The management of surgical patients in the emergency setting during COVID-19 pandemic: the WSES position paper

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Abstract

Background

Since the COVID-19 pandemic has occurred, nations showed their unpreparedness to deal with a mass casualty incident of this proportion and severity, which resulted in a tremendous number of deaths even among healthcare workers. The World Society of Emergency Surgery conceived this position paper with the purpose of providing evidence-based recommendations for the management of emergency surgical patients under COVID-19 pandemic for the safety of the patient and healthcare workers.

Method

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) through the MEDLINE (PubMed), Embase and SCOPUS databases. Synthesis of evidence, statements and recommendations were developed in accordance with the GRADE methodology.

Results

Given the limitation of the evidence, the current document represents an effort to join selected high-quality articles and experts’ opinion.

Conclusions

The aim of this position paper is to provide an exhaustive guidelines to perform emergency surgery in a safe and protected environment for surgical patients and for healthcare workers under COVID-19 and to offer the best management of COVID-19 patients needing for an emergency surgical treatment.

We recommend screening for COVID-19 infection at the emergency department all acute surgical patients who are waiting for hospital admission and urgent surgery. The screening work-up provides a RT-PCR nasopharyngeal swab test and a baseline (non-contrast) chest CT or a chest X-ray or a lungs US, depending on skills and availability. If the COVID-19 screening is not completed we recommend keeping the patient in isolation until RT-PCR swab test result is not available, and to manage him/she such as an overt COVID patient.

The management of COVID-19 surgical patients is multidisciplinary.

If an immediate surgical procedure is mandatory, whether laparoscopic or via open approach, we recommend doing every effort to protect the operating room staff for the safety of the patient.

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Most cited references 116

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Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

Chaolin Huang, Yeming Wang, Xingwang Li … (2020)

Summary Background A recent cluster of pneumonia cases in Wuhan, China, was caused by a novel betacoronavirus, the 2019 novel coronavirus (2019-nCoV). We report the epidemiological, clinical, laboratory, and radiological characteristics and treatment and clinical outcomes of these patients. Methods All patients with suspected 2019-nCoV were admitted to a designated hospital in Wuhan. We prospectively collected and analysed data on patients with laboratory-confirmed 2019-nCoV infection by real-time RT-PCR and next-generation sequencing. Data were obtained with standardised data collection forms shared by WHO and the International Severe Acute Respiratory and Emerging Infection Consortium from electronic medical records. Researchers also directly communicated with patients or their families to ascertain epidemiological and symptom data. Outcomes were also compared between patients who had been admitted to the intensive care unit (ICU) and those who had not. Findings By Jan 2, 2020, 41 admitted hospital patients had been identified as having laboratory-confirmed 2019-nCoV infection. Most of the infected patients were men (30 [73%] of 41); less than half had underlying diseases (13 [32%]), including diabetes (eight [20%]), hypertension (six [15%]), and cardiovascular disease (six [15%]). Median age was 49·0 years (IQR 41·0–58·0). 27 (66%) of 41 patients had been exposed to Huanan seafood market. One family cluster was found. Common symptoms at onset of illness were fever (40 [98%] of 41 patients), cough (31 [76%]), and myalgia or fatigue (18 [44%]); less common symptoms were sputum production (11 [28%] of 39), headache (three [8%] of 38), haemoptysis (two [5%] of 39), and diarrhoea (one [3%] of 38). Dyspnoea developed in 22 (55%) of 40 patients (median time from illness onset to dyspnoea 8·0 days [IQR 5·0–13·0]). 26 (63%) of 41 patients had lymphopenia. All 41 patients had pneumonia with abnormal findings on chest CT. Complications included acute respiratory distress syndrome (12 [29%]), RNAaemia (six [15%]), acute cardiac injury (five [12%]) and secondary infection (four [10%]). 13 (32%) patients were admitted to an ICU and six (15%) died. Compared with non-ICU patients, ICU patients had higher plasma levels of IL2, IL7, IL10, GSCF, IP10, MCP1, MIP1A, and TNFα. Interpretation The 2019-nCoV infection caused clusters of severe respiratory illness similar to severe acute respiratory syndrome coronavirus and was associated with ICU admission and high mortality. Major gaps in our knowledge of the origin, epidemiology, duration of human transmission, and clinical spectrum of disease need fulfilment by future studies. Funding Ministry of Science and Technology, Chinese Academy of Medical Sciences, National Natural Science Foundation of China, and Beijing Municipal Science and Technology Commission.

