Special article

Submitting author: Dr. Stuart White

Department of Anaesthesia, Royal Sussex County Hospital,

Eastern Road, Brighton, E. Sussex, BN2 5BE, UK.

Pragmatic COVID-19 preparedness in older people requiring emergency surgery

S. M. White, 1 M. Paul.1

1Consultant, Department of Anaesthesia, Royal Sussex County Hospital, Brighton, UK

Correspondence to: S. White

Email: stuart.white6@nhs.net

Keywords: older adult, frail; COVID-19; perioperative care

Twitter: N/A

Short title:

COVID-19 and older emergency surgical patients

Summary

COVID-19 is a respiratory pandemic illness caused by a novel coronavirus (2019-nCov, SARS-CoV-2)

that is spread between people in close contact, mainly via respiratory droplets. Although confirmed

cases have occurred in less than 0.1% of populations affected worldwide, case ascertainment rates

are low (10-25%) and attack rates high (30-60%), contributing to significant potential for illness

transmission. National case fatality rates of up to 6% (mean ~2%) have been reported. Approximately

20% of infected people become severely or critically ill, with acute respiratory distress syndrome

(ARDS) and multiple organ failure affecting ~15% and ~5% of hospitalized cases, respectively,

necessitating high flow oxygen therapy or ventilatory support. There are no licensed vaccines or

antiviral drugs to treat patients with COVID-19.

Older people with comorbidities are at disproportionately higher risk of COVID-19- and

emergency surgery-related mortality and morbidity, compared to younger, fitter people. COVID-19-

infected, older, sicker patients requiring emergency surgery merit special consideration during an

epidemic, to avoid cross-infecting other inpatients, visitors and healthcare workers during prolonged

inpatient stays, and to reduce avoidable excess peri-operative morbidity/mortality associated with

their infection.

Anaesthetists, intensivists and allied health professionals will play pivotal roles in managing the

sickest patients infected with COVID-19. Although considerable evidential uncertainties remain about

how to best manage this (and any future) pandemic, this article amalgamates the current available

knowledge on how to manage older patients with COVID-19 requiring emergency surgery, and

references important further sources of information for planning service provision ahead of imminent

national epidemics and managing patients when they present for surgery.

Scientia timor vincit (‘knowledge conquers fear’)

Introduction

COVID-19 (COronaVIrus Disease 2019, hereafter: ‘C-19’) is a respiratory illness caused by a novel

coronavirus (2019-nCov, SARS-CoV-2) that is spread between people in close/direct contact (typically

less than 2 metres, > 15 minutes) via respiratory droplets (coughing, sneezing) or (less commonly)

direct/indirect contact with infected secretions (touch) [1].

At the time of writing (11th March, 2020), the World Health Organisation (WHO) [2], the Centres

for Disease Control (CDC) [1] and Public Health England (PHE) [3] have declared C-19 a pandemic, as

there is sustained local transmission of the infection. C-19 is classified as a high consequence

infectious disease (HCID) in the UK, being an acute infectious disease without effective prophylaxis or

treatment that can be difficult to recognise and detect rapidly, can spread in the community and

within healthcare settings and has a high case-fatality rate, requiring an enhanced individual,

population and system response to ensure it is managed effectively, efficiently and safely [3].

More than 110 000 cases have so far been recorded worldwide, of which ~4 000 (3.5%) have

died, with over 110 countries having reported laboratory-confirmed cases [2]. All three agencies have

issued guidance for members of the public about travel to and from high risk of infection countries

(currently China (where C-19 cases have been confirmed in 0.006% of the population), Korea

(0.015%), Iran (0.008%), Italy (0.015%)), limiting person-to-person viral transmission, self-isolation

and contacting health care providers, and more specific guidance for health care professionals about

investigation and clinical management [4].

A review of 12 studies estimating the basic reproduction number (R0) for C-19 conducted

between 01/01/2020 and 07/02/2020 reported a mean of 3.28 (median 2.79), exceeding WHO

estimates of 1.4-2.5, and indicating that an infectious person can infect a mean 3.28 new people in a

population previously unexposed to C-19 [5]. Exceeding an R0 of 1.00, this suggests that the number

of symptomatic people is likely to increase until the size of the survivor population with acquired C-19

immunity begins to match/exceed that of the non-infected population, or containment is effective, or

a vaccine becomes available, or the virus mutates into a less virulent strain for humans. In the

interim, public health interventions are essential in containing transmission or deferring case

presentation. This will enable health services to better match care provision to peak demand, and

allow time for vaccine development, ahead of any future, polyphasic C-19 re-emergence.

