新型冠状病毒肺炎疫情期间开展显微外科手术专家共识

目前,国内新型冠状病毒肺炎(简称新冠肺炎,COVID-19)疫情防控形势持续向好,各地生产、生活秩序加速恢复.然而,复工、复产带来的人员聚集和流动可能增加疫情反复的风险,境外疫情爆发带来的病例输入压力与日俱增.在“内防反弹,外防输入”的疫情防控要求下,如何开展显微外科手术,做到既满足患者日常诊治需求,又避免疫情扩散,亟待一份专家指导意见.中华医学会显微外科学分会和《中华显微外科杂志》编辑部组织部分显微外科专家,总结、讨论在新冠肺炎疫情期间进行疫情防控及开展显微外科手术的经验,形成专家共识:①根据患者新冠病毒感染风险的级别选择治疗方案,对于高风险患者,可选择非手术治疗或延迟手术,不影响预后者应暂缓进行手术,必须实施急诊手术者,应在Ⅲ级防护下进行手术;对于低风险患者,可在Ⅰ级防护下开展各类显微外科手术.院前急救或需进行紧急手术而未完成新冠肺炎排查,未能确定风险级别者,需在Ⅱ级以上(含Ⅱ级)防护条件下进行手术.②设置过渡病房(病区),集中收治中、高风险患者.③医务人员实施分级防护,正确使用防护用品.④中、高风险患者围术期处置应统一指挥,严格遵守疫情防控指引,有序落实人员、物品及环境准备.⑤需加强医护人员新冠肺炎知识及院感培训,以及手术人员在防护条件下进行显微外科操作的培训.     

显微外科预防新型冠状病毒肺炎的应急护理管理措施

目的 探讨手足显微外科在新型冠状病毒肺炎(COVID-19)期间的应急护理管理方法,并评价效果. 方法 2020年1月20日至2月20日,采取应急护理管理措施:做好急诊患者的体温及肺部CT筛查,对所有在院患者及家属进行体温及指脉氧监测,高热或肺部CT异常患者的隔离与确诊,疑似及确诊患者病房的消毒与终末处理,医护人员的个人防护与培训,防护用具的规范使用与管理,病房人力资源的调配与管理,加强住院患者COVID-19的知识宣教以缓解焦虑等,确保患者及医务人员的安全.结果 本科室持续发热患者4例,2例排除COVID-19;1例确诊后转诊;1例高度疑似,已居家隔离.医护人员培训完成率100%,合格率100%.支援一线医护人员共48人,后备人员17人.疫情初期1例医生感染,应急管理措施落实之后无人感染;科室防护用具使用得当;在院患者无过激情绪反应,口罩佩戴依从性100%.结论 科室疫情期间所采取应急管理办法有效避免了院内交叉感染的发生,保障了医务人员及患者的安全,科学及时有效.     

Hospital surge capacity in a tertiary emergency referral centre during the COVID-19 outbreak in Italy

The first person-to-person transmission of the 2019 novel coronavirus in Italy on 21 February 2020 led to an infection chain that represents one of the largest known COVID-19 outbreaks outside Asia. In northern Italy in particular, we rapidly experienced a critical care crisis due to a shortage of intensive care beds, as we expected according to data reported in China. Based on our experience of managing this surge, we produced this review to support other healthcare services in preparedness and training of hospitals during the current coronavirus outbreak. We had a dedicated task force that identified a response plan, which included: (1) establishment of dedicated, cohorted intensive care units for COVID-19–positive patients; (2) design of appropriate procedures for pre-triage, diagnosis and isolation of suspected and confirmed cases; and (3) training of all staff to work in the dedicated intensive care unit, in personal protective equipment usage and patient management. Hospital multidisciplinary and departmental collaboration was needed to work on all principles of surge capacity, including: space definition; supplies provision; staff recruitment; and ad hoc training. Dedicated protocols were applied where full isolation of spaces, staff and patients was implemented. Opening the unit and the whole hospital emergency process required the multidisciplinary, multi-level involvement of healthcare providers and hospital managers all working towards a common goal: patient care and hospital safety. Hospitals should be prepared to face severe disruptions to their routine and it is very likely that protocols and procedures might require re-discussion and updating on a daily basis.     

