Keywords
COVID-19 - surgeon - safety measure - operation room
The World Health Organization (WHO) declared the novel coronavirus disease 2019 (COVID-19)
as a public health emergency of international concern on January 30, 2020.[1]
[2] On March 11, 2020, COVID-19 was declared as a pandemic.[1]
[3]
[4]
[5] Health care workers who are in direct contact with patients are three times more
likely to get admitted due to COVID-19 than health care workers who are indirectly
involved in patient care.[6]
General surgeons provide care to COVID-19-positive patients requiring emergency surgeries
and hence are exposed to the virus.[7] Surgery on COVID-19-positive patient itself is a major risk factor for surgeon to
contract COVID-19 infection. Noticeably, there are no data regarding number of surgeons
who have contracted COVID-19 after operating on COVID-19-positive patients. We noticed
this number to be surprisingly low at our department. Hence this study was planned
to find out the exact incidence of COVID-19 among surgeons operating on COVID-19-positive
patients and to analyze the impact of safety measures practiced by us.
Objectives
The aim of this study was to find out the number of surgeons contracting COVID-19
after performing surgery on COVID-19-positive patients in a tertiary care center in
Mumbai and to find out the impact of each safety measure undertaken while performing
surgery.
Methodology
The study was conducted in a tertiary care center in Mumbai after obtaining institutional
ethics committee approval. It was a retrospective observational study with duration
of 5 months from May 1, 2020, to September 30, 2020. Only those surgeons (faculty
and resident doctors) were included who performed surgeries on COVID-19-positive patients
(diagnosed by RT-PCR test) and gave consent for participation. As an institutional
protocol, all patients undergoing surgery were tested by RT-PCR test (irrespective
of chest X-ray or symptoms). Nasopharyngeal swabs for COVID-19 disease were collected
prior to procedure but in some of these, results came after surgery. Still such patients
were included in this study. Irrespective of COVID-19 status, same precautions were
taken for all surgeries.
The details of the patients, like date of surgery, age, sex, surgery performed, duration
of surgery, type of anesthesia used, and operating surgeon, were noted from operation
room (OR) register. Details of surgeons (faculty and resident doctors) who fulfilled
inclusion criteria were noted by interview in terms of their demographic parameters,
such as age, sex, designation, experience in years after completing postgraduation,
comorbidities, whether they ever contracted COVID-19 (if yes, date), and safety measures
practiced (yes, no, or cannot recollect). Safety measures included the following:
whether followed standard steps of donning personal protective equipment (PPE; including
body cover, shoe cover, and hood), N95 mask, goggles, face shield, double pair of
gloves, intubation box was used by anesthetist during induction of anesthesia (for
general anesthesia cases), air conditioner was switched-off, smoke evacuator (cautery
with attached suction) used, followed standard steps of doffing PPE, clinical documentation
(handling of patient's file) done outside OR, shower taken immediately after surgery,
fogging of OR after each surgery, 20-minute interval between two surgeries, patient
wearing mask (at all possible times, i.e., preoperative, intraoperative, and postoperative),
and anesthetist and support staff wearing PPE. Every surgeon was given the details
of surgeries in which he/she was involved during the study period, for ease of remembrance.
Patient was assumed to be the source only if the surgeon contracted COVID-19 within
14 days of surgery (maximum incubation period is assumed to be 14 days according to
WHO and Ministry of Health and Family Welfare [MOHFW], India guidelines).[8]
[9]
Results
A total of 34 surgeons (7 faculty and 27 resident doctors) conducted 41 surgeries
on COVID-19-positive patients during the study period. All of them gave consent for
participation in the study. More than one surgeon was involved in a particular surgery.
Hence, there were 79 occasions when surgeons were at risk to contract COVID-19 while
operating on patients. One occasion was omitted from the analysis because one faculty
surgeon was COVID-19 positive and recovered before performing one particular surgery.
Hence, he was likely to have intrinsic antibodies against the virus and we cannot
assess effectiveness of the safety measures practiced. So, 78 occasions (faculty during
16 occasions and resident doctors on 62 occasions) were considered for statistical
analysis (n = 78).
These surgeries had similar/comparable risk of COVID-19 exposure to surgeons and procedures
with excessive exposure risk like airway procedures did not happen during the study
period.
The mean age of surgeon was 27.92 years (n = 78, standard deviation [SD] = 5.71) and median experience of faculty after completion
of postgraduate degree was 7 years (n = 16, IQR = 1.25–11.0). Only one faculty had comorbidity (diabetes mellitus). Duration
of surgeries ranged from 50 to 420 minutes with median being 190 minutes (n = 41, IQR = 120–240). Only one surgeon (male faculty) contracted COVID-19 within
14 days of surgery (1.3% incidence, n = 78), a total of 7 surgeons contracted COVID-19 during study period but not within
14 days of surgery (source other than patient operated) and all remaining surgeons
were asymptomatic throughout the study period. The surgeon who contracted COVID-19
(within 14 days) performed surgery for 260 minutes and under general anesthesia ([Table 1]).
