BSAPS Journal

Since early March 2020, the health authorities of our country have been trying to contain the spread of COVID-19 virus infection. Unfortunately, the situation is such that widespread community transmission is currently taking place throughout the country.

We all know that the American College of Surgeons (ACS), Royal College of Surgeons (RCS), and the Society of Surgeons of Bangladesh (SOB) have laid down some guidelines, based on which surgeons stopped doing elective surgeries from the middle of March. Similarly, Bangladesh Society of Aesthetic Plastic Surgeons (BSAPS) also formulated a guideline on 30th June 2020 (version 1) discouraging major aesthetic procedures. Emergency and some semi-emergency surgeries continued in various hospitals of the country.

Due to the changing scenario and new gadgets being available now for additional safety, BSAPS issued a 2nd version of the guidelines on 23rd August 2020.

Sections

1. Preparation to resume practice
2. Covid consent
3. Chamber/OT setup and staff training
4. Prioritization of procedure and preoperative measures
5. Operative considerations
6. Postoperative considerations
7. Post-treatment COVID-19 positive cases
8. Precautions when going back home

Preparing to resume practice

Triaging of patient should be done over phone to select which patient should come for face-to-face consultation. Only low-risk group patients will fall in this category.

Most of the preoperative as well as many of the postoperative patients should be encouraged to avail virtual consultations or telemedicine.

*Screening for symptoms of COVID-19: All patients must be symptom and contact-free for 7 days prior to consultation, treatment or surgery

*Surgical Team testing: Diagnostic screening test for health care workers: you need to test theatre staff once every two weeks.

Documentation & consenting

Consent: Specific COVID-19 consent should be taken in addition to the procedure-specific consent. it should include

*Risk of contracting infection Outcome in case of covid

* Positive is much worse May need to be shifted to

* Covid ICU/separate hospital

CONSENT FORM FOR SURGERY DURING COVID-19 PANDEMIC

I....................................................... (Patient name) understand that I am opting for an elective procedure …………………………………………….…. that is not urgent. I recognize that …………………………...…………………… (doctor's name) and all the staff at ........................................................................... (hospital/clinic name) have put in place reasonable preventative measures to reduce the spread of COVID-19, which I understand is very contagious. I also understand there is risk of becoming infected with COVID-19

I understand that, even if I have been tested for COVID and received a negative result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test. I understand the possible exposure to COVID-19 before/during/after my treatment may result in the following a positive COVID-19 diagnosis, self-isolation, additional tests, hospital isolation that may require medical therapy, intensive care treatment, possible need for intubation and ventilator support other complications including the risk of death. In addition, after my elective treatment, I may be required to go to a different hospital for additional treatment.

I have been given the option to defer my treatment to a later, However, I would like to proceed with my desired treatment.

----------------------------------------

Surgeon's Signature

PRIORITISATION OF PROCEDURE

Setting up practice

* Consider the physical layout of your chamber and OT and the patient flow.

* Consider waiting room spacing and link corridors. Social distancing should be maintained.

* Transparent plastic screens for reception desk, doctor's chamber and patient beds should be considered.

* Schedule more time between patients and preferably having one patient in the practice at a time.

Preoperative measures

* Testing and self-isolation: Patient should self-isolate at least 7 to 10 days before any surgical procedure.

* Antigen testing for COVID-19 by RT PCR 3 days before surgery.

* Preoperative Rapid Antibody Test can be done to screen patients on 2 occasions, 10 days, and again 3 days before surgery (95% sensitivity and 99% Specificity). This is a routine practice in Italy now. If negative, proceed for surgery. If positive, do an RT-PCR test to confirm if the patient still infected

* A routine Chest X-ray/ HR CT Scan to be done immediately prior to the surgery.

* Nasal packs and a screen taped across the upper lip and sides of the face to allow oral breathing to be diverted away from the surgeon

*Avoid combination surgeries, such as Lipoabdominoplasty with Reduction Mammoplasty/Mastopexy in the same session. Reduce the complexity of procedures and the operating time

* Hospital stay and recovery period should be minimum; encourage 'Day Cases' in the beginning.

Treatment & operative considerations

Surgery consultations and treatment should be away from the treatment area of COVID-19 patients. Treatment should take place in dedicated theatres and wards that are on a different floor.

* Vacuum Aerosol filters (which can trap virus particles) are now available. This device sucks in the OT air from one side and after filtering, the air is circulated back into the OT

* Air cleaning/filter devices should be used for doctor's chamber and also patient waiting areas also Cleaning and decontamination: Thorough cleaning of the treatment area and minor operating facility will be required after each treatment episode.

* Attendants should remain outside the building, preferably in a waiting car. The patient can be discharged directly to their car without any members of the family entering the building.

* Follow-up by virtual consultations should be done from home. In-person follow-ups should be minimum e.g., only for stitch or drain removal.

Post-treatment covid-19 positives

It is possible that some patients can become COVID-19-positive after the procedure. The outcomes of post-operative COVID-19-positive patients (complex major surgeries and in ASA 3 and 4) are much worse. Here mortality can be as high as 20% or more. But in minor surgeries, there is very little or no impact on the outcome.

Precautions for the clinical staff while going back home

To protect family members from getting the infection:

1. Be sure to wash your hands and arms up to elbows for 20 seconds when leaving the clinical setting

1. Keep your hospital shoes outside.

1. Sanitize cell phone, car keys, spectacles, and wrist watch better not to take it to the hospital)

1. Take shower and dip clothes in soap water

PPE

Current PPE guidelines

Face-to-face clinic consultations should be done at a professional distance of >2m. A water-resistant surgical mask should be worn with a visor/face shield. Thin transparent plastic screens should be placed between surgeon and patient. Similar screens should also be used in the reception desk. Visors/eye protection should be cleaned with anti-viral solutions between patients.

PAPR (Powered Air Purifying Respirator)

* Surgeons and theatre staff should wear full PPE for GA procedures including N95 masks. Nowadays PAPR (Powered Air Purifying Respirator) has become available in our country to provide "near total" safety for the surgeons working in OT. It pumps air through a HEPA filter into an airtight hood worn by the surgeon.

They should not be present in theatre at the time of intubation (wait for two air changes before entering theatre) and extubation.

* All members of staff should be trained in donning and doffing techniques and should adhere to protocols for performing this safely to minimize risks of infection. A staff member should be allocated to help/guide the process (as lapses are possible specially during the doffing process).

Half face respirator with (HEPA filters)