Reducing the risk of COVID-19 transmission in hospitals: focus on additional infection control strategies

Hospitals under pressure from the COVID-19 pandemic have experienced an additional challenge due to clusters of hospital-acquired COVID-19 infection occurring on non-COVID-19 wards. These clusters have involved both staff and patients and compromise staffing, bed management and routine care, especially delivery of elective surgical procedures. They have also contributed towards the overall morbidity and mortality of the pandemic. COVID-19 infection rates are rising again, so it is important to consider implementing additional activities designed to impede transmission of SARS-CoV-2 in acute hospitals. These aim to protect staff, patients and visitors, and conserve safe and continued access for patients needing routine and emergency surgical interventions. Current infection prevention strategies include hand hygiene; patient and staff screening; surveillance; personal protective equipment; cohorting and isolation; and enhanced cleaning. Additional activities include restriction of staff and patient movement; COVID-19 pathways for wards, operating theatres and outpatient services; bathroom management; and ensuring fresh air in the absence of effective mechanical ventilation systems. Seasonal pressures and spread of more contagious and/or vaccine-tolerant variants will continue to disrupt routine and emergency care of non-COVID-19 patients, as well as increase the risk of COVID-19 infection for staff and patients. Supplementary practical and cost-effective actions to limit spread in hospitals are explored in this article.     

Transmission of infection among health care personnel performing surgical tracheostomies on COVID-19 patients

BackgroundStaff and patient safety are of paramount importance while performing a surgical tracheostomy (ST) during the corona virus disease (COVID-19) pandemic. The aim was to assess the incidence of COVID-19 infection among the healthcare personnel (HCP) performing ST on COVID-19 patients.MethodsOne hundred and twenty-two HCP participating in 71 ST procedures performed at our institution between 26th March 2020 and 27th May 2020 were identified. A COVID-19 health questionnaire was distributed among staff with their consent. Data related to the presence of COVID-19 symptoms (new onset continuous cough, fever, loss of taste and/or loss of smell) among HCP involved in ST as well as patient related data were collected.ResultsOf the HCP who responded, eleven (15%,11/72) reported key COVID-19 symptoms and went into self-isolation. Ten members from this group underwent a COVID-19 swab test and three tested positive. Only one HCP attended hospital for symptomatic treatment, none required hospitalisation. Sixty percent (43/72) of the responders had a COVID-19 antibody test with a positive rate of 18.6% (8/43).Among the patients undergoing a ST, 67% (37/55) required a direct intensive care unit (ICU) admission; the mean age was 58 years (29–78) with a male preponderance (65.5%). The median time from intubation to ST was 15 days (range 5–33,IQR = 9). The overall mortality was 11% (6/55).ConclusionsST can be carried out safely with strict adherence to both, personnel protective equipment and ST protocols which are vital to mitigate the potential transmission of COVID-19 to the HCP.     

Risks to healthcare workers following tracheal intubation of patients with COVID-19: a prospective international multicentre cohort study

Healthcare workers involved in aerosol-generating procedures, such as tracheal intubation, may be at elevated risk of acquiring COVID-19. However, the magnitude of this risk is unknown. We conducted a prospective international multicentre cohort study recruiting healthcare workers participating in tracheal intubation of patients with suspected or confirmed COVID-19. Information on tracheal intubation episodes, personal protective equipment use and subsequent provider health status was collected via self-reporting. The primary endpoint was the incidence of laboratory-confirmed COVID-19 diagnosis or new symptoms requiring self-isolation or hospitalisation after a tracheal intubation episode. Cox regression analysis examined associations between the primary endpoint and healthcare worker characteristics, procedure-related factors and personal protective equipment use. Between 23 March and 2 June 2020, 1718 healthcare workers from 503 hospitals in 17 countries reported 5148 tracheal intubation episodes. The overall incidence of the primary endpoint was 10.7% over a median (IQR [range]) follow-up of 32 (18–48 [0–116]) days. The cumulative incidence within 7, 14 and 21 days of the first tracheal intubation episode was 3.6%, 6.1% and 8.5%, respectively. The risk of the primary endpoint varied by country and was higher in women, but was not associated with other factors. Around 1 in 10 healthcare workers involved in tracheal intubation of patients with suspected or confirmed COVID-19 subsequently reported a COVID-19 outcome. This has human resource implications for institutional capacity to deliver essential healthcare services, and wider societal implications for COVID-19 transmission.     