Table 1
Descriptive characteristics of surgeons who operated on COVID-19-positive patients
during study period
|
Variables
|
Results
|
n (%)/mean (SD)/median (IQR)
|
|
Sex (n = 78)
|
Male
|
50 (64.1)
|
|
Female
|
28 (35.9)
|
|
Age in years (n = 78)
|
|
27.92 (5.17)
|
|
Designation (n = 78)
|
Faculty
|
16 (20.5)
|
|
Resident
|
62 (79.5)
|
|
Faculty (n = 16)
|
Assistant professor
|
15 (93.7)
|
|
Professor
|
1 (6.3)
|
|
Resident doctor (n = 62)
|
First year resident
|
2 (2.9)
|
|
Second year resident
|
28 (45.2)
|
|
Third year resident
|
30 (48.4)
|
|
Senior resident
|
2 (3.2)
|
|
Experience in years (n = 16)
|
|
7.0 (1.25, 11.0)
|
|
Comorbidities (n = 78)
|
Yes
|
1 (1.3)
|
|
No
|
77 (98.7)
|
|
Duration of surgeries in minutes (n = 41)
|
|
190.0 (120.0, 240.0)
|
|
Number of surgeries one particular surgeon was scrubbed in (n = 78)
|
|
3.0 (2.0, 4.0)
|
Abbreviations: COVID-19, novel coronavirus disease 2019; IQR, interquartile range;
SD, standard deviation.
All the surgeons followed standard steps of donning and doffing, used PPE body cover,
shoe cover, hood, double pair of gloves, and N-95 masks at all times (n = 78). Intubation box was used in 100% cases of general anesthesia (n = 19). Fogging of OR after each surgery and interval of 20 minutes between surgeries
was followed in 100% cases. Also, patient was wearing mask at all possible times and
anesthetist and support staff used PPE during all surgeries. Hence, the relationship
between contraction of COVID-19 and these safety measures cannot be assessed.
Goggles and face shields were not used on 88.5% (n = 78) and 93.2% (n = 73, because five surgeons could not recollect whether they used face shields or
not) occasions, respectively. Also, shower immediately after surgery was not taken
on 93.6% occasions (n = 78). The surgeon who contracted COVID-19 had neither used goggles nor face shield.
Also, he did not take shower immediately after surgery. However, there was no significant
association between use of goggles, face shields, or shower immediately after surgery
and contraction of COVID-19 after operating patients (Fisher's exact p = 1.000).
Air conditioner was switched-off only in 7.3% surgeries (n = 41). Smoke evacuator (cautery with attached suction) was not used in 97.6% cases.
While, clinical documentation (handling of patient's files) was done outside OR in
only 17.1% surgeries (n = 41). However, there was no significant association between these safety measures
and contraction of COVID-19 (Fisher's exact p = 1.000; [Fig. 1] and [Table 2]). General anesthesia was used in 19 surgeries (46.3%) while spinal anesthesia in
16 surgeries (39%), local anesthesia in 5 surgeries (12.2%), and total intravenous
anesthesia (TIVA) in one surgery (2.4%). However, there was no significant association
between type of anesthesia given during surgery and contraction of COVID-19 after
operating on patients with Fisher's exact p-value of 1.000.
Table 2
Statistics of safety measures where there is no significant association between safety
measure and contraction of COVID-19[a]
|
Safety measure
|
If contracted COVID-19 within 14 days of surgery
|
Total
|
|
SM 6 (n = 78)
|
No (n = 77)
|
Yes (n = 1)
|
|
|
Yes (%)
|
9 (11.7)
|
0 (0.0)
|
9 (11.5)
|
|
No (%)
|
68 (88.3)
|
1 (100.0)
|
69 (88.5)
|
|
SM 7 (n = 73)
|
No (n = 72)
|
Yes (n = 1)
|
|
|
Yes (%)
|
5 (6.9)
|
0 (0.0)
|
5 (6.8)
|
|
No (%)
|
67 (93.1)
|
1 (100.0)
|
68 (93.2)
|
|
SM 10 (n = 41)
|
No (n = 40)
|
Yes (n = 1)
|
|
|
Yes (%)
|
37 (92.5)
|
1 (100.0)
|
38 (92.7)
|
|
No (%)
|
3 (7.5)
|
0 (0.0)
|
3 (7.3)
|
|
SM 11 (n = 41)
|
No (n = 40)
|
Yes (n = 1)
|
|
|
Yes (%)
|
1 (2.5)
|
0 (0.0)
|
1 (2.4)
|
|
No (%)
|
39 (97.5)
|
1 (100.0)
|
40 (97.6)
|
|
SM 13 (n = 41)
|
No (n = 40)
|
Yes (n = 1)
|
|
|
Yes (%)
|
7 (17.5)
|
0 (0.0)
|
7 (17.1)
|
|
No (%)
|
33 (82.5)
|
1 (100.0)
|
34 (82.9)
|
|
SM 14 (n = 78)
|
No (n = 77)
|
Yes (n = 1)
|
|
|
Yes (%)
|
5 (6.5)
|
0 (0.0)
|
5 (6.4)
|
|
No (%)
|
72 (93.5)
|
1 (100.0)
|
73 (93.6)
|
Abbreviations: COVID-19, novel coronavirus disease 2019; SM6, used goggles; SM7, used
face shield; SM10, air conditioner was switched-off; SM11, used smoke evacuator; SM13,
clinical documentation of medical records done outside Operation Room; SM14, shower
taken immediately after surgery.
