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The Aftermath of COVID-19 Lockdown- Why and How Should We Be Ready?
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.293471
Keywords: Anesthesia, corona, elective, emergency, infection, neurosurgery, radiosurgery, SARS COV2, trauma, tumor
The far-reaching effects of the viral pandemic and the global shutdown have significantly challenged the scientific community. Our priority rides on the immediate effects of the current world scenario on surgical practice. Once this crisis starts fading away, we should be ready for a possible second wave of infections and resurgence of neurosurgical cases. We need to be prepared with a triage strategy so that the already strained system does not get overwhelmed. Every patient believes that one's disease should get priority care irrespective of its seriousness. When the patient management system starts getting flooded with 'new' and 'wait-listed' patients, a worsening glioma may need priority over a meningioma. So, even the waiting list needs to be triaged. Evolving evidences suggest that social distancing will be a new way of life.[1] We need to formulate novel strategies for volume restrictive approach, capacity building, triage of non-emergent cases, and non-overlapping team approach. A sizeable number of global fatalities have occurred, and the impact is being felt worldwide. There are a plethora of articles on how to manage cases during the lockdown. A notable article from the largest neurosurgical center in Wuhan has even claimed a 'zero infection rate' among nurses and doctors.[2] The same could not be replicated in any other study. Various published series have reported up to 20% mortality even in asymptomatic COVID carriers, who were operated upon.[3] In India, there has been a historical preemptive effort by the government with the lockdown of 1.4 billion people hoping to 'flatten the curve' of coronavirus spread. This has led to a situation where all elective surgeries have been canceled, and only emergencies are being operated. While it is perhaps the only available measure against this pandemic, patients with neurosurgical diseases are waiting for treatment during this period.[4] There is a lack of data on how many patients would be adversely affected because of this delay in treatment. Neurosurgeons should be prepared for expected challenges in the post-lockdown phase. Just like the HIV epidemic changed the way universal precautions are taken for fluid transmission diseases,[5] this pandemic will change the way for airborne diseases. It is nearly impossible to predict when the situation will stabilize. Eventually, social movement will be allowed in a staggered fashion. Our healthcare system has followed a 'patient-centric approach' while the current situation demands a 'community-centric approach.' The healthcare systems are not very conversant with such an unprecedented pandemic.[6] Even when the situation starts normalizing, we would need an epidemiologist and social scientist to guide us with bold measures to prevent the chances of recurrences. We need a long-term plan[1] for the management of all our patients, emergent and nonemergent. Our aim with this article is to provide recommendations and suggest strategies in dealing with the staged/sudden reopening of neurosurgical centers in the Covid-19 background.[7]
We have studied the available evidence and the experience of the affected countries ahead of us in the curve of corona pandemic. We have attempted consensus-based recommendations for different scenarios of neurosurgical care in the Indian perspective. The recommendations are formulated in the dynamic wave of COVID crisis with evolving understanding of the disease. The author group includes the neurosurgeons in institutional and private set ups of different capacities from different geographical locations of India. We discussed the prevailing challenges and locoregional difficulties, in variegated operating environments. Consensus was reached when all authors agreed on the presented recommendations.