Strategies for prevention and control of the 2019 novel coronavirus disease in the department of kidney transplantation

To summarize measures for the prevention and control of the 2019 novel coronavirus disease (COVID-19) in the department of kidney transplantation. We retrospectively analyzed the clinical data of outpatients and inpatients in the department of kidney transplantation from January 20 to March 1, 2020, and followed up the in-home kidney transplant recipients and those waiting for kidney transplantation through the Internet platform. Our department had formulated detailed prevention and control measures, mainly including kidney transplant outpatient management, kidney transplantation ward management, management of kidney transplant surgery, dialysis management of patients waiting for kidney transplantation, personal protection of medical staff, and follow-up management of discharged patients after kidney transplantation. During the epidemic period, there were no COVID-19 cases among 68 outpatient examined kidney transplant recipients, 32 hospitalized kidney transplant recipients, 19 patients waiting for kidney transplantation in hospital, and 30 medical staff. There were no COVID-19 cases among 160 follow-up recipients after kidney transplantation and 60 patients waiting for kidney transplantation. During the epidemic period, we implemented strict prevention and control measures and adjusted working methods and procedures to ensure safe and orderly work of the department.     

How has COVID-19 affected surgical practice in Oral and Maxillofacial Surgery in the East Midlands,UK?

The impact on the provision of care within the NHS due to COVID-19 can not be understated. It has created various challenges for Oral and Maxillofacial Surgeons due to the high-risk nature of working within this specialty. The aims of this study were to identify the ongoing clinical activities at the height of pandemic, the guidance issued to staff regarding the use of personal protective equipment and the changes to maxillofacial practice. A prospective analysis was commenced within six Oral and Maxillofacial Surgery units in the East Midlands, UK with data being collected by means of a 10-item questionnaire relating to changes in patient care during this time. The responses were analysed to identify compliance with the national guidance produced by the British Association of Oral and Maxillofacial Surgeons.An 87% response rate was obtained (26 respondents from 30 invitations). 73.1% of participants confirmed all surgical members of staff were offered fit tests for FFP3 masks. All units reported a continuation of Head and Neck cancer and emergency operations with a complete reduction in TMJ and orthognathic surgery. FFP3 masks were the most popular masks used for theatre activity whilst FFP2 and surgical masks were more widely used for examining patients and performing procedures in the emergency department. Changes in maxillofacial practice included the use of local flaps compared to free flaps, use of intermaxillary fixation (IMF) where appropriate for craniofacial trauma and routine COVID-19 testing for all inpatients.     

Personal Protective Equipment for Liver Transplant in SARS-CoV-2 Polymerase Chain Reaction-Positive Convalescing Recipients

Personal protective equipment (PPE) comes in several variations, and is the principal safety gear during the COVID-19 pandemic. Unfortunately, the user is severely impacted by its serious nonergonomic features. What PPE is appropriate for labor-intensive cases, like liver transplant (LT), remains unknown. We describe our experience with 2 types of PPE used during 2 separate LT performed in COVID-19 positive recipients. We conclude that for the safety of both health care workers and patients, hospitals should designate a few PPE kits for labor-intensive surgical procedures. These kits should include powered air-purifying respirators, or a similar loose-fitting powered air hood.     