The median (IQR [range]) incubation period (time from exposure to symptom appearance) for C-

19 is 5 days (2-7 [1-14]), during which time the person can potentially transmit C-19 to other people

[6, 7]. The median time from the onset of symptoms to first negative reverse transcriptase-

polymerase chain reaction (RT-PCR) results for oropharyngeal swabs in 66/292 RT-PCR confirmed C-

19-infected Chinese patients has been found to be 9.5 (range 6.0-11.0) days [8]. C-19 may persist

after symptom resolution, meaning that individuals may remain virus carriers for up to 2 weeks after

recovery, although may be less contagious [9].

Most people contracting C-19 report only mild viraemic symptoms: fever ~90%, dry cough

~75%, dyspnoea ~50%, fatigue/myalgia ~45%, headache ~10%, diarrhoea ~5%. Bilateral, multifocal,

peripheral, ground glass lung opacity is the commonest abnormality reported on computerised

tomography, occurring in ~65% cases, although ~20% of cases present without radiographic changes.

Leuco- (lympho-)cytosis (~85%) is commoner than leucopoenia. It should be noted that these are

proportions derived from numerous, observational reports from single institutions of mainly Chinese

origin, rather than from centrally collected, independently-verified sources or meta-analyses, at

present [10].

Approximately 20% of infected people become severely or critically ill (Chinese data, > 44 600

patients) [11]. More severe respiratory symptoms appear to occur in the second week of illness.

Acute respiratory distress syndrome (ARDS) affects ~20% of those hospitalized with C-19, who require

high flow oxygen therapy (‘severe’ cases, ~15%) or ventilatory support (‘critical’ cases, ~5%) on an

intensive care unit for diffuse alveolar damage. Rarer complications include acute cardiac injury

(~10%), acute kidney injury (~7%), shock and multiple organ failure (~7%) and secondary lung

infection (~10%).

Importantly for the purposes of this article, the case-fatality rate increases with age,

comorbidity and C-19 disease severity. Overall, ~2.0% of confirmed infected individuals worldwide

have died after contracting C-19 (3.5% in Europe, 1.2% outside Italy), most within a month of ICU

admission (if admitted) [2]. However, case-fatality worldwide is 3.6% for people aged 60-69 years, 8%

70-79 years and 14.8% ≥80 years [10]. It should be noted that ~85% of people over the age of 80

years contracting C-19 will survive the illness. Data from China have found a case-fatality rate of

13.2% for those with cardiovascular disease, 9.2% for diabetes, 8.4% for hypertension, 8.0% for

chronic respiratory disease, and 7.6% for cancer. Approximately half (49%) of patients die if they

develop respiratory failure, septic shock, or multiple organ dysfunction (Chinese data [12]).

There are no licensed vaccines or antiviral drugs to treat patients with COVID-19, although the

investigational antiviral remdesivir (GS-5734) is currently undergoing urgent trials [10]. Empirical

administration of oseltamivir (Tamiflu) does not appear to affect outcome in hospitalized patients [7,

13].

This places older emergency surgical patients at particular risk of C-19- related mortality or

morbidity, and may well result in a temporary reversal in recent downward trends in 30-day

postoperative mortality after hip fracture, emergency laparotomy and ruptured abdominal aortic

aneurysm.

The median age of patients undergoing emergency surgery for hip fracture in the UK is ~83

years (female), and approximately 66 000 cases (aged >60 years) present to hospital annually, with a

30-day postoperative mortality rate of 6.1% (2018 [14]). The equivalent statistics for ruptured

abdominal aortic aneurysm surgery and laparotomy are 79 years, 2 200 (aged >65 years), ~40% (aged

>65 years, 2016-18 [15]), and 67 years, 13 000 (aged >65 years), ~13% (aged >65 years, 2018 [16]),

respectively. Eighty-four percent of UK hip fracture patients have one comorbidity at least (most

commonly cardiovascular, respiratory or neoplastic) (26% >= 3 comorbidities) [17], as do 55% of UK

patients requiring emergency laparotomy [16].

Such greater risk of morbidity/mortality is unsurprising, given that more severe C-19 infection

appears to contribute a further hypoxic/ischaemic insult to the pathophysiological burden of the

condition needing surgery and the surgery itself, superimposed upon the declining physiological

reserve of older patients (particularly those with cardiorespiratory disease) who maybe taking several

medications or are physically/cognitively frail. Age-, morbidity- and/or medication-related

immunocompromise may be expected to further increase mortality/morbidity, and limit the efficacy

of any future vaccine [18]. Moreover, C-19 infection may further increase the risk of falls in older

patients [19], leading to fragility fracture. Access to critical care with isolation facilities for those

requiring organ support after ruptured AAA or emergency laparotomy with/without C-19 infection is

likely to become limited as the number of C-19 cases increases in the population [20].