a For other safety measures, we cannot assess the relationship between safety measure
and contraction of COVID-19.
Fig. 1 Frequency of use of individual safety measure. PPE, personal protective equipment;
SM, safety measure; SM1, followed standard steps of donning PPE; SM2, used PPE body
cover; SM3, used PPE shoe cover; SM4, used PPE hood; SM5, used N95 mask; SM6, used
goggles; SM7, used face shield; SM8, used double pair of gloves; SM9, intubation box
was used by anesthetist for induction in general anesthesia cases; SM10, air conditioner
was switched-off; SM11, used smoke evacuator; SM12, followed standard steps of doffing
PPE; SM13, clinical documentation of medical records done outside OR; SM14, shower
taken immediately after surgery; SM15, fogging of OR after each surgery; SM16, 20-minute
interval between two surgeries; SM17, patient wearing mask at all possible times;
SM18, anesthetist and support staff wearing PPE.
Discussion
Through well-conducted research studies, it has become clear that adopting universal
pandemic precautions is in everyone's best interest.[10] Various studies and guidelines have been published for safe surgical practices in
COVID-19 pandemic.[11]
[12]
[13]
[14]
[15] But all the recommendations for safety measures are based on universal safety precautions
and prior experiences related to management of surgical patients during previous epidemics
like severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS),
Ebola virus disease, and others.[16] For example, based on experience with other respiratory viruses, consistent use
of PPE and masks is recommended for health care workers during treatment of COVID-19
patients.[17]
[18]
[19]
[20] But there have been no studies to validate the efficacy of these safety precautions
per se for COVID-19.
During the study period, only emergency open surgeries were performed at our institute.
Only one surgeon contracted COVID-19 possibly from the patient he operated. This too
cannot be ascertained since there are innumerable ways of contracting COVID-19. Nevertheless,
even if we assume the patient to be the source of COVID-19 for that surgeon, incidence
was only 1.3%.
In their study, Park et al concluded that duration of contact with COVID-19-positive
patient played a major role in the spread of virus.[21] There is a possibility of severe illness when exposed to a higher virus load.[22] Although there are no studies correlating duration of surgery and exposure to viral
load, it can be stated that the longer the duration, the higher is the risk of contracting
COVID-19 illness and with increased severity as well. In our study, the surgeon who
contracted COVID-19 performed surgery for 260 minutes (median = 190 minutes).
The viral load in the peritoneal fluid is high as compared with respiratory fluid.[23] Viral RNA has also been demonstrated in blood and feces of COVID-19 patients.[24]
[25] All surgical procedures potentially provoke aerosolization of the virus and put
surgeons at risk. Both laparoscopic and open surgical procedures result in vapor forming
maneuvers and hence aerosolize the virus. Also, there is a possibility of splash of
body fluids coming in contact with eyes, nose, mouth while operating. Use of either
N95 or FFP2 masks by surgeons is recommended by the Center of Disease Control and
Prevention[26] and Wang et al.[27] Chen et al demonstrated conjunctiva to be a potential route of transmission of coronavirus.[28] So routine use of eye protection is recommended to avoid exposure to virus while
performing surgery.[27]
[29] Similarly, along with surgical caps, use of surgical hood is also recommended for
the aerosol-generating procedures.[27]
[29] Continuous use of masks by patients at all possible times has also been recommended
to reduce transmission.[30] Use of double pair of gloves has also been recommended while operating.[27]
[30]
In our study, N95 mask was used in 100% cases. Hence the relationship between COVID-19
status and use of N95 mask cannot not be assessed. But surgeons did not use goggles
in 88.5% cases and face shields in 93.2% cases. Possible reasons for noncompliance
can be hampered vision due to accumulation of fog on goggles and face shield, improper
fitting of goggles over spectacles, and others. This might be because majority of
the general surgeries we dealt with did not pose great risk of splash of body fluids.