The impact of respiratory protective equipment on difficult airway management: a randomised,crossover, simulation study

The current international COVID-19 health crisis underlines the importance of adequate and suitable personal protective equipment for clinical staff during acute airway management. This study compares the impacts of standard air-purifying respirators and powered air-purifying respirators during simulated difficult airway scenarios. Twenty-five anaesthetists carried out four different standardised difficult intubation drills, either unprotected (control), or wearing a standard or a powered respirator. Treatment times and wearer comfort were determined and compared. In the wearer comfort evaluation form, operators rated mobility, noise, heat, vision and speech intelligibility. All anaesthetists accomplished the treatment objectives of all study arms without adverse events. Total mean (SD) intubation times for the four interventions did not show significant differences between the powered and the standard respirator groups, being 16.4 (8.6) vs. 19.2 (5.2) seconds with the Airtraq™; 11.4 (3.4) vs. 10.0 (2.1) seconds with the videolaryngoscope; 39.2 (4.5) vs. 40.1 (4.8) seconds with the fibreoptic bronchoscope scope; and 15.4 (5.7) vs. 15.1 (5.0) seconds for standard tracheal intubation by direct laryngoscopy, respectively. Videolaryngoscopy allowed the shortest intubation times regardless of the respiratory protective device used. Anaesthetists rated heat and vision significantly higher in the powered respirator group; however, noise levels were perceived to be significantly lower than in the standard respirator group. We conclude that standard and powered respirators do not significantly prolong simulated advanced intubation procedures.     

新型冠状病毒肺炎疫情期急诊手术患者的安全防护

目的探讨新型冠状病毒肺炎疫情期急诊手术患者的安全防护管理措施,以预防医务人员及患者感染。方法新型冠状病毒肺炎疫情期对87例患者行急诊手术,手术室加强三级防护,做好安全防护管理,包括实施手术区改造分区、医务人员培训及防护,加强患者术前、术中及术后管理等措施。结果 87例急诊手术均顺利完成,医务人员均未发生新型冠状病毒感染。结论加强新型冠状病毒肺炎疫情期急诊手术患者的安全防护,能确保手术顺利实施的同时,保障患者和医务人员的安全。     

Infection prevention and surgery in the pandemic era

The COVID-19 pandemic has had a significant impact on surgical specialties. COVID-19 carries a significant risk to the surgical patient and the healthcare workers looking after them, with an increased incidence of pulmonary complications and mortality in patients who test positive perioperatively. Appropriate infection prevention and control measures are critical to ensure appropriate care is given and to reduce the risk of onward transmission. This article will discuss the measures that have been instigated and contributed to infection control in surgery, such as testing, patient isolation, personal protective equipment and ventilation. The COVID-19 pandemic has led to healthcare workers across many specialities working together to provide essential clinical care. This collaborative approach is critical to maintain excellent infection prevention and control practices required during this pandemic, which protect patients and preserve surgical services.     

Delivering Telerehabilitation to COVID-19 Inpatients:A Retrospective Chart Review Suggests It Is a Viable Option

Background

Guidelines for physical therapy management of patients hospitalized with COVID-19 recommend limiting physical therapists’ contact with patients when possible. Telehealth has been viewed as “electronic personal protective equipment” during the COVID-19 pandemic; although telerehabilitation has been shown to be effective with outpatients, it is unknown whether it is a viable option for hospitalized patients.

Purpose

Our facility developed an algorithm for the use of a physical therapy telerehabilitation program for inpatients with COVID-19. We sought to investigate the safety and viability of the program.

Methods

We conducted a retrospective chart review of patients admitted with a diagnosis of COVID-19 who received either telerehabilitation only or a combination of telerehabilitation and in-person rehabilitation. Based on the algorithm, COVID-19 inpatients were selected to receive telerehabilitation if they could ambulate independently, could use technology, had stable vital signs, required minimal supplemental oxygen, and were cognitively intact. We analyzed data of inpatients who received telerehabilitation only, which included patient education, therapeutic exercises, and breathing techniques.

Results

Of 33 COVID-19 inpatients who received telerehabilitation, in-person rehabilitation, or a combination of the two, 12 patients received telerehabilitation only (age range, 33 to 65 years; all but one male). They demonstrated independence with their individualized home exercise programs in one to two sessions, did not require an in-person rehabilitation consultation, did not require increased oxygen, experienced no exacerbation of symptoms, and were discharged home.