There are two possible scenarios in the times to come. The less-likely possibility will be a sudden lifting of the lockdown after reasonable control of the infection. The more probable endpoint is a staged lifting of the lockdown in areas where the new cases have come down substantially while small hot spots remain under curfew. We are aware that even after easing the restrictions, newer waves of severe and rampant infections may appear. It is of utmost importance that physical distancing is followed till no new cases are reported. It is imperative that we should prepare ourselves to deal with the ongoing and forthcoming crisis that may mandate precautions while ensuring patient care. Although we now know that the return to normalcy would be in phases, it would be useful to understand why a phased return is better. For this, we need to examine the hypothetical scenario of a sudden return to normalcy. If the lockdown was lifted suddenly, the cases which have built up over time would suddenly demand overdue care. In addition, a 'second wave' of Covid-19 infection may be inevitable; hence, precautions will need to be continued. Such would be the rush of cases that the real 'pandemic' would start for neurosurgeons with an increase in the risk of infections and a substantial number of cases arriving in a deteriorated state.[8] This would overwhelm the system which already has been crippled due to the reassortment of allied health care workers towards containment and treatment of Covid-19. We should keep in mind that health care workers need to be quarantined similar to the contacts of COVID-positive patients. If there is a rampant spread of infection in hospital setup, then a large proportion of health care workers would be quarantined, crippling the hospital systems[1],[2],[3],[4],[9] Staged return The staggered release of lockdown in certain zones with very low transmission rates being opened up first and local transport is being allowed. The majority of patients who were previously planned for surgery during the lockdown would be referred to tertiary centers for further management. It is here that a real chance of preventing a respread and dealing with emergencies needs to be understood. All patients who were previously allotted dates for surgery need to be counseled and triaged well before they arrive at the hospitals. Any primary care/referring hospital should divide cases during this time as simple and complex. Only those cases requiring expert care should be referred to the centers of excellence, while the rest should be managed at the local neuroscience centers. This will not only reduce the need for transport across state borders but would distribute cases at different centers as per the level of their complexities. Outpatient services Teleconsultation before attending OPD 'Telemedicine Practice Guidelines' should be simple but comprehensive without prohibiting any method (text/audio/video) and platform (social media) of telemedicine consultation. Telemedicine consultation needs to be through an appointment. Telemedicine practice guidelines advocate in-person consultation during emergency care. It restricts the role of doctor for first-aid counseling, facilitating referral and health advice during emergency care. The doctor should enquire about the patient's identity through the government identity card and it is the duty of the doctor to introduce himself with his qualification, registration number, and specialization. The duration of the telemedicine consultation is fixed. The patient needs to be precise and prepared for the telemedicine consultation by writing down concerns and issues to be discussed on a piece of paper. If possible, having a properly filled proforma [Appendix 1] for the first or follow-up consult would help in documentation and to conduct the telemedicine session effectively. Getting the previous treatment details/admission discharge slips will help in effectual management. The presence of the patient is essential during the telemedicine consultation. The patient has the right to choose in-person consultation anytime/stage. Doctors also have the professional discretion to choose the mode (in-person/text/audio/video) of consultation. Doctors need to arrive at a diagnosis/provisional diagnosis before prescribing medication. They also need to avoid prescribing Schedule-X and drugs listed under Narcotic Drugs and Psychotropic Substance Act, 1985. A copy of the telemedicine practice guidelines can be sent to the patient during fixing up an appointment.[8] Once the outpatient services start, two key issues need to be tackled. One is the risk of spread to patients visiting the out patient department. Rigid screening and physical distancing while waiting for the consultation are necessary and should be strictly followed.[10] Level 2 personal protective equipment (PPE) for all health care workers should be the norm and regulation of the number of people entering critical areas should be done. The cases coming only for prescription of medications (e.g., epilepsy cases) can be dealt with at a separate counter. The second issue is the increased footfall once the lockdown is lifted. This can be managed with both thermal and questionnaire screening.[11] There is an urgent need for the decentralization of resources so that the patients do not have to cross their containment zone and neurosurgical emergencies should be managed if possible, locally. However, in case of need, travel should be facilitated to higher centers of expertize. The patients should be divided into two simple categories during screening [Figure 1].
Case selection- Triage after COVID-19 A lot has been spoken about triage in the times of COVID-19, but we should be prepared for another triage after this pandemic. There has been an argument that testing all patients for the Covid-19 may not be a viable option considering its prevalence. However, the counterargument is that (OPDs) and emergency surgeries exponentially increase the number of contacts [Figure 2]. Even one positive case can push the entire surgical team into quarantine. Hence, at this time, routine testing for all cases should be recommended, although one must be warned that a negative test does not rule out infection completely [Table 2].[12],[13],[14]
