COVID-19 for neurosurgeons

COVID-19 for neurosurgeons

In every country, all surgical plans have been modified. In Wuhan, the staff was enrolled in COVID-units. In New York, the Mount Sinai Hospital Health System was in lockdown mode. In South Korea, sterilizing chambers have been placed. In Italy, some Departments were reorganized in a Hub and Spoke fashion. In the Latin American region, they adopted special measures for every case. In the UK a conference center has been used to accommodate intensive care unit (ICU) beds. The third part was about neurosurgical practice during the COVID-19 pandemic. In Wuhan, the main hospital was used for urgent non-COVID patients. In New York, the neurosurgeon staff works in ICU as an advanced practitioner (APP). In South Korea, every patient is screened. In Italy, the on-duty Hub neurosurgeons have been doubled. In the Latin American region recommendations have been developed by some neurosurgical societies. In the UK local non-specialists and rheumatologists, neurosurgical experts are collaborating in terms of best practice. The final part touched upon how to perform safe surgery and re-start after the pandemic. In China, elective surgical procedures are performed very carefully. In New York, surgery planning will be based on the patient’s viral load. In South Korea and in Italy disinfection plans and negative-pressure O.R. were created. In the Latin American region, the aim is to have a rapid testing system. In the UK they have developed flowcharts to guide trauma patient management.

In general, the pandemic scenario was presented as a thought-provoking challenge in all countries which requires tireless efforts for both maintaining emergency and elective neurosurgical procedures 1).

Role

see Role of Neurosurgeons in the COVID-19 Pandemic.

While neurosurgeons are not on the frontline of COVID-19 management and treatment, they commonly care for critically ill patients who will continue to present with subarachnoid hemorrhages, subdural hematomas, brain tumors, traumatic brain injuries, spinal cord injuries, and compressive myelopathies while the pandemic occurs. While public health measures such as quarantine and social distancing are proving effective at slowing the spread, 2) 3) surgeons remain in direct contact with their patients throughout their operations. Protecting the surgical team from contracting COVID-19 is of utmost importance as they are both a potential vector for patient contamination and a scarce resource that cannot be easily replaced.


COVID-19 appears to be principally spread, either directly or via fomites, through droplets from respiratory epithelium— especially the upper respiratory tract. Blood is not at this point a recognized vehicle; if the significant virus were present in the blood, we would be able to do a blood test for the disease. Similarly, it does not seem to concentrate on the cerebrospinal fluid. Thus, most neurosurgical procedures to the spine and head should be safe with routine face and eye protection if Personal protection equipment is unavailable.

Recommendations

COVID-19 recommendations for neurosurgeons.

COVID-19 in chronic subdural hematoma

COVID-19 in chronic subdural hematoma.

Pituitary Surgery During Covid-19

Pituitary Surgery During Covid-19

New York City

In an Invited Commentary, Ammar et al. describe their experiences and share lessons learned regarding triage of patients, staff safety, workforce management, and the psychological impact as they have adapted to a new reality in the Department of Neurosurgery at Montefiore Medical Center, a COVID-19 hotspot in New York City. Department of Neurosurgery at Montefiore Medical Center, a COVID-19 hotspot in New York City 4).

Italy

see COVID-19 in Italy.

Switzerland

Switzerland neurosurgery is doing, where urgent or elective cases are performed in a separate location, and providers and patients require negative COVID-19 tests and chest radiographs prior to entry. Furthermore, there would be greater demand for rapid data analysis and iterative systems research to ensure the best neurosurgical practices 5).

COVID-19 and central nervous system

COVID-19 and central nervous system.

Emotional impact

The emotional impact of COVID-19: from medical staff to common people was published by Montemurro from the Department of Neurosurgery, Azienda Ospedaliera Universitaria Pisana (AOUP), Pisa, Italy 6).

Neurosurgery in an infant with COVID-19

Administering general aneasthesia to infants with respiratory infections is a challenge because aneasthetic drugs suppress immunity and can thus contribute to intubation-related mechanical stress and inflammation. Neurosurgery in infants with coronavirus disease 2019 (COVID-19) therefore poses a dilemma because the infection is associated with relative immune suppression and a dysregulated inflammatory response, which act as drivers of the disease 7).