But for cardiovascular or oral surgeries, they might have a significant impact. To
improve compliance, various antifogging measures have been described like application
of antiseptic liquid (cetrimide or sterillium) over plastic/glass surfaces.[31]
[32]
In the review of literature conducted by Chirico et al,[33] there was not enough evidence to either support or refute the fact that air-conditioning
systems favor the spread of SARS-coronavirus-2 (SARS-CoV-2). However, in previous
coronavirus epidemics of SARS-CoV-1 and MERS-CoV, heating, ventilation, and air conditioning
(HVAC) systems were suspected of facilitating the spread of these viruses. The guidelines
released by various agencies, like elimination of any air recirculation within the
ventilation system, use of HVAC system, switching-off of air conditioners, and others,
are based on these studies.[34] However, switching-off of the air conditioner causes excessive sweating and discomfort
while operating, especially in PPE, which ultimately hampers decision-making. In our
study, air conditioner was switched-off in only 7.3% surgeries and we did not find
any significant association between this safety measure and contraction of COVID-19.
A smoke evacuator (cautery with attached suction) has been recommended by Prakash
et al[3] and Livingston[35] It is based on the fact that coronavirus is present in body fluids and use of electrocautery
may aerosolize the virus. Coronavirus has not yet been demonstrated in surgical smoke,
although there are case reports of surgeons contracting papillomavirus rarely when
surgical smoke exposure was suspected to be the source.[36] However, in our study, cautery with attached suction was not used in 97.6% cases.
Hence, it is imperative to conduct further studies before recommending this as a safety
precaution.
It is advised that clinical documentation (handling of patients file) of medical records
must be done outside the OR.[30] Also, shower immediately after surgery as a protective measure against COVID-19
has been recommended in literature.[30] But, in our study clinical documentation was done outside OR in only 17.1% surgeries
and only 6.4% surgeons took shower immediately after surgery. Hence, it is recommended
to conduct further studies before suggesting these as safety precautions.
Induction of general anesthesia is an aerosol generating procedure. Hence, whenever
possible regional anesthesia is to be preferred which is associated with decreased
risk to surgical staff as stated by Shanthanna and Uppal.[37]
[38] However, in our study, we did not find significant association between type of anesthesia
given during surgery and contraction of COVID-19 after operating on patients.
A review by Al-Benna[39] and Braude and Femling[40] suggested that at least 12 air flow changes per hour are necessary to maintain required
environment. Air exchanges prevent air (and hence the virus) from stagnating in a
particular area. Also, creation of negative pressure ORs with separate ventilation
system is recommended.[11]
[27] A negative pressure room works on the principle of lower air pressure inside the
room as compared with its surroundings. This prevents potentially harmful particles
within the room to escape outside. Hence, people outside the room are protected from
exposure. This should theoretically increase the exposure of people inside the room
to the contaminant if it is not associated with air exchanges and use of high efficiency
particulate air (HEPA) filter. HEPA filter fitted in air handling unit (AHU) that
filters out viruses, and thereby reduces the viral load of environment both inside
and outside of the OR. Our center does not have negative pressure OR. Hence, larger
studies are required to support or refute their role in surgeon's protection against
COVID-19. The cost of constructing negative pressure ORs can be reduced which will
significantly reduce health care costs especially in low-income countries.
Coccolini et al suggested that patients requiring surgery must be treated as COVID-19-positive
until proven otherwise to minimize the chances of infection.[30] In emergency situations, it is not feasible to wait for swab report and life-saving
surgeries have to be performed as recommended by systematic review done by De Simone
et al[41] and study conducted by Gök et al.[42] This mandates use of safety measures in all patients requiring emergency surgery[41] and adds to health care costs. Hence it is necessary to conduct larger studies to
evaluate the need of each safety measures. This will help to reduce financial burden
on health care system by decreasing the number of unnecessary safety measures.
Limitations
This study is retrospective observational study. No COVID-19 RT-PCR testing of operating
surgeon was done until symptomatic as per institutional guidelines. Hence, asymptomatic
carrier is the limitation of the study. Also, this data are limited to emergency open
surgeries as elective and laparoscopic surgeries were not performed at our institute
during study period.
Conclusion
Even though safety measures, like goggles, face shield, switching-off the air conditioner,
use of smoke evacuator, and shower immediately after surgery, were not practiced in
majority of cases, surgeon positivity rate was significantly less. Also, there was
no use of negative pressure OR. Hence, their significance becomes questionable. Although
adopting all universal safety measures is in everyone's best interest, it is seldom
cost-effective. Use and promotion of unnecessary safety measures lead to added health
care costs and fear among health care workers in case of unavailability. Even though
our study has a small sample size and has its own limitations, it can guide future
studies to strengthen recommendations and reduce health care costs. This will also
help in future epidemics/pandemics.