Case counselling – Operating patients in poor clinical status The burden of the waitlist bears heavily on the neurosurgical patients. While poor clinical status patients would need surgery, their outcomes must be understood and proper counseling is necessary for these situations. In cases, where high-grade gliomas have crossed the midline or developed severe necrosis and edema, the outcomes after operating the same shall be poorer than if they were operated before the worsening.[15] As a dictum, the postoperative outcome of the neurosurgical patients is dependent on their neurological status at the time of their presentation. A disease operated in the advanced status is bound to have worse outcomes than early in its natural course, e.g., a compressive myelopathy in advanced Nurick grade would have guarded outcomes due to the increased waiting time in the lockdown. This complication due to circumstantial limitations is an exceptional scenario and should be duly explained to the patient for mitigating any medicolegal concerns. The same should be substantiated with a proper consent detailing the reasons for triage among patients and possible consequences due to delayed surgery. It has also been reported that patients who undergo surgery in the incubation period of Sars-Cov-2 virus have poorer outcomes. In a series of 34 cases who were unintentionally scheduled for elective surgeries during the incubation period of the covid-19 infection, 44·1% patients needed ICU care and the mortality rate was 20·5%.[3] Thus, extensive testing and risk of poorer outcomes must be honestly explained to every case being considered during this period. Similar to what is already being practiced in many referral hospitals with a large volume of cases, neurosurgical teams may have to be divided into 3–4 teams.[7] Each team may work for one week followed by two weeks of quarantine. Another team may be kept as reserve to replace members who are either sick or tired. Operating room strategy The COVID19 outbreak will need structural changes in operating rooms irrespective of their case load and practice patterns[16] [Appendixs 2 and 3]. Hospitals should change to high flow air-conditioners and negative-pressure operation theatres to prevent in-hospital spread of the infection. Possibly, intubation and extubation areas need to be negative pressured as suggested by the Anesthesiology guidelines [[Table 3] and Appendix 4]. The total surgical time is bound to increase due to wheeling in and out from several stations.[17] Similarly, ward and ICU tracheostomies should be discouraged and all need to be done in operation theaters. It may increase additional burden on the operation theatre (OTs) but reduce the aerosol generation and contamination of other areas. Since negative suction OTs may not be available at all centers, different OT complexes with wet fumigation after every case may be a more feasible alternative in such resource-limited settings. It is understood that all surgical clothes, surgical kit, and surgical shields should be disposable.
Due to the sudden surge of cases, OT numbers may need to be increased temporarily. We should encourage day-care surgeries and surgeries demanding shorter stay without need of critical care services. We should prefer procedures that can allow a rapid reduction in intracranial pressure with definitive surgery after some time.[18] We should consider non-operative approaches and palliative care in patients least likely to gain significant benefit from treatment, e.g., elderly patients with a clear radiologic diagnosis of high-grade glioma. Low-grade glioma, where a period of interval monitoring with MRI is a reasonable management option (in the event of 3–6 months delay), consider adding a 3-month interval scan to ensure no tumor progression.[19] Some ideas can help mitigate problems like using subcutaneous sutures for skin closure requiring no extra visit for suture removal. Tracheostomy should be done for head injury cases presenting below GCS 8 during surgery or where prolonged ventilation is suspected. CSF diversion in cases of posterior fossa surgeries with a high risk of persistent hydrocephalus so that chances of CSF leak or hydrocephalus and follow up due to the same can be curtailed. Local services can be used for reducing travel and OPD visits especially for wound complications or immediate postoperative seizures. Perhaps a change in the way we practice neurosurgery may be needed after the outbreak 'flattens'. In an Italian study, all neurosurgeons concentrated in one hospital and carried all neurosurgical care of the city. They used the utmost precautions and followed universal protocols for all cases. They used conference calls on cases that needed further discussion. We need to divide the entire neurosurgical staff into two major groups with one lead consultant, a senior resident, and one junior resident with proper training in PPE handling and operating only on COVID-19 suspect cases. Another team should handle nonsuspect cases only and should be ready as a backup team (Two team approach).[18] Upon accidental exposure to one team, only that team needs to be quarantined allowing the rest of the system to deliver in emergency. Senior residents and trainees with a consultant on supervision should be preferred to shorten the operation duration. For complicated operations, two neurosurgeons can work simultaneously for quick performance.