From Milan, Italy, we report the case of an 8-month-old male patient with a complex hydrocephalus who had a shunt malfunction during the COVID-19 pandemic. The infant presented with a mild temperature, a dry cough, and an occipital cerebrospinal fluid collection, suggestive for shunt malfunctioning. Neurological examination was negative, but the infant deteriorated and vomited repeatedly. The head CT scan indicated a shunt disconnection. A chest x-ray was negative for overt interstitial pneumonia and the nasopharyngeal swab tested positive for severe acute respiratory syndrome coronavirus 8)

While the baby showed upper respiratory symptoms due to COVID-19, concerns emerged regarding the need for general anaesthesia for shunt revision. To our knowledge, no reports exist regarding the risk of general anaesthesia in infants with COVID-19. Nevertheless, considering the certainty of progressive neurological deterioration if no intervention was taken, the neurosurgical intervention was arranged.

According to the available protocols for patients with COVID-19, 9)

a negative pressure operating room was set up. The staff were provided with full-head hoods, eye protection, filtering facepiece 3 masks, fluid-resistant gowns, double long-sleeved gloves, and impermeable disposable shoe covers. Surgeons and scrubbing nurses had additional sterile surgical suits and an additional pair of long-sleeved gloves. The patient was transferred from a ward dedicated to patients with COVID-19 to the surgical theatre through an isolated and restricted area by trained personnel wearing protective gear 10) Surgery lasted approximately 1 h, and the infant recovered from general anaesthesia promptly. 4 days after surgery, vomiting had worsened and a second neurosurgical revision of the shunt was done. Again, the baby underwent surgery under general anaesthesia without respiratory complications. The baby was promptly extubated, and the neurosurgical course was favourable. To the best of our knowledge, this is the first reported case of an infant with COVID-19 undergoing neurosurgical operations under general anaesthesia. This case might reflect a general observation of relative resistance of babies and children to COVID-19, 11) suggesting the possibility that paucisymptomatic infants with COVID-19 can undergo major surgical procedures without additional morbidity. This early case report needs confirmation and extension and might have broader implications for other surgical procedures addressing potentially life-threatening conditions in infants 12).

References

1)

Fontanella MM, Saraceno G, Lei T, Bederson JB, You N, Rubiano AM, Hutchinson P, Wiemeijer-Timmer F, Servadei F. Neurosurgical activity during COVID-19 pandemic: an expert opinion from China, South Korea, Italy, United Stated of America, Colombia and United Kingdom. J Neurosurg Sci. 2020 Apr 29. doi: 10.23736/S0390-5616.20.04994-2. [Epub ahead of print] PubMed PMID: 32347685.
2)

Chinazzi M, Davis JT, Ajelli M, et al. The effect of travel restrictions on the spread of the 2019 novel coronavirus (COVID-19) outbreak. Science. published online: March 6, 2020 (doi:10.1126/science.aba9757).
3)

Wilder-Smith A, Chiew CJ, Lee VJ. Can we contain the COVID-19 outbreak with the same measures as for SARS? Lancet Infect Dis. published online: March 5, 2020 (doi:10.1016/S1473-3099(20)30129-8).
4)

Ammar A, Stock AD, Holland R, Gelfand Y, Altschul D. Managing a Specialty Service During the COVID-19 Crisis: Lessons From a New York City Health System. Acad Med. 2020 Apr 17. doi: 10.1097/ACM.0000000000003440. [Epub ahead of print] PubMed PMID: 32304386.
5)

Robertson FC, Lippa L, Broekman MLD. Editorial. Task shifting and task sharing for neurosurgeons amidst the COVID-19 pandemic. J Neurosurg. 2020 Apr 17:1-3. doi: 10.3171/2020.4.JNS201056. [Epub ahead of print] PubMed PMID: 32302998; PubMed Central PMCID: PMC7164328.
6)

