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Neurosurgery and Neurology Practices during the Novel COVID-19 Pandemic: A Consensus Statement from India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.283130
Keywords: COVID-19, neurology, neurosurgery, protocols
“According to Darwin's Origin of Species, it is not the most intellectual of the species that survives; it is not the strongest that survives; but the species that survives is the one that is able best to adapt and adjust to the changing environment in which it finds itself.” —Leon C Megginson, 1963 Introduction and Background: The COVID-19 pandemic has raised significant threats to public health and life across the globe. By 10th April 2020, nearly 1,645,428 cases of COVID-19 were confirmed worldwide and nearly 7347 cases were reported from India. Despite prudent healthcare measures taken by the Indian Government, the projected impact of coronavirus infection falls to 2%.[1] Therefore, it is pertinent to curtail the infection, rationalize the use of resources, and manage the patient rush in the given scenario. The symptoms vary with every patient. The typical “cytokine storm” elicited depends on the immune dysregulation rather than the peak viremia. This induces insufficient and a late-type I interferon (IFN) response which leads to aberrant proinflammatory cytokine secretion by alveolar macrophages and subsequent CD4, CD8 T cell dysfunction. There is a marked increase of 14 cytokines in COVID-19 patients and there are high levels of three cytokines (CXCL 10, CCL7, and IL-1 receptor antagonist) which are associated with increased viral load, loss of lung function, lung injury, and a possibly fatal outcome.[2],[3] The typical clinical manifestation of COVID-19 positive patients are fever, cough, and dyspnea. However, several patients present with neurological symptoms, such as vomiting, headache, dizziness, and delirium. Anosmia and ageusia can also be early symptoms.[2],[3] The diagnosis and severity of illness are based on the SARS-CoV-2 guidelines by WHO [Supplementary File 1]. The patients are categorized into five levels of severity: mild illness, pneumonia, severe pneumonia, acute respiratory distress syndrome (ARDS), and septic shock. A study by Gautret et al. have shown that combined treatment with azithromycin and hydroxychloroquine significantly reduces the viral load from the COVID-19 positive cases.[4] The COVID-19 patients may be managed by hydroxychloroquine or chloroquine or lopinavir/ritonavir or combination of HCQ and lopinavir [Figure 1].
The COVID-19 pandemic has raised great challenges for both neurologists and neurosurgeons worldwide.[5],[6],[7] The novel-SARS-CoV-2 has been directly associated with acute hemorrhagic necrotizing encephalopathy[8] or may also cause central nervous system (CNS) infection together with systemic inflammation.[9],[10] Restricted clinical work has a great impact on patients' mental and physical health and thus becomes even more challenging to manage patients with CNS diseases.[11] The situation regarding COVID-19 is rapidly evolving and dynamic. Although timely policies have been laid down by the state and central governments to facilitate objective decision-making, such directives will inevitably need to be adapted to this ever-changing environment. The policies laid down by the government and individual hospitals aim to provide efficient resource management to tackle the sudden surge of patients, management of patients which require immediate neurosurgical intervention and engaging in neurosurgical research during the COVID-19 outbreak. The infectivity period may start several days before the person becomes symptomatic. They can spread the infection in the preclinical stage. This increases the risk of healthcare providers. This paper aims to provide comprehensive recommendations for neurological and neurosurgical patient management, efficient resource management, and protecting the healthcare provider during the COVID-19 epidemic. In addition to a literature review, we have included the advice and expertise from neurologists and neurosurgeons from various key centers. These recommendations aim to minimize infections to doctors, nurses, and paramedical staff of the neurology and neurosurgery division and fight the novel coronavirus infection. Recommendation for Patient Management (for details see Supplements 1-3) [Additional file 1] [Additional file 2] [Additional file 3] The incubation period of the n-CoV-SARS2 ranges from 3–14 days[12] henceforth, every patient presenting for treatment should be treated as a potential asymptomatic infected case. History regarding respiratory illness, international travel and/or, contact with COVID-19 patients should be documented in every case sheet separately. All patients, as well as their attendants, should be screened for COVID-19 before entering the emergency room. Any patients suspected of COVID-19 should be immediately isolated while emergency treatment is being administered. All doctors/nurses/paramedical staff are advised to wear surgical scrubs along with a plastic apron, face masks, and other protective equipment as necessary while in the triage area. They should wear PPE, N95 masks as well as a face visor while examining/intubating suspected or proven COVID-19 patients in the emergency. A dedicated operating room (OR) and the same anesthesia machine should only be used for COVID-19 positive cases for the duration of the epidemic. The risk of aerosol dispersion is maximum during intubation, hence it has been suggested that the whole face area may be covered by a transparent sheet and the hands may be inserted under the sheet to intubate the patients, while the edges should be stuck to the surface. Alternatively, the use of a transparent Perspex square box has been suggested which is placed over the patient's head and has two ports for the anesthesiologist to insert his/her arm so that the whole intubation may be performed inside the box. A preferred protocol is the use of a separate room for intubation and then bringing the patient to the OR, so the risk is minimized to the surrounding health personnel. Patients should be categorized based upon priority (i) acute (requiring immediate treatment/surgery within 24 h.) (ii) sub-acute (requiring treatment within a maximum of 7–10 days) or (iii) chronic (requiring treatment within a month) [Figure 2] and Supplementary File 1]. The COVID-19 positive patients should be strictly managed according to the WHO guidelines [Supplementary File 2].