[20] Double surgical gloves and minimal drilling/nibbling is recommended for neurosurgeons to avoid infection due to accidental glove ruptures. High-speed drilling should be avoided and electric drill should be preferred to pneumatic drill. The use of CUSA should also be discouraged for the same reasons. The operating field should be properly flooded with the irrigation fluid to minimize aerosol generation. Post-surgery care Neurosurgery wards should be segregated into several areas maintaining proper distance. There should be separate rooms for COVID-positive, COVID-suspected, and COVID-negative patients. The nursing stations and doctors' lounge should be a clean area. Individual accommodation would be ideally recommended for all patients but may not be possible in every situation and rigorous quarantine should be applied to the confirmed cases. Daily sterilization should be performed for every single room. Doctors and nurses must take strict third-level protection before contacting positive patients. Pulmonary CT scan or X-ray chest and nucleic acid sequencing of throat swab should be repeated at least three times (in 2 weeks) after operation.[21] Ventilator support Because of the dire shortage of ventilators, this resource should be used with utmost caution. There is a high chance of transmission in case any patient requires emergency postoperative intubation. If the ventilation or respiratory support is expected, these cases can be shifted with the tube in situ or directly to the ICU where (PPE) would be sufficiently available [Table 4] and Appendix 5]. The air ducts of the ventilator should be replaced daily. Nutritional support is often a neglected domain but is important for maintaining immunological function and reducing the possibility of superimposed infections. If the pulmonary CT scan and nucleic acid sequencing of throat swab are negative for COVID-19 after 2 weeks, the quarantine could be terminated. The recovered patients without COVID-19 should be transferred to the neurosurgery recovery ward located on another floor or to the rehabilitation center directly.[22]
Neurotrauma Special considerations With most countries and areas under lockdown, neurotrauma will not be at the forefront during this crisis but once the same is lifted, a sudden surge of trauma is expected. In such a case, the facility should be ready to manage this 'epidemic.' One thing we should be aware of is on any day, deaths and disabilities due to traumatic brain injury is more than that due to Covid-19. All incoming cases of trauma can be potentially corona positive. The screening doctor should insist on thorough check of temperature, history (especially the travel history and fever and cough manifestations in the last 2 weeks), and any Covid-19-suggestive symptomatology. The screening doctor should be conversant with the clinical signs of neurosurgical emergencies such as impending herniation to differentiate the cases based on their urgency. Strict third-level protection (medical masks, protective goggles, and suit) should be rigorously followed as numerous examples have been seen where one infected health care worker has led to a situation of mass quarantine further burdening the health care services.[23] It may be advisable to do an emergent X-ray chest or pulmonary computed tomography (CT) scan with nucleic acid sequencing of throat swab for preliminary diagnosis of COVID-19 or antibody testing depending on availability. The results of the swab may be delayed after the surgery. If we identify any positive case in retrospect, the staff, surgeons, and their contacts may have to be quarantined immediately. The checklist is an opportunity to verify and strengthen the requirements to perform a surgical procedure safely (i.e., decompressive craniectomy) and allow recommunication, foster teamwork between clinical disciplines, and identify the future challenges.[23],[24],[25] A comprehensive step-by-step checklist[26] can prevent complications, reduce the burden on an already strained system, and allow even junior residents to manage trauma under the supervision of consultants, who may be better utilized for complex cases. Need for Covid-free hospitals and testing of health care workers As we go higher up the curve of COVID-19, it has become apparent that protection of hospitals and health care workers is necessary for the marathon that is SARS-COV2.[27] This can be achieved by geographically isolating patients inside a hospital and by geographically isolating hospitals. We have already spoken in detail regarding the former, hence the need for creating 'COVID-free' hospitals to limit the number of health care personnel exposed and conserve supplies.[27] This type of geographic capacity generation is extremely difficult as each case admitted can be positive but it is necessary as these hospitals can help mitigate the burden of care which was supposed to be handled by hospitals that are now overwhelmed by COVID-19. An example is glioma. While the pandemic rages on, many glioma patients who were scheduled for surgery may not seek medical attention due the fear of contracting the virus in a 'COVID- designated hospital', thus may progress to an inoperable state. If safe pathways for these cases can be identified, they can be effectively shunted to these hospitals reducing the risk of infection and progression of their disease. Hospitals are a major source of infection with many healthcare workers succumbing to the disease. There is a need to rapidly reorganize the health care facilities based on essential and shared principles in order to continue to offer specialized and high-standard neurosurgical care. In addition to designating the same, it is necessary to screen the elective cases for COVID-19, 48 hours before surgery. Since most of the infected cases are asymptomatic, relying only on epidemiologic criteria is not advisable. Moreover, immunosuppression due to the surgical stress, steroid intake, and the disease itself would further jeopardize the safety of COVID-19 elective cases. In turn, inadequate management of these patients would further spread the disease to other admitted patients and to their caregivers. Ideally, COVID-19–negative patients should proceed with the regular “COVID-free” surgical pathway. At the same time, patients who tested positive, albeit asymptomatic, should be home quarantined or sent to dedicated facilities. When the infection is resolved, the patients can proceed to surgery after proper restaging. On the other hand, healthcare personnel need to be safeguarded through periodic screening and adequate safety precautions.