COVID-19 TELE-EDUCATION SERIES FOR HEALTHCARE PROVIDERS IN LMICS
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COVID-19 TELE-EDUCATION SERIES FOR HEALTHCARE PROVIDERS IN LMICS COVID-19 and Implications for Surgery Dr. SaeedahAsaf, MBBS Dr. Christopher Chanda, MMed Dr. Mark Newton, MD, FAAP Associate Professor and Head National Coordinator, Anesthesia Services Professor, Anesthesiology and Pediatrics The Department of Anesthesia, Ministry of Health, Zambia Vanderbilt University Medical Center (VUMC) The Children's Hospital & Institute of Child Head, Department of Anesthesiology Nashville, Tennessee, USA Health, Lahore, Pakistan and Critical Care Head, Department of Anesthesiology Assistant Professor, Consultant, Pediatric Anesthesiologist AIC Kijabe Hospital, Kenya Arkansas Children's Hospital University Teaching Hospitals, Zambia Little Rock, AR, USA
Disclosures I have no financial conflicts of interest to disclose
Objectives 1. Describe the Impact of COVID-19 on surgery in LMICs 2. Explain the healthcare worker safety issues related to the Operating Room and COVID-19 3. Describe some possible algorithms for surgical systems and COVID-19 4. Discuss a Case Report at the hospital level in Pakistan 5. Discuss a Case Report at the national level in Zambia
COVID Changed the World: How are we going to face this challenge?
COVID -19 Education Community: >27 Countries
COVID and Healthcare Workers 1. China’s National Health Commission, by early March, 3300 HCW’s infected and from local media, 22 have died 2. In Italy, 20% of responding healthcare workers have become infected COVID-19: protecting health-care workers www.thelancet.com Vol 395 March 21, 2020 COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU)
COVID Spread to SE Asia and Africa: April 2020
Mapping Risk Factors for the Spread of COVID- 19 in Africa Africa Center for Strategic Studies, April 3,2020
Estimation of Surgical Procedure need by world regions Lancet Glob Health. 2015 Apr 27; 3(Suppl 2): S13 – S20.
Operating Rooms in South-SE Asia and Africa >45,000 Operating Rooms Global operating theatre distribution and pulse oximetry supply: an estimation from reported data Luke M Funk, Thomas G Weiser, William R Berry, Stuart R Lipsitz, Alan F Merry, Angela C Enright, Iain H Wilson, Gerald Dziekan, Atul A Gawande Lancet; Vol 376 September 25, 2010.
Will the surgical burden allow us to stop operating? Infectious and Parasitic Diseases Surgical Procedures Lowest Median Highest Region of the World Western Europe Andean Latin America Western Africa Percentage of Surgical Burden 0.32% 3.0% 35.3% Maternal Conditions Surgical Procedures Lowest Median Highest Region of the World Western Europe Andean Latin America Eastern Africa Percentage of Surgical Burden 2.1% 7.5% 20.4 % Estimated need for surgery worldwide based on prevalence of diseases: a modelling strategy for the WHO Global Health Estimate Lancet; Vol 3 (S2) April 2015
Ti, L.K., Ang, L.S., Foong, T.W. et al. What we do when a COVID-19 patient needs an operation: operating room preparation and guidance. Can J Anesth/J Can Anesth (2020)
COVID-19 and the Risks Posed to Personnel During Endo-Tracheal Intubation • Severe Respiratory Distress inpatients from COVID-19 : 8 % will require intubation and mechanical ventilation • Aerosol-generating procedures will generate more infectious respiratory aerosol than coughing, sneezing, talking, or breathing • No general definitions: intubation , extubation, manual ventilation, bronchoscopy, tracheostomy • High viral loads of SARS-CoV-2 are found in sputum and upper respiratory secretions of patients with COVID-19 David N. Weissman, MD 1 ; Marie A. de Perio, MD 2 ; Lewis J. Radonovich Jr, MD 1 JAMA. Published online April 27, 2020
Exposure to a Surrogate Measure of Contamination From Simulated Patients by Emergency Department Personnel Wearing Personal Protective Equipment • Where are the droplets spreading during intubations? • Scenario 1: 74 yo male with respiratory distress in ED who then needed an IV line and intubation, during the management the patient coughed twice, patient intubated by most experienced doctor, one other doctor, one nurse pushing drugs, one nurse recording the vitals and drugs • Simulation 2: pediatric patient with secretions on nose, mouth, upper chest, hands and similar respiratory distress and intubation. • Methods: 8 total participants, UV light post scenario and pre-removal of PPE, with photography of the participants and video recording Oren Feldman, MD 1 ; Michal Meir, MD 2 ; Danielle Shavit, BSc 3 ; et al JAMA. Published online April 27, 2020.
