|Year : 2021 | Volume
| Issue : 2 | Page : 164-168
Demographic profile and clinical characteristics of surgical patients operated in COVID-19 operation theater in a tertiary care hospital
Sapna Bathla1, Mahak Mehta1, Akshaya Kumar Das2, Parul Mullick1, Dharam Singh Meena1, Usha Ganapathy1
1 Department of Anesthesia, VMMC and Safdarjung Hospital, New Delhi, India
2 Department of Anesthesia and Critical Care, AIIMS, Jodhpur, Rajasthan, India
|Date of Submission||05-Apr-2021|
|Date of Decision||22-Apr-2021|
|Date of Acceptance||09-May-2021|
|Date of Web Publication||29-Sep-2021|
Dr. Akshaya Kumar Das
VIVEK, Plot No-1, Subhash Nagar, Jodhpur - 342 008, Rajasthan
Source of Support: None, Conflict of Interest: None
Background and Aim: Surgical procedures in patients with COVID-19 disease are associated with increased perioperative morbidity and mortality. A retrospective study was conducted to evaluate the demographic and clinical data of surgical patients with suspected or confirmed COVID-19 disease.
Methods: After taking hospital ethics committee approval, medical records of surgical patients operated during the period from May 2020 to November 2020 in a COVID-19-designated tertiary care hospital of northern India were assessed. The demographic data such as age, gender, associated comorbidities, type of surgery, intraoperative complications, and data on the postoperative status of the patients were collected and analyzed.
Results: Ninety-four patients underwent surgical procedures during the study period. Out of all patients, 87.2% were females. The median age of patients was 28 years (range: 1 month–59 years). The emergency cesarean section was the most common surgery performed. The subarachnoid block was the most commonly used anesthesia technique. Out of 94 patients, 70 patients were confirmed COVID-19 positive, and 24 were suspected cases. Most of the patients were American Society of Anesthesiologists II (83%) and 43.6% of patients had comorbidities.
Conclusion: The cesarean section was the most commonly performed surgical procedure. The most common anesthesia technique used was the subarachnoid block. The patients operated under subarachnoid block had a better prognosis and did not require intensive care unit stays in the postoperative period.
Keywords: Cesarean section, COVID-19 disease, emergency surgery
|How to cite this article:|
Bathla S, Mehta M, Das AK, Mullick P, Meena DS, Ganapathy U. Demographic profile and clinical characteristics of surgical patients operated in COVID-19 operation theater in a tertiary care hospital. Indian Anaesth Forum 2021;22:164-8
|How to cite this URL:|
Bathla S, Mehta M, Das AK, Mullick P, Meena DS, Ganapathy U. Demographic profile and clinical characteristics of surgical patients operated in COVID-19 operation theater in a tertiary care hospital. Indian Anaesth Forum [serial online] 2021 [cited 2021 Dec 7];22:164-8. Available from: http://www.theiaforum.org/text.asp?2021/22/2/164/326982
| Introduction|| |
The first case of the novel coronavirus was detected in Wuhan city of China in late December 2019.,,, The disease rapidly spread to different parts of the world and was declared as a world pandemic by the WHO on March 11, 2020. COVID-19 disease created huge panic among the public because of its highly contagious nature and little knowledge regarding the disease manifestation. The manifestation of COVID-19 disease varies from asymptomatic cases to severe COVID-19 disease with acute respiratory distress syndrome and multi-organ failure.
In most of the hospitals, elective surgical procedures are being performed only in patients with preoperative negative reverse transcriptase-polymerase chain reaction (RT-PCR) report. Time constraints before the emergency surgical procedures, a lack of availability of a rapid and sensitive screening tool for detection of SARS-CoV-2 virus, and a large proportion of asymptomatic patients have been a few of the challenges faced in the management of emergency surgical procedures during the COVID-19 era.
Anesthesiology and surgical societies have released guidelines and advice regarding the conduct of surgical procedures in patients with COVID-19 disease to prevent its spread to health-care workers. In our institute, elective surgical procedures were not being undertaken in patients suffering from COVID-19 disease. However, emergency surgical procedures were performed with due precautions to prevent the spread of the aerosol among health-care personnel during the perioperative period. There are limited data, regarding the demographic profile prognosis and mortality of COVID-19 patients who underwent emergency surgical procedures.