The clinical management of older patients requiring emergency surgery requires special

considerations, therefore, concerning:

1. Reduce the risk of uninfected patients contracting C-19 as an inpatient, from their visitors,

other inpatients or healthcare workers;

2. Reduce the risk of infected patients transmitting C-19 to uninfected visitors, other inpatients

or healthcare workers;

3. Reduce any avoidable excess morbidity/mortality associated with requiring necessary

emergency surgery during a C-19 epidemic;

4. Minimise the propagation of psychological distress among patients, healthcare workers and

the general public that might retard efforts to contain or delay the epidemic [21].

At the time of writing, 30 NHS hospitals are on stand-by to receive patients with suspected/confirmed

C-19 infection, and most cases have been taken to 5 of these. However, a number of specific

considerations need to be addressed by all hospitals, as patients may be or become too unstable to

transfer to a designated specialist hospital, or unable to be transferred because the designated

specialist hospital has reached treatment capacity, or most likely because C-19

suspicion/confirmation occurs as an inpatient.

These considerations relate to case ascertainment, communication, patient placement,

multidisciplinary care and staff protection, peri-operative care and decontamination, critical care

management and equitable access to critical care. It should be noted that many of the principles

described below apply equally to all surgical patients, although it would seem prudent to delay any

elective surgery in patients with confirmed C-19, or older patients with comorbidities with suspected

C-19.

Much of the following material represents a synthesis of relevant information provided by

Public Health England [22], the World Health Organisation [23] and the World Federation of Societies

of Anaesthesiologists [24], and Wax and Christian’s review from Canada about caring for C-19-

infected patients [25], and Peng et al.’s editorial on what anaesthetists should know about

coronavirus [26], to which documents readers should refer more closely for further specific guidance.

The material alludes primarily to the management of older people after hip fracture, unless specific

considerations relating to emergency laparotomy or ruptured AAA apply.

Case ascertainment/triage

The vast majority of older patients requiring emergency surgery will be admitted to hospital from the

community, and are likely to present for management of their surgical condition rather than for C-19.

However, this entry point should facilitate early risk assessment of C-19 status and hospitals should

ensure a process is in place on admission to identify possible cases, so triggering relevant case

management and infection control policies [22].

It would seem sensible to have completed a risk assessment before patients are moved out of

the Emergency Department for further inpatient care, given the potential for nosocomial cross-

infection within this medically high-risk patient group.

Risk assessment should address two factors in determining where patients should be cared for

as inpatients: firstly, does the patient have C-19, and secondly, is the patient medically at high risk of

mortality/morbidity related to C-19 infection? These factors triage patients into 1 of 4 categories: (1)

not infected, low medical risk (2) not infected, high medical risk (3) infected, low medical risk (4)

infected, high medical risk. For infected cases, a third factor needs to be assessed concerning the

timing of emergency surgery.

Possible cases are defined by clinical and/or epidemiological criteria [27], which should be

formally sought in all patients. Symptomatic patients or those in recent (<14 days), direct close

contact with a confirmed case of C-19, or having travelled to/transited in specified C-19-affected

countries or areas [28], should be isolated, tested for C-19 and reported (Fig. 1). Test results become

available the same working day, but patients should be managed in respiratory isolation in the

interim, and attended to by personnel wearing appropriate personal protective equipment.

Consideration needs to be given to transferring patients for further tests (for example, radiography)

and to their surgical admission ward.

Patients have higher mortality/morbidity risks related to C-19 infection if they are over 70 years

of age, and/or have cardiorespiratory disease, diabetes or are immunosuppressed.

C-19 non-infected cases

Non-infected (no risk factors, negative test, recovered from C-19) patients with low medical risk

should probably follow normal protocolised pathways for ongoing care.

Institutionally, however, there should sensibly be some consideration about whether non-

infected patients with higher medical risks of any nosocomial C-19 infection should be ‘cocooned’ as

inpatients, that is, admitted to a ward facility that effectively isolates them from nosocomial

infection. For example, ‘cocooned’ wards may be staffed by personnel tested regularly for C-19, with

the reasons for limited contact (e.g. from relatives) sympathetically communicated to external

agencies and advertised at entry points to wards.