Droplet Spread via Simulation: Conclusions • Fluorescent markers found on Uncovered skin, shoes, neck • PPE needs to cover the neck and the removal of the PPE material was not tested which could also induced droplet spread Oren Feldman, MD 1 ; Michal Meir, MD 2 ; Danielle Shavit, BSc 3 ; et al JAMA. Published online April 27, 2020.
When evaluating patients with concern for Coronavirus Disease 2019 (COVID- 19), providers should wear a surgical mask, gown, gloves, and eye protection. This is a (WHO) and (CDC) recommendation. Conserve PPE: • Do multiple tasks when caring for the patient such as BP, VS and all preoperative history • Limit the numbers of non-essential personnel in the ORs. • Do not take off N-95 between cases • Wear a normal surgical mask on the outside of the N-95 • Always wear a face shield over your N-95 when with patients • Construction glasses or googles work to cover eyes, if needed and clean outside with bleach
PPE: Clear Plastic Face-Shield Make your own Face-Shield: • Clear Plastic PVC Binding/ Report Covers (A-4), Pack 100 • Masking Tape, Pieces of Foam • Adhesive Glue • 8 mm Elastic Bands in rolls • Total cost: 8/$1 USD
PPE: N-95 What can we use? Surgical Masks do not block the virus Filtering Face Piece Grades 2,3 (FFP 2,FFP 3) Euro Standards = N-95 Mask
N-95 Reuse Ultraviolet Germicidal Irradiation
How to do this in LMICs? Very Expensive UV Light https://www.youtube.com/watch?v=P5HsKmTTa-c https://www.nebraskamed.com/sites/default/files/documents/covid-19/n-95-decon-process.pdf
How to Prepare the Anesthesia Machine? Viral Filtration Efficiency (VFE) rating of 99.9% is commonly used Reusing filters is not recommended but you can, if you have limited supplies and not necessary to place on inspiratory limb
Intubation and COVID Consensus guidelines for managing the airway in patients with COVID-19 T. M. Cook, K. El-Boghdadly, B. McGuire, A. F. McNarry, A. Patel and A. Higgs; Anaesthesia 2020, March
Intubation in LMICs: Algorithm Adjustment Capnography not available, use clinical signs Use stethoscope, post ETT cuff inflation, and visual with uncuffed pediatric ETT No video-laryngoscope, no problem Have clamp available to clamp the ETT, if disconnect the circuit
Intubation Box Raj Gupta, MD Associate Professor Anesthesiology VUMC https://www.youtube.com/watch?v=e-wOGnr0OLk
Intubation Box: PVC Pipe and Shower Curtain
Intubation Assist Devices Dr. Raj Gupta and Dr. Matt McEvoy VUMC Dept of Anesthesiology
COSECSA Surgery Guidelines
Guidelines on Cancer Treatment During Pandemic A War on Two Fronts: Cancer Care in the Time of COVID-19. Annals of Internal Medicine. 31 March 2020 Alexander Kutikov, MD; David S. Weinberg, MD, MSc; Martin J. Edelman, MD; Eric M. Horwitz, MD; Robert G. Uzzo, MD, MBA; Richard I. Fisher, MD
Surgery Algorithm with Testing Available
PPE USE in the Operative Environment • Suspected (PUI) or Confirmed COVID Positive • Wear N-95, Face Shield, Gown, gloves for the entire case • After extubation, the drapes and disposables are removed by those with PPE in the room, then you wait 30 mins until you clean with PPE on the cleaners • High Risk Procedure (Bronchoscopy, airway, sinus surgery) • Use all PPE as above for the entire case and N-95 used for the entire day • Other Procedures and Intubation and Extubation • Anesthesia team limited numbers, most experienced person intubates • All other personnel outside the room, only enter once ETT in place and cuff inflated.
PPE Use in the Operative Setting Credit: Matt McEvoy. MD Brent Dunworth, CRNA
Guideline for PPE Use in the Operating Room Credit: Matt McEvoy MD Brent Dunworth, CRNA
Recommendations for COVID in the Operating Room
The Children’s Hospital: Lahore, Pakistan
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