We thus planned to perform a retrospective analysis of the demographic profile, perioperative course, prognosis, and mortality of patients undergoing emergency surgical procedures in our hospital, a COVID-19-designated tertiary care hospital of Northern India.
| Methods|| |
This retrospective study was conducted in Vardhman Mahavir Medical College and Safdarjung Hospital, a COVID-19 dedicated tertiary care hospital, after taking hospital ethics committee approval. The demographic and clinical data of suspected or confirmed positive SARS-CoV-2-infected surgical patients during the period from May 2020 to November 2020 were collected.
Patients were suspected to have COVID-19 disease if they had symptoms such as high-grade fever, shortness of breath, sore throat, and lower respiratory tract infection and were either in contact with a confirmed positive case of COVID-19 disease or had a history of travel or residents of the containment zone. Those patients whose RT-PCR was positive were considered as confirmed COVID-19 positive.
The demographic data including age, gender, American Society of Anesthesiologists (ASA) physical status classification, associated comorbidities, type of surgery, intraoperative complications, and data on the postoperative status of the patients were collected and analyzed. The collected data were expressed in Microsoft Excel. The continuous variables were expressed in the median and range whereas the categorical data were expressed as percentages. The statistical analysis was performed by SPSS (SPSS - 25,IBM,New Delhi ,Delhi , India) latest version.
| Results|| |
A total of 94 patients underwent surgical procedures during the study period. Most of the patients were females (87.2%) with a median age of 28 years (age range: 1 month–59 years).
Out of 94 patients, 70 patients were confirmed COVID-19-positive patients and 24 were suspected cases. The demographic profile of patients is shown in [Table 1]. Most of our patients belonged to ASA Class II (83%). Out of 94 patients, 43.6% had some comorbidities. The most common comorbidities were hypertension (13.3%) followed by diabetes mellitus (11.5%) and hypothyroidism (8.6%). The various other comorbidities present in our patients are shown in [Table 1].
|Table 1: Demographic profile and clinical characteristics of patients operated in COVID-19-dedicated operation theater|
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Seventy-four patients were referred from the obstetrics and gynecology department whereas ten patients were referred from the general surgery department; four patients were from the orthopedics department and there were two patients each from the ENT, neurosurgery, and pediatric surgery department.
Cesarean delivery was the most common surgery performed (83%) followed by exploratory laparotomy with (11.7%). Other surgical procedures performed are shown in [Table 2].
|Table 2: Anesthesia characteristics of patients operated in COVID-19-dedicated operation theater|
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Most of the surgeries were performed under the subarachnoid block (68 patients), 23 patients received general anesthesia, 3 patients were given monitored anesthesia care. Out of 23 patients received general anaesthesia there was one case in which subarachnoid block was converted to general anesthesia(GA), 22 patients were induced initially with general anaesthesia where as one patient is converted to GA after spinal anesthesia failure as shown in [Table 2].
The majority of the surgeries were uneventful. During the intraoperative period, four patients had hypotension, out of which two patients were confirmed COVID-19 positive while the other two were COVID-19-suspected cases. One of the COVID-19-positive patients had ST depression in the intraoperative period. Excessive bleeding during surgery was observed in one of the COVID-19-suspected patients. There was one confirmed case of COVID-19 disease having dilated cardiomyopathy with pacemaker in situ on dual vasopressor support as shown in [Table 3].
|Table 3: Number and percentage of patients operated with intraoperative complication operated in COVID-19-dedicated operation theater|
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Following completion of surgery, 77.7% of patients were directly shifted to ward while 23.3% required intensive care unit (ICU) stay.
| Discussion|| |
In patients with COVID-19 disease, elective surgical procedures were postponed due to the risk of spread of SARS-CoV-2 disease among the health-care providers and increased mortality after surgery in SARS-CoV-2-infected patients. A systematic review and meta-analysis showed: postoperative mortality among surgical patients with COVID-19 was as high as 20%. However, the emergency surgical procedures were performed under due precautions to prevent the spread of disease among health-care personnel during the intraoperative period and to decrease the mortality in these patients.