Conclusions

Inpatient telerehabilitation appears to be a viable option for selected hospitalized patients with COVID-19 and may be a safe way of delivering inpatient rehabilitation to isolated or at-risk populations. At our hospital, the use of inpatient telerehabilitation reduced staff exposure while providing important education and services to patients. To our knowledge, no studies have investigated the use of telerehabilitation for hospitalized patients, including those with COVID-19. Our findings suggest that this innovative approach warrants further study.

     

Airway management in the intensive care unit

Airway management practices in the intensive care unit (ICU) are still evolving, evidenced by an increasing proliferation of guidelines and algorithms in recent years. Specific considerations relate to the out-of-theatre environment and the physiological state in this patient population. Airway management in ICU is ultimately a multifaceted process spanning team training, simulation, preassessment, preparation, positioning of the patient, equipment decisions, guidelines/algorithm adherence and most recently the consideration of the coronavirus disease (COVID-19) pandemic. The use of video laryngoscopy has increased, as have the practices of apnoeic oxygenation and the use of checklists. Emergency front-of-neck access (FONA) should be taught to all staff and standardized equipment made available. This article highlights the factors a multidisciplinary team must navigate when approaching airway management in the ICU.     

创伤骨科在新型冠状病毒肺炎疫情期间应急流程管理及防控策略专家共识

由于新型冠状病毒肺炎(COVID-19)潜伏期长,早期症状无特异性,以往针对严重急性呼吸综合征冠状病毒(SARS-CoV)的筛查和防护手段已经不能满足COVID-19疫情控制的需求,必须对COVID-19进行全新的认识并采取特殊的处理流程。由于骨科创伤、出血及疼痛等急性症状的掩盖,COVID-19疫情容易被忽略,使得创伤骨科门急诊亦存在一定的风险和隐患。为了规范创伤骨科门急诊患者的收治,加强创伤骨科医护人员的防护,本文对COVID-19感染的特点及防治原则、疫情期间创伤骨科门急诊的管理、创伤骨科病房和手术室的防控策略、医护人员COVID-19感染防控知识培训进行阐述,为创伤骨科患者的救治以及医护人员的防护提供依据。     

Preparing for a COVID-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in Singapore

The coronavirus disease 2019 (COVID-19) outbreak has been designated a public health emergency of international concern. To prepare for a pandemic, hospitals need a strategy to manage their space, staff, and supplies so that optimum care is provided to patients. In addition, infection prevention measures need to be implemented to reduce in-hospital transmission. In the operating room, these preparations involve multiple stakeholders and can present a significant challenge. Here, we describe the outbreak response measures of the anesthetic department staffing the largest (1,700-bed) academic tertiary level acute care hospital in Singapore (Singapore General Hospital) and a smaller regional hospital (Sengkang General Hospital). These include engineering controls such as identification and preparation of an isolation operating room, administrative measures such as modification of workflow and processes, introduction of personal protective equipment for staff, and formulation of clinical guidelines for anesthetic management. Simulation was valuable in evaluating the feasibility of new operating room set-ups or workflow. We also discuss how the hierarchy of controls can be used as a framework to plan the necessary measures during each phase of a pandemic, and review the evidence for the measures taken. These containment measures are necessary to optimize the quality of care provided to COVID-19 patients and to reduce the risk of viral transmission to other patients or healthcare workers.     

Manejo de vía aérea en pacientes COVID-19: una encuesta sobre la experiencia de 1125 médicos en España