Acute cases A pulmonary computed tomography (CT) scan and nucleic acid sequencing (RT-PCR) of throat swab are recommended in all cases, again subject to the National/Government guidelines. However, these examinations may be canceled and a direct surgical intervention may be performed. The surgical indications should be rigorously evaluated and surgical treatment should be preserved for patients with an emergency condition such as intracranial hemorrhage, significantly raised ICP, ruptured aneurysm. COVID-19 positive or suspected cases should be operated in the dedicated OR. In acute stroke patients requiring mechanical thrombectomy at least, chest X-ray should be done if not pulmonary CT scan while shifting to the intervention room without causing a delay in procedure and intervention in COVID-19 suspect cases should also be done in separate dedicated intervention room. Pre-op and Post-op transfer from the ward to the OR and back should be done by the ward nurses in full personal protective equipment (PPE) including a well-fitting N95 mask, goggles or face shield, splash-resistant gown, and boot covers. Double surgical gloves are recommended for neurosurgeons to avoid cross-infection due to glove rupture. Postoperatively the OR should be fumigated after the case is completed. It is suggested that during the acute stage of the pandemic, elective surgeries should be postponed to the extent possible [Figure 1]. A recent study from Wuhan, Hubei[13] showed that 34 patients who underwent elective surgeries during the incubation period of COVID-19 infection developed pneumonia, 44% needed ICU care and the mortality rate was 20%. Sub-acute cases Although these cases do not require immediate intervention, however, if not treated can have significant morbidity and mortality e.g. Low-grade glioma, arteriovenous malformation, unruptured aneurysm, Pituitary apoplexy. Treatment decisions need to be made on a case-by-case basis. Case prioritization should be done in consultation with a senior consultant. Risks for patients should be determined by weighing the risks of proceeding versus delaying surgery. Priority should be based on both COVID-19 associated and other risks, given the competing risks that many neurosurgical emergencies may come with. Chronic cases Suspected or confirmed COVID-19 cases should be treated with more caution and conservative treatment should be given priority. Non-essential elective surgeries such as pituitary adenoma, (without visual deterioration) craniopharyngioma, etc., should be postponed after informing the patient. For patients whose health condition is likely to deteriorate with more than 1-month delay and are keen to proceed with treatment can be done on the elective list as per prioritization. It is advisable to avoid admitting cases requiring elective postoperative ICU management. Routine patient follow-up may be avoided or postponed. Among all procedures, endoscopic endonasal procedures and techniques like bone drilling are at the highest risk due to aerosol dispersion.[14] Hence, it is important to carefully screen the patient before performing such procedures. Creating COVID specific operating room protocols: Wong et al.[14] in their article described a systematic set of protocols they have taken at Singapore General hospital to streamline their surgical cases. Coronavirus disease (SARS-CoV-2) is likely going to stay for a prolonged period, even though we hope that the pandemic will be controlled.[14],[15],[16],[17],[18],[19],[20],[21],[22] These measures have to become part of the protocol similar to universal precautions taken for other infectious diseases like HIV and viral hepatitis. Their strategies include
Intra and postoperative patient management Postoperative pulmonary CT scan and nucleic acid sequencing (RT-PCR) of throat swab are recommended in all cases. All postoperative patients should be assumed to be suspected cases and quarantined for at least 2 weeks. Postoperatively, a pulmonary CT and nucleic acid sequencing (RT-PCR) of throat swab should be repeated three times in 2 weeks. If the tests are negative after 2 weeks, the quarantine may be terminated and patients may be shifted to the ward or an individual room. The median duration of IgM and IgA antibody detection is usually around 5 days (3–6 days), while IgG is detected at 14 days (10–18 days) after symptom onset. The positive rate was 85.4%, 92.7%, and 77.9%, respectively. In confirmed and probable cases, the positivity of IgM antibodies was 75.6% and 93.1%, respectively. The detection efficacy by IgM ELISA was shown to be higher by the qPCR method by 5.5 days of symptom onset. The positive detection increased significantly when combined ELISA and PCR were done as compared to a single PCR (98.6% vs 51.9%). A combination of RT-PCR with a CT scan of the chest again increased the sensitivity to 92%.