Montemurro N. The emotional impact of COVID-19: from medical staff to common people. Brain Behav Immun. 2020 Mar 30. pii: S0889-1591(20)30411-6. doi: 10.1016/j.bbi.2020.03.032. [Epub ahead of print] PubMed PMID: 32240766.
7)

Lu X Zhang L Du H et al. SARS-CoV-2 infection in children. N Engl J Med. 2020; (published online March 18.) DOI:10.1056/NEJMc2005073
8) , 9)

Wax RS Christian MD Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Can J Anesth. 2020; (published online February 12.) DOI:10.1007/s12630-020-01591-x
10)

Tien HC Chughtai T Jogeklar A Cooper AB Brenneman F Elective and emergency surgery in patients with severe acute respiratory syndrome (SARS). Can J Surg. 2005; 48: 71-74
11)

Li G Fan Y Lai Y et al. Coronavirus infections and immune responses. J Med Virol. 2020; 92: 424-432
12)

Carrabba G, Tariciotti L, Guez S, Calderini E, Locatelli M. Neurosurgery in an infant with COVID-19. Lancet. 2020 Apr 22. pii: S0140-6736(20)30927-2. doi: 10.1016/S0140-6736(20)30927-2. [Epub ahead of print] PubMed PMID: 32333840.

COVID-19 recommendations for neurosurgeons

COVID-19 recommendations for neurosurgeons

On April 4, 2020, at 13.30 CET, a webinar was broadcasted, organized by Global Neuro and supported by WFNS. Expert neurosurgeons from 6 different countries (China, Italy, South Korea, USA, Colombia and United Kingdom) reported on the impact of the COVID-19 pandemic on their health care systems and neurosurgical activity.

RESULTS: The first part focused on the epidemiology until that date. The USA were the most affected State with 450.000 cases, followed by Italy (140.000 cases and 19.000 casualties), China (83.305 cases and 3.345 had died), South Korea (10.156 cases with 177 casualties), the UK (38.168 cases and 3.605 deaths) and Colombia (1.267 cases and 25 deaths). The second part concerned Institution and staff reorganization. In every country all surgical plans have been modified. In Wuhan the staff was enrolled in COVID-units. In New York, the Mount Sinai Health System was in lockdown mode. In South Korea, sterilizing chambers have been placed. In Italy some Departments were reorganized in a Hub and Spoke fashion. In the Latin American region, they adopted special measures for every case. In the UK a conference center has been used to accommodate intensive care unit (ICU) beds. The third part was about neurosurgical practice during the COVID-19 pandemic. In Wuhan the main hospital was used for urgent non-COVID patients. In New York the neurosurgeon staff work in ICU as advanced practitioner (APP). In South Korea every patient is screened. In Italy the on-duty Hub neurosurgeons have been doubled. In the Latin American region recommendations have been developed by some neurosurgical societies. In the UK local non-specialists and traumatologists neurosurgical experts are collaborating in terms of best practice. The final part touched upon how to perform safe surgery and re-start after the pandemic. In China elective surgical procedures are performed very carefully. In New York, surgery planning will be based on patient’s viral load. In South Korea and in Italy disinfection plans and negative-pressure O.R. were created. In the Latin American region, the aim is to have a rapid testing system. In the UK they have developed flowcharts to guide trauma patient management.

In general, the pandemic scenario was presented as a thought-provoking challenge in all countries which requires tireless efforts for both maintaining emergency and elective neurosurgical procedures 1).

Recommendations

• Operate on as few patients as possible:

◦ Only perform surgeries that cannot be delayed

◦ When an alternative to surgery exists and is equally valid, favor the alternative

◦ If the healthcare system becomes overwhelmed, only offer surgery to patients who have a reasonable prognosis

• Involve as few people as possible in the surgical procedures:

◦ Keep the number of individuals in the OR to the minimum required for safe completion of the surgery

◦ Do not involve observers, students, and even residents who do not have an indispensable role

◦ Minimize personnel turnover by extending shifts and minimizing breaks

◦ Segregate surgeons in specific hospitals to minimize nosocomial transmission from one hospital to another

◦ If possible, assign all COVID-19 patients to a single team that will minimize contacts with other surgeons

◦ Once immune status testing becomes available and reliable, consider assigning contamination-prone tasks and COVID-19 patients to staff with proven immunity.