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Clinical Characteristics of Coronavirus Disease 2019 in China

Wei-jie Guan, Zheng-yi Ni, Yu Hu … (2020)

Abstract Background Since December 2019, when coronavirus disease 2019 (Covid-19) emerged in Wuhan city and rapidly spread throughout China, data have been needed on the clinical characteristics of the affected patients. Methods We extracted data regarding 1099 patients with laboratory-confirmed Covid-19 from 552 hospitals in 30 provinces, autonomous regions, and municipalities in mainland China through January 29, 2020. The primary composite end point was admission to an intensive care unit (ICU), the use of mechanical ventilation, or death. Results The median age of the patients was 47 years; 41.9% of the patients were female. The primary composite end point occurred in 67 patients (6.1%), including 5.0% who were admitted to the ICU, 2.3% who underwent invasive mechanical ventilation, and 1.4% who died. Only 1.9% of the patients had a history of direct contact with wildlife. Among nonresidents of Wuhan, 72.3% had contact with residents of Wuhan, including 31.3% who had visited the city. The most common symptoms were fever (43.8% on admission and 88.7% during hospitalization) and cough (67.8%). Diarrhea was uncommon (3.8%). The median incubation period was 4 days (interquartile range, 2 to 7). On admission, ground-glass opacity was the most common radiologic finding on chest computed tomography (CT) (56.4%). No radiographic or CT abnormality was found in 157 of 877 patients (17.9%) with nonsevere disease and in 5 of 173 patients (2.9%) with severe disease. Lymphocytopenia was present in 83.2% of the patients on admission. Conclusions During the first 2 months of the current outbreak, Covid-19 spread rapidly throughout China and caused varying degrees of illness. Patients often presented without fever, and many did not have abnormal radiologic findings. (Funded by the National Health Commission of China and others.)

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Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Fei Zhou, Ting Yu, Ronghui Du … (2020)

Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p<0·0001), and d-dimer greater than 1 μg/mL (18·42, 2·64–128·55; p=0·0033) on admission. Median duration of viral shedding was 20·0 days (IQR 17·0–24·0) in survivors, but SARS-CoV-2 was detectable until death in non-survivors. The longest observed duration of viral shedding in survivors was 37 days. Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.

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Author and article information

Contributors

Belinda De Simone:

ORCID: http://orcid.org/0000-0002-7956-3097

desimone.belinda@gmail.com

Elie Chouillard: Elie.Chouillard@ght-yvelinesnord.fr

Massimo Sartelli: massimo.sartelli@gmail.com

Walter L. Biffl: Biffl.Walter@scrippshealth.org

Salomone Di Saverio: salo.75@inwind.it

Ernest E. Moore: Ernest.Moore@dhha.org

Yoram Kluger: y_kluger@rambam.health.gov.il

Fikri M. Abu-Zidan: fabuzidan@uaeu.ac.ae

Luca Ansaloni: aiace63@gmail.com

Federico Coccolini: federico.coccolini@gmail.com

Ari Leppänemi: Ari.Leppaniemi@hus.fi

Andrew B. Peitzmann: andrewpeitzmanab@upmc.edu

Leonardo Pagani: lpaganiID@gmail.com

Gustavo P. Fraga: fragagp2008@gmail.com

Ciro Paolillo: ciro.paolillo@asst-spedalicivili.it

Edoardo Picetti: epicetti@ao.pr.it

Massimo Valentino: mvm.valentino@gmail.com

Emmanouil Pikoulis: mpikoul@med.uoa.gr

Gian Luca Baiocchi: gianluca.baiocchi@unibs.it

Fausto Catena: faustocatena@gmail.com

Journal

Journal ID (nlm-ta): World J Emerg Surg

Journal ID (iso-abbrev): World J Emerg Surg

Title: World Journal of Emergency Surgery : WJES

Publisher: BioMed Central (London )