[24] As mentioned above, endonasal procedures are at high risk of transmission. The use of debriders and drills within the nasal cavity will produce a highly dangerous droplet aerosol. It is recommended to avoid sinus breach whenever possible and avoid the use of any instrument which causes aerosol droplets to form. Usage of drills/craniotomes is known to be associated with significant aerosol formation. Hence, all craniotomies should be done using Hudson's brace and Gigli saw. During the usage of these instruments, the scrub nurse/assistant should liberally irrigate the surgical site to prevent/reduce aerosol formation. If drills are used during spinal/cranial procedures, they must be used at lower speeds and with liberal irrigation to reduce the risk of aerosol contamination of the theatre milieu. Transcranial procedures, on the other hand, are safer as there is no evidence at present that virus concentrates in either blood or cerebrospinal fluid (CSF). Care must be provided to reserve surgery for urgent cases and minimize the length of stay at the hospital (day case, single night stay). Each patient ward should be divided into three categories i.e. COVID-19 Positive, Suspected, and Negative area. Daily sterilization is recommended in each room. The doctors, nurses, and paramedical staff must take strict third level protection before entering the room. Efficient human resource management The prevailing crisis may lead to a risk of PPE supply shortage, and hence efficient human resource management is required to curb the wastage of resources. The neurosurgeons should limit the outpatient clinic, surgeries of sub-acute and chronic cases to a maximum of 25%. This volume-limiting approach will ensure the maximal availability of hospital supplies where the demand is high. Telemedicine consultations are now advised. The hospital management should now be encouraged to modify the OPD chambers by creating barriers e.g. transparent glass barriers may be created between the doctor and the patient with a communication facility through a mic. Physical examination should be performed in full protective gear especially oral, endoscopic examination, etc., The entry of doctors and patients should also be separated into the OPD chamber. The neurology, neurosurgery, and anesthesia departments are encouraged to form teams based on the expertise of members. Each team may include resident doctors, nurses, paramedical staff, attendants, etc., A designated team performs designated tasks to avoid the frequency of contact within the team and the patient while preserving efficacy, hospital supplies, and the quality of care. The teams should have prefixed working hours and should not have any overlapping clinical time with each other. The teams may initially rotate on a weekly cycle i.e. work for 1–2 weeks and stay in quarantine for 2 weeks. Later as the pandemic reduces, this may accordingly reduce in duration. A stand by the team should always be present so that if one team falls sick, the stand by the team can take over. The desperate measures require remodeling the hospital treatment system. During this outbreak situation, small and medium neurosurgery super-specialty hospitals are encouraged to collaborate and form teams.[16] Each team should only rotate at one hospital (no cross-covering) at a given time. Collaborative teamwork will ensure the efficient and safe management of more patients at a given time. Tertiary care hospitals are encouraged to form a back-up or alternative team substitutes for any team member who shows signs of illness. In case a particular team is contaminated, the substitute team will fill the gap [Figure 3]. Seniors doctors (age above 60) may avoid going to the hospital. During this time, they are encouraged to work from home engaging in research activities i.e. writing research papers, projects, or data analyses. The senior doctors may also actively participate in taking classes for students over video conferencing. They can also be involved in patient consultations via teleconsultations and also in virtual ward rounds using mobile video conferencing methods. Similarly, pregnant and potentially immunocompromised staff should not be involved in the care of COVID patients. The above protocols are going to place tremendous stress on the health infrastructure, but a well-laid out protocol is much more effective in the long run rather than risk the health personnel falling sick and jeopardizing the entire hospital. Identify the hotspots in the hospital It is important to have a team discussion through video conferencing with the entire hospital administrative team to identify the potential hotspots. These include commonly (i) the hospital canteen (ii) the cafeteria and the doctor's lounge (iii) the hospital reception and the patient waiting for areas (iv) hospital ambulances (v) emergency and outpatient's department. A recent study from Lombardy, Italy showed that the maximum cross infections occurred while transporting the patients to the hospital in ambulances.[7] Similarly, intelligent modifications must be performed in patient waiting areas (allowing patients to sit only in alternate chairs, sanitizing the chairs after every patient, compulsory wearing of masks by all patients in the hospital). Similarly, overcrowding should be avoided and distancing must be maintained in the elevators. All canteens, cafeteria, and eateries should be closed during the active pandemic. The patients may be provided with room delivery or take away counters. It is desirable to create a special COVID team that can look into all these matters and reports actively to the administrators and doctors of the hospital. Protecting the healthcare provider, changing professional, and personal lifestyles The COVID-19 virus is a high-risk pathogen with high transmissibility and infectivity. Consulting physicians, resident doctors, and nurses are at significantly high risk of infection (both symptomatic and asymptomatic) during patient care.