Given the clinical implications of untested patients manifesting, or test-negative patients

contracting, C-19 during their relatively long inpatient stay, C-19 criteria should sensibly be re-

assessed daily as any epidemic progresses, and suspected cases managed accordingly; median

inpatient length of stay is ~19 days after hip fracture [14], ~12 days in survivors after ruptured AAA

repair [15]), and ~15 days in older, sicker emergency laparotomy patients [16]).

C-19 infected cases – when and where to operate

If a patient tests positive for C-19, then a senior multidisciplinary decision needs to be made about

when and where emergency surgery should take place. Ideally, this should be informed by latest

institutionally-agreed policies, that take into account: the patient’s medical condition, the availability

of trained personnel/PPE and isolation/critical care/specialist theatre facilities across the hospital,

and any transfer arrangements linking these.

Confirmed cases mandate the use of full PPE measures by healthcare personnel (Fig. 1), as do

any subsequent aerosol generating procedures (AGPs, for example, airway management during

general anaesthesia (Fig. 1), and staff assessing or caring for infected patients should have ready

access to PPE that has been tested for fit, know how their PPE works, how to put the PPE on [29] and

take it off [30], and what to do in the case of malfunction [22]. Senior anaesthetists in particular need

to understand (and, ideally, have practiced) airway management procedures whilst wearing PPE [24].

Infection rates among healthcare workers

A significant proportion of confirmed cases in previous respiratory virus epidemics have been

healthcare workers. Approximately 20% of confirmed SARS cases in 2002/3 and MERS cases 2014-19

were health care workers [31, 32], and ~25% of confirmed cases during the current C-19 outbreak in

China have been healthcare workers (0.3% of which have died) [11]. These figures echo UK

government estimates that up to one fifth of employees may be absent from work during peak

weeks [33].

Any decision where to treat infected patients can be complex, and contrary to normal

procedure. For example, across a Trust containing two hospitals, hip fractures may normally be

repaired at the non-acute Trust and looked after by an orthogeriatric team on a single ward with few

side rooms. During a C-19 epidemic, however, it may be more appropriate to admit infected patients

to a negative-pressure side room on a general surgical ward without orthogeriatric care, close to

critical care facilities, managed by an appropriately-trained and equipped general trauma surgical

team. Ideally, patients should not be transferred between hospitals [22], and so consideration needs

to be given to pre-hospital pathways of care and admission to the most appropriate facility.

In general, infected patients with low medical risk can probably be managed in specified ward-

based isolation rooms, unless their medical condition deteriorates. Infected patients with high

medical risk may need to be managed in isolated critical care facilities, if available.

When risk-assessing infected patients, a third factor needs to be considered early in their

inpatient care and reviewed regularly, namely when to operate. This can be a difficult decision, and

should be made jointly by senior clinicians together with the patient, if possible. Normally, older

patients requiring urgent (hip fracture) or emergency (laparotomy, ruptured AAA) repair have poorer

outcomes after prolonged pre-operative delay, but he mortality/morbidity benefits of timely surgery

need to be balanced against the potential risks of operation for a C-19-infected older, co-morbid

patient with (or developing) cardiorespiratory compromise. Life-threatening surgery, for example for

ruptured AAA or faecal peritonitis, may need to proceed immediately, with the attendant risks of C-

19 infection (hypoxia, ARDS, shock) managed accordingly. Less emergent (for example, for bowel

obstruction) or urgent (hip fracture) surgeries may warrant closely reviewed delay to enable

resolution of increased oxygen requirements/ARDS/shock, but even so, the risks of delay should be

balanced against the risks of delay (for example, abdominal distension splinting diaphragmatic

excursion, venous/pulmonary thrombo-/fat embolism worsening ventilation/perfusion mismatch).

There may patients for whom conservative management is considered the correct option unless they

recover from severe/critical C19 infection.

General principles of peri-operative care

Public Health England have produced excellent guidance on infection prevention and control, and

colleagues should read and familiarise themselves with this [22], together with all relevant Trust

policies.

PHE infer that both surgical patient and healthcare worker exposure to C19 is reduced by:

minimising

– transfers of patients, their effects and medical equipment

– the number of healthcare personnel involved in a patient’s care

– the number of visitors to patients

maximising

– communication

– the implementation of standard infection principles (particularly handwashing),

respiratory and cough hygiene (‘Catch it, bin it, kill it’), transmission based precautions

(PPE), aerosol generating procedures (airway management), isolation, decontamination

strategies, waste disposal and theatre practice.

However, the PHE recommendations and other authoritative sources of information relating to

anaesthetists’ involvement in C-19 cases [22-26], have tended to focus on the anaesthetic

management of C-19 infection per se (i.e. infection control and how/when to intubate/ventilate).

