primary palmar hyperhidrosis. Each patient must undergo strict outpatient department evaluation before entering the inpatient department. The preadmission management team of thoracic day surgery will follow through when the patient is advised by a specialist to make a day surgery appointment. For the first time, patients must bring all their test results and anesthesia consultation to the Day Surgery Appointment Center for the surgeon to review and confirm whether all the tests have been completed prior to surgery. Subsequently, the preadmission management team will inform the patient via telephone when surgery is scheduled. A nurse will usually contact the patient one business day before surgery and give the patient a short introduction. Following this, the nurse will ask about the patient's medical history and current medications, and give general guidelines for surgery preparation: two weeks prior to the surgery, the patient should stop taking aspirin, clopidogrel, or any products that contain aspirin or anticoagulation substances, unless specified by the surgeon, as these can cause prolonged bleeding. The patient should be reminded to bring all relevant medical records, including laboratory results, EKG reports, and imaging studies (CTs, X‐rays, or magnetic resonance imaging [MRI]), on the day of the surgery. Based on ERAS protocols, patients may consume eight ounces of a carbohydrate beverage up to two hours before surgery. In addition, for patients with fever, cough, or any other condition that makes surgery unsafe, the surgery should be canceled; moreover, patients would need to be re‐evaluated in the outpatient department. The patient and companion should wear a mask before surgery. (Fig 1). Figure 1 The flow chart of perioperative preparation in thoracic day surgery. Intraoperative preparation for thoracic day surgery To prevent the SARS‐CoV‐2 epidemic, some basic principles and requirements must be followed. First, epidemic‐related inspections should be performed again in the ward in the morning of the operation day, and the medical staff should analyze the epidemic situation. The operating room should be examined; this process should involve all staff, including anesthesiologists and nursing staff. Second, strict epidemic prevention measures should be taken in working and patient aisles. Third, patients should be examined pre‐, intra‐, and postoperatively. Finally, materials should be fully prepared before the operation to reduce the number of people going back and forth. Furthermore, visits should be prohibited to reduce the risk of infection for patients and doctors. (Fig 1). Positive or suspected patients should complete preoperative preparation in the isolation ward. Patients who undergo surgery should be placed in a separate negative pressure operating room. If there is no negative pressure operating room, the operating room of an independent purification unit should be selected to avoid cross‐infection with other patients. Reducing the number of surgical participants as much as possible is vital, and the surgeon, hand‐washing nurses, circuit nurses, and anesthesiologists should implement a three‐level protection mechanism. The anesthesiologist should use a face mask to prevent infection during tracheal intubation. Where possible, intubation should be attempted after taking anesthesia measures to prevent coughing and sputum spraying, which can cause contamination. Disposable filters should be placed between tracheal intubation and breathing circuits to reduce pollution and keep the suction process as closed as possible when suctioning the patient. After entering the operating room, the surgeons should not be allowed to come randomly in and out. All fields should be provided by nurses outside the operating room. During the transfer of the patient, he or she should wear masks, and medical staff should wear medical protective masks, protective clothing, protective screens, gloves, shoe covers, etc. During the operation, the protection of medical staff should strictly follow the three‐level protection standard. Surgeons and hand‐washing nurses on duty should wear disposable protective clothing, disposable surgical gowns, protective slippers and shoe covers, and other medical protective equipment outside the hand‐washing suit, including masks, goggles, face shields, and two gloves. During the operation, patients' blood, secretions, and excreta need to be properly handled. More attention should be paid to tracheal intubation, sputum suction, and aerosols generated during the use of electrosurgical equipment (electric knife, ultrasonic knife). Aerosols can be suspended in the air for a long time, and they can enter the human body through the respiratory tract. Therefore, anesthesiologists should also take good care of themselves when suctioning sputum; they should wear goggles or face shields. Doctors should adjust the power to the minimum acceptable power as much as possible when they use an electric burning tool, and the first assistant should suck the smoke in time in order to minimize aerosol proliferation. The indwelling thoracic drainage tube after surgery is also infectious. Attention should be paid to avoiding environmental pollution during the patient transfer process. After, the surgical specimens should be sealed in double bags and submitted for inspection. The operating room should be thoroughly disinfected after surgery, and can be used again after passing the sampling test of the infection management department. Postoperative preparation for thoracic day surgery Regarding COVID‐19 infection during hospital stay, the symptoms of both the patient and companion should be monitored. More attention should be paid to the inflammation parameters, and the relative test of all patients should be repeated promptly. When indicators of infection suggest the possibility of viral infection, such as leukocyte decline or even an inflammatory stimulation leading to an increase in leukocyte count, and lymphocyte decline, or patients with dry cough and other respiratory symptoms, the patient should undergo chest CT immediately to eliminate COVID‐19. A teleconference consultation should be organized to reduce contact if there is a COVID‐19 diagnosis. (Fig 1). Video‐assisted thoracoscopic surgery (VATS) is the most common procedure for the Thoracic Surgery Department, performed at the Day Surgery Center. Generally, postoperative patients will transfer to the day surgery center ward after PACU for stage II recovery. The chest tube can be removed when chest X‐rays show no signs of chest pneumatosis, pleural effusion, or lung collapse. Surgeons should assist patients in performing breathing exercises during the hospital stay. A numerical rating scale (NRS) was used for pain assessment and management. In daily practice, multimodal analgesia is prescribed for one week regarding the goal of an NRS score ≤ 3. Usually on days 2, 3, and 30 after discharge, the follow‐up team will conduct a telephone follow‐up, which focuses on the breathing, temperature, pain, and rhythm of the heart. During the COVID‐19 pandemic, patients may receive two more phone calls on postoperative days 7 and 14, in order to monitor complications and eliminate COVID‐19 infection. In conclusion, the potential therapeutic strategies mentioned above are based on the updated research data for COVID‐19.9, 10 Among these options, we suppose that precaution management that directly targets COVID‐19 will be most effective. To our knowledge, our data provide the first direct program and clinical pathway for thoracic day surgery to prevent the spread of COVID‐19. Thus, extensive preclinical and clinical studies are needed to determine the safe and effective treatment of COVID‐19. Disclosure The authors confirm that there are no conflicts of interest.