BackgroundWe explored the experience of clinicians from the Spanish Society of Anesthesiology in airway management of COVID-19 patients.MethodsAn software-based survey including a 32-item questionnaire was conducted from April 18 to May 17, 2020. Participants who have been involved in tracheal intubations in patients with suspected or confirmed COVID-19 infection were included anonymously after obtaining their informed consent. The primary outcome was the preferred airway device for tracheal intubation. Secondary outcomes included the variations in clinical practice including the preferred video laryngoscope, plans for difficult airway management, and personal protective equipment.Results1125 physicians completed the questionnaire with a response rate of 40,9%. Most participants worked in public hospitals and were anesthesiologists.The preferred device for intubation was the video laryngoscope (5.1/6), with the type of device in decreasing order as follows: Glidescope, C-MAC, Airtraq, McGrath and King Vision. The most frequently used device for intubation was the video laryngoscope (70,5%), using them in descending order as follow: the Airtraq, C-MAC, Glidescope, McGrath and King Vision.Discomfort of intubating wearing personal protective equipment and the frequency of breaching a security step was statistically significant, increasing the risk of cross infection between patients and physicians. The opinion of senior doctors differed from younger physicians in the type of video-laryngoscope used, the number of experts involved in tracheal intubation and the reason that caused more stress during the airway management.ConclusionsMost physicians preferred using a video-laryngoscope with remote monitor and disposable Macintosh blade, using the Frova guide.     

COVID-19 and its effects upon orthopaedic surgery: The Trinidad and Tobago experience

The World Health Organisation(WHO) declared coronavirus disease 2019(COVID-19) a pandemic on March 11, 2020. COVID-19 is not the first infectious disease to affect Trinidad and Tobago. The country has faced outbreaks of both Chikungunya and Zika virus in 2014 and 2016 respectively. The viral pandemic is predicted to have a significant impact upon all countries, but the healthcare services in a developing country are especially vulnerable. The Government of Trinidad and Tobago swiftly established a parallel healthcare system to isolate and treat suspected and confirmed cases of COVID-19. Strick ‘lockdown' orders, office closures, social distancing and face mask usage recommendation were implemented following advice from the WHO. This approach has seen Trinidad and Tobago emerge from the second wave of infections, with the most recent Oxford COVID-19 Government Response Tracker report indicating a favourable risk of openness index for the country. The effects of the pandemic on the orthopaedic services in the public and private healthcare systems show significant differences. Constrained by shortages in personal protective equipment and inadequate testing facilities, the public system moved into emergency mode prioritizing the care of urgent and critical cases. Private healthcare driven more by economic considerations, quickly instituted widespread safety measures to ensure that the clinics remained open and elective surgery was not interrupted. Orthopaedic teaching at The University of the West Indies was quickly migrated to an online platform to facilitate both medical students and residents. The Caribbean Association of Orthopedic Surgeons through its frequent virtual meetings provided a forum for continuing education and social interaction amongst colleagues. The pandemic has disrupted our daily routines leading to unparalleled changes to our lives and livelihoods. Many of these changes will remain long after the pandemic is over, permanently transforming the practice of orthopaedics.     

The prevalence,characteristics, and related factors of pressure injury in medical staff wearing personal protective equipment against COVID‐19 in China: A multicentre cross‐sectional survey

Since December 2019, the medical staff fighting against COVID‐19 frequently reported the device‐related pressure injury (DRPI) caused by personal protective equipment (PPE). We conducted a cross‐sectional survey online to investigate the prevalence and characteristics of DRPI among medical staff. Univariate and multivariate logistic regression analyses were employed to explore the risk factors associated with DRPI. A total of 4308 participants were collected and 4306 participants were valid from 161 hospitals in China. The overall prevalence of DRPI caused by PPE among medical staff was 30.03% (95% CI 28.69%‐31.41%). The prevalence of male was more than that of female (42.25%, 95% CI 37.99‐46.51% vs 26.36%, 95% CI 26.93‐29.80%, P < .001).The categories were mainly stages 1 and 2, and the common anatomical locations were nose bridge, cheeks, ears, and forehead. Logistic regression analysis revealed that the risk factors were sweating (OR = 43.99, 95% CI 34.46‐56.17), male (OR = 1.50, 95% CI 1.12‐1.99), level 3 PPE (OR = 1.44, 95% CI 1.14‐1.83), and longer wearing time (OR = 1.28, 95% CI 0.97‐1.68). The prevalence of DRPI was high among medical staff wearing PPE against COVID‐19, and the risk factors were sweating, male, wearing level 3 PPE, and longer wearing time. Comprehensive preventive interventions should be taken.