The purpose of the remainder of this paper is to consider further specific clinical and

organisational factors when managing C-19 infected patients requiring emergency surgery (fig. 2).

Preoperative considerations

The importance of early risk assessment in determining inpatient destination and level of care has

been discussed above.

In the interests of minimising contacts, ideally the clinician undertaking C-19 risk assessment

should also be familiar with infection prevention/control strategies, and capable of eliciting a full

medical, surgical and anaesthetic history from the patient, examining them (for C-19 and for their

surgical condition), ordering laboratory and radiological (+ other) tests, seeking consent,

resuscitation status/advance directive/powers of attorney, marking the patient for surgery,

determining the likely operation needed and the patient’s postoperative destination, and

communicating relevant information as necessary to other personnel. This may require hospitals to

identify a number of senior ‘first contact’ clinicians, and develop specific paperwork/electronic

patient records that can be isolated from, and accepted/accessed by, all clinicians involved in onward

care.

The ‘first contact’ clinician, as well as other clinicians subsequently involved in an infected

patient’s care, should probably be at low comorbid risk should they contract C-19 themselves (ie they

should not have significant cardiorespiratory disease, diabetes, or be immunosuppressed). This may

require the re-organisation of staff rotas, with clinicians at higher risk covering operating lists for

colleagues involved in C-19 patient management or onerous on-call rotas.

Institutions may consider it appropriate for ‘first contact’ clinicians and nurses to transfer

patients physically for onward care and handover to receiving personnel, or to convene specialist

transfer teams. There may need to be consideration given to low infectivity routes of transfer from

the Emergency Department to the ward, and the minimum necessary single-use equipment needed

for transfer. If possible, the patient should wear a fluid resistant surgical mask during transfer.

The intraoperative management of older patients requiring emergency should be carefully

discussed at specific, pre-operative meetings, if these are not already routinely convened (eg trauma

meetings). This should allow for multidisciplinary determination of whether surgery needs to take

place in an operating theatre [34], the patient’s medical condition and resuscitation status, what

operation(s) needs to be done and in which order, what surgical equipment is needed to do it, strictly

who needs to be present in theatre and during which phases of the procedure, how further

help/equipment might be accessed as required, and the patient’s discharge destination.

Consideration needs to be given to when components of necessary paperwork, such as peri-

operative care proformas and the WHO surgical safety checklist, should be completed, together with

the process of reconfirming consent and resuscitation status. Again, all paperwork should ideally

remain isolated from contamination. In the same vain, patient effects, such as glasses, hearing aids,

and jewellery) should not accompany the patient to theatre.

Intraoperative considerations

The intra-operative management of C-19 infected patients will likely involve procedures and

equipment that are new to healthcare workers and with which they will be unfamiliar, superimposed

upon normal surgical procedures. Understandably, the interaction between novelty and familiarity

might be expected to cause unexpected problems. To a degree, these might be identified, and

contingencies planned for, by rehearsing organisational and clinical aspects of surgery before

performing emergency surgery in an older patient with C-19 [34]. Certainly, anaesthetists should be

familiar with conducting aerosol generating procedures (AGPs) whilst wearing a full PPE ensemble, as

should surgeons conducting specific aspects of an operation, but there are also predictable

difficulties likely to occur, for instance, should common problems arise. Given these circumstances,

hospitals may elect to carry out ‘dry-runs’ of common procedures (hip (hemi-)arthroplasty and

internal fixation, open/EVAR AAA repair, (hemi-)colectomy, Hartmann’s, small bowel resection)

before C-19 patient surgery, communicating lessons learnt to other theatre teams likely to become

involved with C-19 infected patients.

Canadian clinicians reporting emergency surgery undertaken during the 2003 SARS epidemic

concluded ‘In the absence of credible evidence-based guidelines … the benefit of (PPE) precautions is

likely offset by their disadvantages during emergency operations not involving the airway’, identifying

logistical delays in finding and donning PPE. However, 9 health care workers were infected at the

authors’ institution despite wearing standard PPE [35]. PHE recommend ‘staff should wear (full PPE

ensemble) but only those at risk of exposure from aerosol generating procedures’, which include

airway procedures (anaesthetists) and ‘surgery … procedures involving high-speed devices’ (eg

orthopaedic drills), and, possibly, airway-unrelated suctioning (eg general/vascular/orthopaedic

surgery).