In our study, most of the patients who underwent emergency surgical procedures were referred from the obstetric or surgical wards in the COVID-19-designated block of our hospital. Eighty-two out of 94 patients (87.2%) were females. Of the 82 female patients, 70 patients underwent cesarean delivery. Likewise, the majority of the patients who underwent surgery were females in a study conducted by Knisely et al. and Wang et al. Knisely et al. found that most of the surgeries performed were general surgeries followed by emergency lower segment cesarean section, while in our study, the most commonly performed surgical procedure was cesarean delivery (74.4%). The patient's immune function is a major determinant of disease severity, and surgical stress further impairs immune function as well as induces a systemic inflammatory response. As pregnancy is an immunocompromised state, so pregnant females are more susceptible to infection with the SARS-CoV-2 virus. The incidence of COVID-19 in the pregnant females was found to be 14.43% as per the study by Nayak et al.
Most of the surgeries, 68 out of 94, were performed under subarachnoid block. Twenty-three patients received general anesthesia. Surgery was performed under monitored anesthesia care in three patients and there was one case in which subarachnoid block was converted to general anesthesia.
General anesthesia requires airway intervention and may exacerbate pneumonia in COVID-19 patients leading to a high risk of perioperative pulmonary complications as compared to regional anesthesia.,, A previous systematic review reported that the incidence of postoperative pneumonia in patients undergoing neuraxial anesthesia was lower than that in patients undergoing general anesthesia (odds ratio, 0.63). Regional anesthesia is not an aerosol-generating procedure, so the risk of COVID-19 transmission is lesser with general anesthesia. In our study, only the patients in whom regional anesthesia was contraindicated received general anesthesia.
In our study, general anesthesia was admin only to those patients in whom regional anesthesia was either not indicated due to surgical or patient factors or there was a failure of the regional block.
In our study, 43.6% of patients had associated comorbidities. Even Yang et al. found that comorbidities were prevalent in COVID-19 patient with severe manifestations as compared to non-severe patients and hypertension was found to be most prevalent in that patients. We too found the most common one to be hypertension followed by diabetes. The state of hyperglycemia and insulin resistance in diabetic patients would weaken the synthesis of pro-inflammatory cytokines such as interferon-γ and interleukin and their downstream acute-phase reactants which makes diabetic patients more susceptible to SARS-CoV-2. Simultaneously, viral infection may cause sharp fluctuations in blood glucose levels in patients with diabetes, which will adversely affect the rehabilitation of patients.
After the completion of the surgery, patients who had no intraoperative complications were shifted directly to the ward while 23.3% of patients were shifted to ICU. All of these patients had undergone their surgery under general anesthesia.
There was an interesting case of a 25-year-old patient who was in her 39 weeks of pregnancy having dilated cardiomyopathy, tricuspid regurgitation, and mitral regurgitation with ejection fraction 20% and pacemaker in situ, on dual vasopressor support, posted for cesarean delivery.
Since health-care workers are at a high risk of cross-infection. The availability and especially proper donning and doffing of personal protective equipment (PPE) is of utmost importance and may at times be a cause of delay.
To reduce delay in the treatment of these patients, the protocol we followed is that cases were informed to the anesthesiologist before shifting to the operation room (OR). Patient history was obtained telephonically. One anesthesiologist and technician don the PPE kit and check the anesthesia machine and prepare the necessary drugs and arrange equipment. The patient is directly transferred to the OR for surgery. After surgery, the patient is sent back to the COVID-19 ward or COVID-19 ICU as deemed necessary.
Timely treatment of urgent cases with SARS-CoV-2 infection as well as protection of medical staff should both be taken into consideration. In this pandemic, it is essential to ensure emergency surgical care. If there is a failure of nonoperative management and surgery is deemed necessary, appropriate PPE and precautions must be adopted, and surgery should not be delayed while waiting for the swab results., The plan and decision to recognize whether surgery is required should be conducted by a team of senior clinicians with the experienced anesthetist, surgeon, and infection control experts.
| Conclusion|| |
Our retrospective analysis shows that most of the surgical patients were referred from the specialty of obstetrics and gynecology and the cesarean section being the most common surgical procedure performed. A surgical procedure performed under neuraxial anesthesia has a better prognosis and lesser complications than general anesthesia.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]