• Depending on local epidemiology and resources, consider testing all surgical patients for SARS-CoV-2 or treating all patients (even asymptomatic) as potentially infected 2).


Tan et al. focused on the surgical practice in the Neurosurgery Department, Tongji HospitalWuhan, and drafted several recommendations based on the latest relevant guidelines and experience.

As the largest neurosurgical center in Wuhan, Neurosurgery Department of Tongji Hospital performed surgical treatments for patients in the epidemic situation. They carried out some management proposals of the patients on the basis of conventional treatment guidelines and clinical experiences. These recommendations have helped them until now to achieve ‘zero infection’ of doctors and nurses in this department. 3).

Preoperative evaluation and management

All patients have first applied to the special fever clinics in the out-patient department. After temperature test, a careful history query (especially the fever and cough manifestations in the last 2 weeks) and physical examination were performed by doctors from both outpatient and neurosurgery departments under strict third level protection (surgical masks, protective goggles and suit). Surgical indications should be rigorously evaluated and surgical treatment should be preserved for patients with an emergency condition, such as ruptured aneurysm and intracranial hemorrhage. Operations for patients with relatively stable conditions should be postponed, for example, patients with benign brain tumors. These patients were documented and followed up through phone calls. A pulmonary computed tomography (CT) scan and nucleic acid sequencing of throat swab were recommended for preliminary diagnosis of COVID-19 infection before hospitalization. Patients with positive results were identified to be confirmed cases and patients with preliminary negative results were considered to be suspected cases. However, these examinations should be canceled and direct emergency surgery should be performed for patients under life-threating conditions. Patients without immediate life-threating were transferred to the neurosurgery ward through a special lane to avoid cross-infection. The neurosurgery ward was divided into several areas: patient rooms were regarded as an infected area, while the nurse station and doctor office were considered to be a clean area. Patient rooms were further divided into two partitions for suspected cases and confirmed cases. Individual accommodation was recommended for all patients and rigorous quarantine should be applied to the confirmed cases. Daily sterilization was performed for every single room. Doctors and nurses must take strict third level protection before entering patient rooms. Regular preoperative neuroimaging and laboratory examinations were performed after hospitalization. We must emphasize that consultation from anesthesiologists and perioperative nurses was necessary to decide the date of operation and the intraoperative cooperation strategies.

Intraoperative management

Covid-19 intraoperative management recommendations for neurosurgeons

Postoperative management

All postoperative patients should be assumed to be suspected cases and quarantined for at least 2 weeks. Pulmonary CT scan and nucleic acid sequencing of throat swab should be repeated at least 3 times (in 2 weeks) after operation. The conditions of most postoperative patients of neurosurgery were critical. The monitoring and ventilator were necessary equipment for postoperative supportive care. The air ducts of ventilator should be daily replaced. Nutrition support was important for maintaining immunological function and reducing the possibility of virus and bacterial infection. If the pulmonary CT scan and nucleic acid sequencing of throat swab were negative for COVID-19 after 2 weeks, the quarantine could be terminated and patients were transferred to patient rooms of suspected cases. The recovery patients without COVID-19 would be transferred to neurosurgery recovery ward located on another floor.

Precautions for endoscopic transnasal skull base surgery

The impact of COVID-19 on pituitary surgery 4).

Precautions for endoscopic transnasal skull base surgery during the COVID-19 pandemic.

Operating room preparation for COVID-19

see Operating room preparation for COVID-19.

Emergency consideration

In the Lombardy region in Italy, the following clinical situations have been defined as neurosurgical emergencies:

Cerebral hemorrhages (subarachnoid and intraparenchymal)

Acute hydrocephalus

Tumors at risk of intracranial hypertension

Spinal cord compressions with neurological deficit or at risk of

Traumatic cranial and spinal trauma emergencies 5).