In addition to PHE recommendations for donning/doffing PPE, it is worth reminding clinicians

not to take personal items between ‘dirty’ and ‘clean’ areas, including wallets, purses, jewellery,

mobile telephones, food/drink and writing equipment, alternatives for which may need to be

provided. Similarly, clearly signposted ‘theatre entry points’ should be identified in rehearsals,

demarcating ‘dirty’ and ‘clean’ areas, the transfer of essential items across which should be

minimised and protocolised during surgery.

Contrary to normal practice, all operations should take place in a (single) theatre with a

negative pressure ventilation system, or an unventilated theatre or in an airborne isolation room [22,

26]. This may require reverse engineering by an institution’s biomedical engineering department

[25], or manual sealing of ventilation systems (which should not exhaust into other clinical areas or

public corridors). Additional communication about, and attention to diagnosing, wound infection

may be necessary using a negative/no pressure ventilation system. An equipment audit should

enable identification of any items routinely kept in theatre that could become contaminated in the

course of managing a C-19 patient, and therefore need removal before patient transfer to theatre.

C-19- infected patients should be admitted via the most appropriate route direct to theatre (ie

not via anaesthetic rooms). Only necessary, senior staff should be present in theatre [22, 25, 26],

which may exclude, in some circumstances for example, operating department practitioners (ODPs)

and theatre assistants to remain in anterooms (anaesthetic rooms, theatre equipment preparation

rooms).

As mentioned, most of the guidance and reviews pertaining to the anaesthetic management of

patients with C-19 infection pertain to PPE use [22, 25, 26], minimising contamination during aerosol

generating procedures (intubation, suctioning) [22, 25, 26], securing the airway by intubation in

variously severe levels of respiratory function [24, 25] and managing severe respiratory infection

[23]. Anaesthetists should familiarise themselves with these, as they will not be restated here.

Less published consideration, however, has been given about whether C-19-infected patients

require intubation and general anaesthesia. Whilst the necessity for both is clear in emergency

laparotomy and ruptured AAA surgery, alternative methods of regional anaesthesia (+/- sedation)

exist for emergency orthopaedic operations in older patients, particularly involving the upper

(fracture dislocations of the shoulder and elbow with arterial impingement) and lower (hip fracture,

(periprosthetic) femoral fracture) limbs [36, 37].

General anaesthesia with intubation maybe more beneficial in augmenting oxygenation and

ventilation in more severe/critical pneumonia/ARDS, and provides a closed airway system reducing

aerosol dispersal of infected respiratory secretions. However, regional anaesthesia may reduce the

pathophysiological cardiorespiratory impacts of positive pressure ventilation and general anaesthesia

in less severe respiratory impairment, avoids ‘anaesthetic’ aerosol generating procedures, and

reduces the need for opioid analgesia (which can impair respiratory function) and antiemetic drugs

(which can have deleriant (cyclizine) or specific C-19 immunosuppressive (steroids [38]) side-effects).

Supraglottic airways [26], awake fibreoptic intubation, high-flow nasal oxygen and non-invasive

ventilation (continuous and bilevel positive airway pressure devices (CPAP and BiPAP)) should be

avoided, as they increase the risk of aerosol formation from the upper airway [24-26]. Similarly, the

use of open airway suction should be minimised.

Ideally, sedation during regional anaesthesia should be avoided or administered lightly, to avoid

respiratory depression, apnoeic episodes/coughing and the need for supplemental oxygen (which

disperses aerosol, unless a tight fitting mask with a high-efficiency hydrophobic exhalation filter

attached to a low-flow oxygen source is used [25, 26].

Inhalational anaesthesia may be less practical in locations outside operating theatres, but the

ability to administer intravenous anaesthesia in theatre may be hampered by the availability of total

intravenous anaesthesia/target controlled infusion (TIVA/TCI) equipment and drugs during the peak

of an epidemic when large numbers of C-19 infected patients are requiring mechanical ventilation

and sedation [25]. Likewise, the availability of other anaesthetic equipment (drugs, ventilators,

monitoring, airway) may decline during the peak of an epidemic, as it will be being used,

decontaminated, disposed of, or in transit via interrupted supply chains. Hospitals should prepare for

these eventualities by undertaking an equipment audit during the early phases of an epidemic,

calculating their ‘maximum patient ventilation capacity’, defining pathways of care if/when this

capacity is exceeded [22, 39, 40] and identifying possible measures to isolate equipment from

patient/aerosol contact during use.

During femoral surgery, cardiorespiratory compromise can occur during preparation of the

femoral canal, and insertion of bone cement and/or prosthesis when used (‘bone cement

implantation syndrome’ (BCIS)). Moderate and severe compromise occurs in ~20% and ~3% of

arthroplasty procedures in which bone cement is used [41]. Older, male patients with significant

comorbid cardiorespiratory disease are at higher risk of BCIS. When planning hip fracture surgery in a

patient with C-19 infection, therefore, consideration needs to be given as to whether cement should

be used on this occasion, particularly if the patient is already showing clinical signs of

cardiorespiratory compromise.