[28] Protecting the healthcare workers will result in more medical and paramedical teams to serve, and containment of the infection. This has been exemplified by the weekly testing done by the National Health Service (NHS) which allowed 1414 health-care workers for early return to serve in the past 3 weeks. Although the initial rates of positive tests were low, the number steadily rose up as the testing was uniformly practiced.[29] It also has a positive effect on the mental health of care givers. An asymptomatic but infected worker can now self-isolate with mild symptoms knowing with early pre-emptive diagnosis. It prevents nosocomial spread and the tendency of the overworked staff to push on with the infection.[30],[31],[32] Limitation- Institutional versus personal practice The limitation of the current strategy is its applicability only to the high-volume centers such as tertiary care institutes or a department with a good capacity of care providers at distinct levels such as consultants, fellows, residents, and dedicated nursing staff. The low-volume centers and the private practitioners would have to individualize the management on the case-to-case basis and their understanding of the resources in their quiver. The low-volume centers should be encouraged to operate on nonemergent cases or the cases in the waiting list of high-volume centers to act as a buffer zone. One important strategy to minimize the cross infections within the same department is the 'divided–dedicated–different' team approach so that all the team members do not get infected at the same time jeopardizing the existing system. Neurological manifestations of Covid-19 There have been isolated reports that the coronavirus is neurotropic.[33] The occurrence of gastrointestinal symptoms suggests that the gastrointestinal system is a possible route of invasion and transmission to the enteric nervous system. How does it exactly enter inside the brain is still not known but the main considered route is olfactory bulb. The other pathways are permeation of the blood–brain barrier (BBB) and through the Vagus nerve as evidenced by the other members of the same family.[34] Once they get inside the brain, they may permeate the CNS in less than a week and begin to appear in the cerebrospinal fluid.[35] So, the complete spectrum and its effect on the CNS is yet to be known, the main pathophysiology is encephalomyelitis. The other presentations are myalgia, headache, hypogeusia, hyposmia, and in rare cases, necrotizing encephalopathy, multiple sclerosis etc. While the effects of Covid-19 on olfactory and gustatory perception may be transient, the possibility that viruses and other contaminant agents can be the initiating etiology of neurodegenerative diseases such as Parkinson's disease (PD) has been raised before. Many a time, neurosurgeons are requested by their neurologist colleagues to do a stereotactic biopsy to rule out other inflammatory pathologies. We need to be skeptical about these cases in the near future.[36] What is Corona virus teaching us? This Corona virus outbreak should be considered as a lesson for the neurosurgical community. Hopefully, this would help us in preparing a task force that can handle neurosurgical emergencies during an infectious crisis and other disasters. Although infectious disorders are a part of the wide spectrum of neurosurgical care, a crisis like novel coronavirus is completely unprecedented. Contemporary studies from the leading centers in the worst-hit Wuhan and the Lombardy region of Italy have given an insight not only in the execution of the services but also the changes this virus has imported on the psyche of the physicians and the patients. Considering our unique status as a country with high patient load, an adapted Indian Neurosurgery Severity scale needs to be followed during the forthcoming months [Table 5].
A recent report from China[37] has highlighted a welcome response that there was no ripple effect or violence against doctors when they started resuming their routine neurosurgical outpatient clinics after the lockdown of three months. They claim that the doctor–patient relationship and in-hospital violence has reduced drastically. Contrary to this in India, the violence against doctors has persistently increased in these challenging times. It is the duty of not only the doctors to brave the battle but also the careseekers and the governing bodies to develop more respect and tolerance in the face of Armageddon. Instead of looking to other nations, an indigenous effort suited to our needs shall be more successful.[38],[39]
Great challenges lead to even greater results. As neurosurgeons, we have always been ahead of the curve. Thanks to our rigorous training and hardened yet empathic attitude, we need to understand that we are not immune to this deadly disease. Till there is a definite treatment or vaccine for coronavirus, the threat looms large. As always, any prevented complication trumps a treated one. The public should be educated to be cautious in preventing and controlling this disease. Otherwise, the mortality 'related' to coronavirus shall be far greater than that 'caused' by it. Acknowledgements We are thankful to the COVID task force at PGIMER, Chandigarh and the Anesthesia team at NIMHANS, Bengaluru for their help and guidance in drafting the appendix. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
[Additional file 1]
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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