[17] A recent study has shown that the COVID-19 virus is detectable up to 4 h on copper, up to 24 h on cardboard, and up to 2–3 days on plastic and stainless steel, and up to 3 h in aerosols.[18] It is recommended the use of hydroxychloroquine for prophylaxis of COVID-19 infection by asymptomatic healthcare workers involved in the care of suspected or confirmed cases of COVID-19[19],[20],[21],[22] [Supplementary File 3]. However, the risks of hydroxychloroquine such as cardiac arrhythmias, etc., should be taken into consideration while using these drugs for susceptible healthcare workers. Due to the epidemic, there is a risk of supply shortages of PPE. Hospitals should keep an inventory of all available PPE and rationalize the use of PPE. All staff should be routinely trained on the correct use of PPE and general hospital gear [Figure 4]. The physician needs to take different precautionary measures while working:
(i) While working in emergency and operating room
(ii) While attending the OPDs
(iii) While taking routine patients rounds
General lifestyle modifications for physicians and surgeons Along-with personal safety, the physicians should ensure strict precautions to avoid passing the infection to their families. The nosocomial transmission can easily be mitigated with careful vigilance and minor lifestyle modifications: While going to the hospital:
In hospital:
While going home
Mental Well-Being of Healthcare Professionals: Often, the mental health of healthcare professionals is often neglected as during the pandemic, the foremost goal is to treat patients and save human lives. It thus becomes important for the team leader to stay in touch with his/her team every day. Video conferencing has emerged as a very useful modality to stay in touch with all the team members. Education and awareness are important especially for lower-level healthcare workers, who need to be trained to prevent the spread of infection. It is also equally important that they are made aware of the fact that if proper precautions are followed, the risk of a healthcare worker getting infected is very low. Social media should also be preferably be avoided by healthcare workers except for focused educational groups as it may become overwhelming and may precipitate negative emotions. In severe cases, psychological counseling may be sought. Insurance Cover for Healthcare Professionals (HCP): All healthcare professionals need to be adequately covered by insurance. The center and state in the country have already announced this coverage. However, this would be important even for the persons living with healthcare workers in the same home. Stigma against healthcare workers by the general public: Recently in India, there have been a spate of isolated events, where some members of the general public have expressed stigma against healthcare workers. The government has taken prompt and stringent action against such erring members of society. However, in the long-term, adequate education, and awareness should be brought out in the general public through media regarding the low risk of contracting an infection from an HCP, as the HCP themselves take much more precautions and safety measures to prevent the spread of the disease and even while providing patient care, adequate protective measures are taken by the HCP. Medicolegal implications and issuing medical certificates: In crises, physicians should document their rationale for a particular decision in case of medico-legal implications. Physicians should refrain from giving medical rest certificates during this pandemic for more than 3–5 days unless deemed necessary.
The COVID pandemic has placed a tremendous burden on the entire human civilization. Most of us in this generation are witnessing a pandemic for the first time. It has brought tremendous changes in the quality of life, challenges to the economy, stress, sickness, loss of loved ones, and suffering. It is putting the entire medical fraternity through testing times. However, at the same time, it has provided an opportunity for significant learning. It is a great opportunity to promote indigenous production of medical devices such as ventilators, diagnostics (rapid diagnostic COVID kits), vaccines and active pharmaceutical ingredients. The COVID pandemic will no doubt change the world from the manner we perceive it. Once the pandemic resolves, we should be ready to adapt to quantum changes in global functioning. It would only increase our resolve to fight for our basic human rights- to remain healthy. From the neurosurgical and neurological perspective, we need to implement COVID safe protocols to ensure better safety for patients and healthcare workers. Disclaimer All the contents of this article are opinions of individual authors based on the current literature at this point of time and are subject to change with time based on evolution of the disease and the guidelines laid down by the Government. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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