Positioning the patient for surgery should remain sympathetic to older patients’

pathophysiology, but attention should also focus on improving their respiratory mechanics, again

particularly if they are already showing clinical signs of cardiorespiratory compromise.

Approximately ninety percent of C-19 patients have fever (>37.5oC axillary) [7, 23], and

attention needs to be paid to their continuous intra-operative temperature management. Rises in

temperature may alert clinicians to worsening illness, declining neurocognitive function, and

increased intravenous fluid/antipyretic requirements. Active cooling does not appear to be

necessary. Forced air warming might be predicted to disperse airway aerosols, and so should not be

used.

Postoperative considerations

In the interests of reducing theatre suite contamination, C-19-infected patients should be recovered

after surgery in theatre. Extubation of the larynx, if feasible, is an aerosol generating procedure [22].

Ideally, the postoperative need for critical care admission should be determined pre-operatively, but

the nature of emergency surgery in older patients with co-morbidities can necessitate emergent or

unexpected admission, in which case pre-planned and agreed protocols should be followed to

achieve this. Again, transferring infected patients from theatre to critical care facilities should involve

a predetermined route that limits hospital contamination, and be undertaken by an appropriately

trained and equipped transfer team (normally, an anaesthetists and a critical care nurse).

Important communication about successes and learning points can occur during a theatre team

debrief once the patient has returned to their postoperative destination, and relevant staff have

completed any necessary waste disposal, environmental decontamination, doffing of PPE and

personal care. It should be agreed between all theatre personnel involved in a case exactly when this

important meeting will be held, before the patient leaves theatre.

Ensuring the health of theatre healthcare workers during an epidemic

The lived experience of health workers providing patient care during an epidemic can have various

physical and emotional consequences. Common themes relate to personal infection/protection and

recovery, fear, duty, work volume and intensity, knowledge and institutional support [21, 34, 42, 43].

Together with confirmed healthcare worker infection (mandating self-isolation away from the

workplace [1, 3], these themes can limit a healthcare system’s ability to meet demand during

epidemic. Hospitals can assist the physical and emotional resilience of theatre staff by, for example,

acknowledging the seriousness of infection risks, ensuring PPE provision and training, supporting

clinical decision making, anticipating and planning for personnel shortages, providing suitable food,

drink, rest and shower facilities within the theatre complex, and enabling in-hospital lines of

communication and external family contact [42-44].

Ethical considerations about equitable access to critical care

Effective containment and deferral measures are designed to delay and flatten off national epidemic

curves, such that the provision of medical services – including critical care - keeps ahead of clinical

demand. Contrasting experience of C-19 containment and deferral in South Korea

(demand<provision) and Italy (demand>provision) has been instructive in this regard, and may be

contributing to lower mortality rates in the former (0.8% vs. 6.2%, respectively).

When the demand for critical care outstrips supply, difficult ethical and legal decisions may

need to be taken about which patients receive critical care treatment, whether they are infected

with C-19 or not.

The Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) have

recognised this dilemma, and published guidance on 6th March, 2020 [45]. This guidance advises that

care should be flexibly prioritised on the basis of clinical need (for those with the ‘greatest life

expectancy’) rather than on a ‘first come, first served’ basis, and decisions taken after discussion with

patients and their relatives carefully communicated, reviewed and recorded.

However, the guidance also recommends that ‘it may be necessary to place an age limit on

entry into critical care facilities’. To distant observers, this is controversial advice based on solely

utilitarian principles (calculating ‘years of life saved’), and may even contravene Articles 2 (Right to

life) and 3 (Prohibition of torture) of the European Convention on Human Rights, codified into the

Human Rights Act 1998 in the UK [46]. Age per se is a poor correlate of clinical need and of outcome

[37, 47]; for example, a 40 year old with severe C-19 pneumonia/multiorgan failure,

immunosuppressed after bone marrow transplant for haematological malignancy, needing

ventilation (potentially for weeks) may be expected to have considerably ‘lower life expectancy’ than

an 80 year old with milder C-19 pneumonia, who was otherwise well but needed ventilation

(potentially for a few days).

In endorsing the SIAARTI recommendations [48], the President, Board of Directors and Ethics

Committee of SIAARTI are on surer ethicolegal grounds in stating ‘… the application of rationing

criteria is justifiable only after all possible efforts have been made by all involved to increase the

availability of (intensive care beds) …’, re-emphasising the importance of containing, deferring and

planning [49] in countries at an earlier stage of their epidemic curve.