ISSN (Electronic): 1749-7922

Publication date (Electronic): 22 March 2021

Publication date PMC-release: 22 March 2021

Publication date Collection: 2021

Volume: 16

Electronic Location Identifier: 14

Affiliations

[1 ]Service de Chirurgie Générale, Digestive, Metabolique, Centre Hospitalier de Poissy/Saint Germain en Laye, Poissy, France

[2 ]Department of General Surgery, Macerata’s Hospital, Macerata, Italy

[3 ]GRID grid.415402.6, ISNI 0000 0004 0449 3295, Department of Trauma and Acute Care Surgery, , Scripps Memorial Hospital, ; La Jolla, CA USA

[4 ]Department of General Surgery, University Hospital of Varese, University of Insubria, Varese, Italy

[5 ]GRID grid.239638.5, ISNI 0000 0001 0369 638X, Trauma Surgery, , Denver Health, ; Denver, CO USA

[6 ]GRID grid.413731.3, ISNI 0000 0000 9950 8111, Department of Emergency and Trauma Surgery, , Rambam Health Campus, ; Haifa, Israel

[7 ]GRID grid.43519.3a, ISNI 0000 0001 2193 6666, Department of Surgery, College of Medicine and Health Sciences, , UAE University, ; Al-Ain, United Arab Emirates

[8 ]GRID grid.414682.d, ISNI 0000 0004 1758 8744, Department of Emergency and Trauma Surgery, , Bufalini Hospital, ; Cesena, Italy

[9 ]GRID grid.5395.a, ISNI 0000 0004 1757 3729, Department of Surgery, , University of Pisa, ; Pisa, Italy

[10 ]Abdominal Center, University Hospital Meilahti, Helsinki, Finland

[11 ]GRID grid.21925.3d, ISNI 0000 0004 1936 9000, University of Pittsburgh School of Medicine, ; F-1281, UPMC-Presbyterian, Pittsburgh, PA 15213 USA

[12 ]Infectious Diseases Unit, Bolzano Central Hospital, Bolzano, Italy

[13 ]Departamento de Cirurgia, Faculdade de Ciências Médicas (FCM) –Unicamp, Campinas, SP Brazil

[14 ]GRID grid.412725.7, Spedali Civili di Brescia, , ASST degli Spedali Civili di Brescia, ; 25123 Brescia, Italy

[15 ]GRID grid.411482.a, Department of Anesthesia and Intensive Care, , Parma University Hospital, ; Parma, Italy

[16 ]Department of Radiology, Tolmezzo Hospital, Tolmezzo, Italy

[17 ]GRID grid.5216.0, ISNI 0000 0001 2155 0800, Department of Surgery, , Attikon General Hospital, National & Kapodistrian University of Athens (NKUA), ; Athens, Greece

[18 ]GRID grid.7637.5, ISNI 0000000417571846, Department of Surgery, , University of Brescia, ; Brescia, Italy

[19 ]GRID grid.411482.a, Department of Emergency and Trauma Surgery, , Parma University Hospital, ; Parma, Italy

Author information

Belinda De Simone http://orcid.org/0000-0002-7956-3097

Article

Publisher ID: 349

DOI: 10.1186/s13017-021-00349-0

PMC ID: 7983964

PubMed ID: 33752721

SO-VID: 6414e1b0-99fd-41d7-905a-ccce0c81f621

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 22 September 2020

Date accepted : 27 January 2021

Custom metadata

ScienceOpen disciplines: Surgery

Keywords: covid-19,emergency surgery,personal protective equipment,2019-ncov,sars-cov-2,laparoscopy,open surgery,trauma surgery,non operative management,screening,follow-up,postoperative care,pandemic

Data availability:

ScienceOpen disciplines: Surgery

Keywords: covid-19, emergency surgery, personal protective equipment, 2019-ncov, sars-cov-2, laparoscopy, open surgery, trauma surgery, non operative management, screening, follow-up, postoperative care, pandemic

The management of surgical patients in the emergency setting during COVID-19 pandemic: the WSES position paper

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Abstract

Background

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Novel Coronavirus Disease COVID-19

Most cited references 116

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

Clinical Characteristics of Coronavirus Disease 2019 in China

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

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