Strategy for treating vascular emergencies during the Covid-19 pandemic in China

Chinese data about patients infected with COVID-19:

• 3019 medical staff found infected with covid-19 in 422 medical institutions housing over 72,314 patients 
• A survey from central south hospital of Wuhan university showed that nosocomial infections accounted for 41.3% of 138 confirmed cases (57/138) of Covid-19, while cases in medical staff accounted for 29% (40/138). 

Covid-19 causes vascular cases such as: 

• acute aortic dissection 
• ruptured thoracoabdominal aortic aneurysms 
• acute arterial embolism 
• Deep Venous thrombosis of lower extremities 
• High mortality vascular diseases  

As there is a short rescue window for such cases it is a very critical situation to deal with also nosocomial infections are most likely to occur from contact during patient transport and management. 

Hospital San yasaya university at Guangzhou (Vascular center) has used 

the national diagnosis and treatment plan and the infection prevention control to prevent frontline medical staff members from being infected. 

Prof. Jinsong Wang also announced their handbook on management and prevention of COVID-19.

Established prevention control protocol in operating centers, it's very critical for vascular centers: 

• Reinforce and ensure protection by medical personnel  
• It also provides protective structures for pre- and postoperative patients  

Blood availability for transfusion is often very challenging: 

As the number of patients needing blood transfusion is much higher than people give blood donation. Also, hospitals need to communicate closely with their local blood banks and keep track of blood available for planning operations.  

Strategy for out-patients: 

• To avoid cross-infections and prevent further spread of the epidemic, elective and non-urgent vascular operations should be delayed based on the current and predicted numbers of COVID-19 patients. 
• Elective operations should only be performed when the number of COVID-19 patients is low. 

Prof. Jinsong Wang explained a graph showing the number of vascular patients between Jan to April 2020. 

Covid-19 screening and triage: 

• History and physical exam with temperature check, chest CT scanning, Pharyngeal swab samples for nucleic acid tests and point of care antibody tests 
• Imaging relevant to the patient’s vascular emergency should be completed. 

Strategy for surgical intervention: 

• Minimally invasive endovascular interventions are preferred due to less blood loss, reduce likelihood of blood infection and decrease the post-operative recovery time. 
• If open surgery is necessary, staged procedures and alternative methods can be used to avoid major surgical operations that involve major blood loss. 
• Life-threatening conditions should be addressed first with secondary operations performed only after limits on personal protective equipment and blood bank volume have been lifted. 
• The type of anesthesia is basically determined by the type of emergency vascular case. Aortic surgery should be performed under intubation and lower limb surgery can be performed under local nerve block or intubation if necessary. 

Training the medical personnel for covid-19 related procedures and rules is a very important step as most of the doctors don’t have enough knowledge for the prevention and control of infectious disease. 

There are some critical steps to avoid nosocomial transmissions such as wearing proper personal protection, enforcing disinfection measures and engaging in proper training 

Overall assessment and treatment principles of vascular emergencies: 

1- Treatment of confirmed Covid-19 patients with acute vascular surgical diseases: 

• patients with vascular emergencies with unstable vital signs  
• Suspected or confirmed COVID-19 patients with unstable vital signs caused by vascular emergencies 
• Patients who have unstable vital signs cannot be screened 

2- Treatment of non-COVID-19 patients with acute vascular surgical disease 

The Medical team performs a rapid assessment of risk and benefit: 

If the benefit is greater than the risk, a surgical treatment plan is formulated and the operation is performed then the patient is transported to an isolated room that actively treats COVID-19 cases. 

If the Risk is greater than the benefit the patient should be isolated for conservative treatment followed by the isolation procedures until his condition is stable   

Strategies for the prevention and control of COVID-19 during emergency vascular surgery: 

1. Preparation of isolation room: 

• An isolated operating room should be under negative pressure 
• If a negative pressure OR is not available, it can be substituted with a separate air conditioner OR. Also limited number of Staff should be in the room. 
  

2. Surgical supply preparation:

• All the supplies should be fully prepared before the patient enters the room and all the medical personnel should be equipped with PPE according to the level three protection standard 
  

 3. Patient transport:

• Special routes designed by the hospital task force. All routes should be cleared and have minimal human traffic before transportation to limit any contact. 
• Medical personnel should wear level 3 PPE and the patient must wear a mask and transported in a negative pressure isolation chamber if available. 
• Equipment should also be disinfected after each use with 2000 mg/L chlorine or 75% ethanol. The elevator used must be immediately closed and disinfected with UV light for 1 hour. 
  

4. Surgical protective wear and intraoperative precautions

• All operative personnel must be equipped with level 3 PPE including the google and the shoe covers to avoid contamination from COVID-19 and during the operation if the environment is infected a solution of 5000 mg/L - 1000 mg/L chlorine should be used immediately. 

5. Postoperative management

• The patient is extubated in the isolated ICU ward. The surgeon and anesthesiologist, while adhering to level 3 protective measures transport the patient to the isolated ICU ward’ 
  

6. Surgical personnel, the PPE worn in the isolated area are removed before entering locker room and personnel should shower and change before leaving. The medical staff who participated in the operation should do medical observation and quarantine for 14 days if necessary

7. Reusable surgical instruments after the operation, they should be disinfected and sterilized in chloride disinfected

8. Pathological specimens should be well labelled with COVID-19 and transported from the OR along the designed pathway to the pathology department

9. Wasteful items are packaged in double layers of yellow medical waste bags and should be labeled COVID-19.

10. Final disinfection, when there are visible contaminants on the ground or any other surface, they are removed first then disinfected with 2000mg/L chlorine disinfected then cleaned with water

11. Indoor air, the operating room post disinfection must be closed for 2 hours before reopening 

In conclusion, establishing detailed infection control and prevention protocols in the operating room, expediting testing procedures and patient screening for COVID-19, Utilizing case specific treatment planning for vascular patients with COVID-19 and establish protective awareness within medical personnel.