Recommendations for Deep Brain Stimulation Device Management

Most medical centers are postponing elective procedures and deferring non-urgent clinic visits to conserve hospital resources and prevent spread of COVID-19. The pandemic crisis presents some unique challenges for patients currently being treated with deep brain stimulation (DBS). Movement disorder (Parkinson’s disease, essential tremor, dystonia), neuropsychiatric disorder (obsessive compulsive disorder, Tourette syndrome, depression), and epilepsy patients can develop varying degrees of symptom worsening from interruption of therapy due to neurostimulator battery reaching end of life, device malfunction or infection. Urgent intervention to maintain or restore stimulation may be required for patients with Parkinson’s disease who can develop a rare but potentially life-threatening complication known as DBS-withdrawal syndrome. Similarly, patients with generalized dystonia can develop status dystonicus, patients with obsessive compulsive disorder can become suicidal, and epilepsy patients can experience potentially life-threatening worsening of seizures as a result of therapy cessation. DBS system infection can require urgent, and rarely emergent surgery. Elective interventions including new implantations and initial programming should be postponed. For patients with existing DBS systems, the battery status and electrical integrity interrogation can now be performed using patient programmers, and employed through telemedicine visits or by phone consultations. The decision for replacement of the implantable pulse generator to prevent interruption of DBS therapy should be made on a case-by-case basis taking into consideration battery status and a patient’s tolerance to potential therapy disruption. Scheduling of the procedures, however, depends heavily on the hospital system regulations and on triage procedures with respect to safety and resource utilization during the health crisis 6).

References

1)

Fontanella MM, Saraceno G, Lei T, Bederson JB, You N, Rubiano AM, Hutchinson P, Wiemeijer-Timmer F, Servadei F. Neurosurgical activity during COVID-19 pandemic: an expert opinion from China, South Korea, Italy, United Stated of America, Colombia and United Kingdom. J Neurosurg Sci. 2020 Apr 29. doi: 10.23736/S0390-5616.20.04994-2. [Epub ahead of print] PubMed PMID: 32347685.
2)

Iorio-Morin C, Hodaie M, Sarica C, Dea N, Westwick HJ, Christie SD, McDonald PJ, Labidi M, Farmer JP, Brisebois S, D’Aragon F, Carignan A, Fortin D. Letter: The Risk of COVID-19 Infection During Neurosurgical Procedures: A Review of Severe Acute Respiratory Distress Syndrome Coronavirus 2 (SARS-CoV-2) Modes of Transmission and Proposed Neurosurgery-Specific Measures for Mitigation. Neurosurgery. 2020 Apr 26. pii: nyaa157. doi: 10.1093/neuros/nyaa157. [Epub ahead of print] PubMed PMID: 32335684.
3)

Tan YT, Wang JW, Zhao K, Han L, Zhang HQ, Niu HQ, Shu K, Lei T. Preliminary Recommendations for Surgical Practice of Neurosurgery Department in the Central Epidemic Area of 2019 Coronavirus Infection. Curr Med Sci. 2020 Mar 26. doi: 10.1007/s11596-020-2173-5. [Epub ahead of print] PubMed PMID: 32219625.
4)

Mitchell RA, King JA, Goldschlager T, Wang YY. The impact of COVID-19 on pituitary surgery. ANZ J Surg. 2020 Apr 25. doi: 10.1111/ans.15959. [Epub ahead of print] PubMed PMID: 32336017.
5)

Zoia C, Bongetta D, Veiceschi P, Cenzato M, Di Meco F, Locatelli D, Boeris D, Fontanella MM. Neurosurgery during the COVID-19 pandemic: update from Lombardy, northern Italy. Acta Neurochir (Wien). 2020 Mar 28. doi: 10.1007/s00701-020-04305-w. [Epub ahead of print] PubMed PMID: 32222820.
6)

Miocinovic S, Ostrem JL, Okun MS, Bullinger KL, Riva-Posse P, Gross RE, Buetefisch CM. Recommendations for Deep Brain Stimulation Device Management During a Pandemic. J Parkinsons Dis. 2020 Apr 24. doi: 10.3233/JPD-202072. [Epub ahead of print] PubMed PMID: 32333552.
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