Marc Giménez-Milà MD, EDAIC, EDIC
“While the brain continues to be a mystery, the universe will continue to be a mystery” (Mientras el cerebro sea un misterio, el universo continuará siendo un misterio) is quoted from Dr Santiago Ramón y Cajal. Decades before being awarded in 1906 with the Medicine Nobel Prize for the description of the structure of the nervous system based on neuron cells, he travelled abroad to Cuba. There, he would experience tough local health conditions particularly after falling ill with malaria. Fortunately, months after being infected he managed to recover and continue to work to fund the basis of modern histopathology. An eminent front-liner, once again, being afflicted by a transmissible disease during the execution of professional duties. Malaria in those days, while nowadays SARS-CoV-2, a distinct viral agent, is the subject of our concerns.
The anxiety to cure the new disease cannot obscure the crude reality that we need still time; time to collect data, interpret it, disseminate it and learn how to implement the knowledge in clinical practice. Our ESA newsletter is aware of these extremely relevant matters but also of the need for exchange of views, and learning how institutions have adapted to overcome difficulties throughout these months. Most of the hurdles are common in different countries and therefore we should also share solutions in an open and transparent forum, which we strongly invite all ESA members to participate in.
A profound adaptation is what we have been doing since pandemic exploded, to cope with the nearly 3 million infected people throughout Europe (as at the beginning of August). However, from now on, we need a reflective reinvention of the whole healthcare system, maintaining the modifications that have been shown to be beneficial and amending the ones that have not so much. Despite not being an exhaustive description, some of these are exemplified in the following paragraphs. Most of them are based on my professional experience in the last 6 months which, I anticipate, may differ grossly from yours, our readers.
Patient-Relative-Doctor relationship. We have implemented strict regulations of no relatives visiting the patient, aiming to limit the transmission of the virus. It is assumed that this may protect the vulnerable patient, but we may differ in end-of-life care, or in critically ill patients. A very restrictive local policy may produce disruptive grief in relatives causing more undesired harm than benefit.
Surgical procedures. It has been described that outcomes of patients infected from SARS-CoV-2 perioperatively have worse outcomes (1) in all surgical specialities with a mortality of up to 25%. Common sense would dictate that elective oncologic procedures should not be delayed in order not to worsen prognosis by delaying surgery. Nevertheless, how we need to approach other types of disease that, if not intervened in soon, may be associated with complications that can cause important functional disability and even mortality. Cataract surgery is a relatively benign surgical procedure, but if not operated soon the vision problems can cause falls and fractures, and considerable morbidity and mortality. On the other hand, should we perform procedures nowadays with no clear mortality benefit such as thoracic sympathectomy for treating uncomfortable palmoplantar hyperhidrosis?
While it can be read as a somewhat philosophical matter, defining what will be non-deferrable procedures will be a key concept to benefit the patients while we protect them from being infected with SARS-CoV-2.
Nosocomial infection. A thorough protocol of preoperative nasopharyngeal detection of the virus with an epidemiological interview may identify asymptomatic or oliogosymptomatic patients (2) may reduce or almost eliminate the risk that an infected patient undergoes an elective surgical procedure. Despite all hygienic measures, contact tracing and even in the case of institutions performing periodic virus testing for all its staff, we have to accept the risk of SARS-CoV-2 nosocomial infection. It is important that preoperatively patients are made aware of this, being reflected in renewed informed consent.
Preoperative assessment. A preoperative outpatient clinic may facilitate execution of rehabilitation programmes, a realistic calculation of patient risk, provision of information and also verification of its understanding. Establishing a bidirectional communication preoperatively with the anaesthesiologist may decrease anxiety (3). Difficulties on phone calls are well known by all of us and therefore we should, under my view, maintain the current preoperative assessment in high-risk patient or surgical procedure. Moreover, in the case of assessment without the patient present, how do we record it or document it. This implies that we need, once again, to modify our pathways to accommodate new normality.
Intraoperative issues. Different gadgets and methods have been described to minimise the risk of aerosol formation during the intubation and extubation period (4). Predicted difficult intubation may be seen as a terrible enemy because awake intubation either with bronchoscope or video laryngoscope is associated with risk of dissemination of upper respiratory secretions.
Choice of locoregional anaesthesia, when possible, maybe a reasonable alternative supported by international guidelines (5). Moreover, from now more patients with cured COVID-19 will be attended in our operating theatres and endoscopy areas, with some sequelae after infection. Neuromuscular deconditioning, microvascular thrombotic diathesis and post-ARDS impaired lung function may affect outcomes after major surgery. We will have to integrate all these to decide when to operate or perform an interventional procedure.
Above all, there is only one absolute truth which is the need to re-invent the current healthcare system focusing on the patient and relatives. The earlier we accept it, the earlier we can work on it.
- COVIDSurg Collaborative… Lancet 2020 4;396(10243):27-38
- Ching-Wei D Tzeng, Mediget Teshome, Matthew H G Katz, et al. Ann Surg. 2020 Aug;272(2):e106-e111
- H A Jlala 1 , J L French, G L Foxall, et al.. BJA 2010, 104; 3: 369–374
- Jolin Wong, Shimin Ong, Lin Stella Ang. Trends in Anaesthesia and Critical Care. 2020 Volume 33, Pages 25-26
- Balakrishnan Ashokka, Arunangshu Chakraborty, Balavenkat J Subramanian, et al.. Reg Anesth Pain Med. 2020;45(7):536-543.
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