To conclude, in all countries affected by COVID-19 infection to date, confirmed cases have occurred in

less than 0.1% of the population. However, national case fatality rates of up to 6% (mean ~2%) have

been reported. C-19-related mortality and morbidity disproportionately affect older people with

comorbidities, in whom the case fatality rate is increased (but only up to ~15% in those aged over 80

years). Older people with comorbidities are also more likely than younger, fitter people to require

emergency surgery, and have poorer postoperative outcomes. Older, sicker patients infected with C-

19 and requiring emergency surgery, therefore, merit special consideration, to both avoid cross-

infecting other inpatients, visitors and healthcare workers, and to reduce avoidable excess peri-

operative morbidity/mortality associated with their infection.

Although the current C-19 pandemic is yet to run its course and there remain considerable

uncertainties about how to manage this and future events, this article has attempted to amalgamate

the current available knowledge for achieving these aims. We strongly encourage anaesthetists and

intensivists, who will play a pivotal role in managing the sickest C-19-infected patients, to educate

themselves and disseminate this knowledge amongst colleagues, when planning service provision

ahead of their national epidemic curves and managing patients when they present for surgery.

Acknowledgments

No funding or acknowledgements to declare.

Competing interests

No competing interests declared.

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Figure legends

Figure 1. Schematic triage for older patients requiring emergency orthopaedic, general or vascular

surgery during a UK Covid-19 epidemic.

Figure 2. Summary of considerations that should sensibly be undertaken by hospitals when planning

how to manage the perioperative care of infected older patients requiring emergency orthopaedic,

general or vascular surgery during a UK COVID-19 epidemic.

Figure 1.

Patient > 65 years requiring emergency surgery

1. RISK ASSESSMENT – might the patient have COVID-19?Epidemiological criteria – less than 14 days before symptom onset: travel to/transit in China, South Korea, Italy, Iran OR a category 2 country OR contact with confirmed cases of COVID-19Clinical criteria any degree/severity of acute respiratory infection AND either shortness of breath and/or cough

(with/without fever) OR asymptomatic fever atypical presentations can occur in immunocompromised patients

Suspected Negative/not suspected

Monitor throughout hospital admission

Usual surgical pathway

Sampling/testing

Implement COVID-19 infection prevention + control policy standard infection control precautions respiratory/cough hygiene transmission based precautions including isolation/PPE aerosol generating procedure (AGP) precautions

2. MEDICAL ASSESSMENT – might the patient be at high risk of postoperative mortality/morbidity? Severe (ARDS)/critical (sepsis/shock/MOF) COVID-19 symptoms AND/OR cardiorespiratory disease, diabetes, cancer

Confirm resuscitation status, contact critical care facility and arrange urgent management/transfer

3. DETERMINE URGENCY OF SURGERY complete paperwork, transfer to theatre/isolation facility (+/- via radiology)

Pre-planned COVID-19 surgical pathway

Confirmed

Figure 2.

General principles of peri-operative care minimize transfers, health personnel, visitors maximize multidisciplinary communication maintain infection prevention + control policy contribute to the physical and mental resilience of theatre personnel

Preoperative considerations early risk assessment (fig. 1) discuss establishing ‘first contact’ senior clinicians isolate paperwork personnel planning and training determine low infectivity routes of transfer (if necessary) specific surgical management planning at preoperative meetings

Intraoperative considerations rehearse organizational aspects of care and solve problems learnt rehearse aerosol generating procedures (AGPs) in full personal protective ensembles (PPE) ‘1 team, 1 theatre’

perioperative care undertaken by smallest number of senior trained personnel identify an appropriate single theatre for all COVID-19 infected cases induce, and recover the patient from, anaesthesia in theatre establish signposted points of entry to theatre

conduct of anaesthesia can the patient have regional anaesthesia only, if the risks of general anaesthesia (AGPs/

cardiorespiratory) outweigh the benefits (oxygenation/ventilation/closed airway system)? avoid supraglottic airways, awake fibreoptic intubation, high flow nasal oxygen, non-invasive

ventilation and forced air warming audit/ensure supply chain/decontamination availability of drugs, ventilators, monitors, airway

equipment, in determining hospital ‘maximum patient ventilation capacity’ follow bone cement implantation syndrome protocols, as appropriate position the patient to optimize respiratory mechanics, as appropriate

Postoperative considerations ensure theatre teams debrief after each procedure ensure equitable access policies for critical care facilities