Updated Intercollegiate General Surgery Guidance on COVID-19 25th March 2020
Surgeons will continue to care for patients in the current crisis, especially emergencies. Patient care will be affected if surgeons become sick and leave work. This current document updates recent guidance as further information has now emerged from government, Italy and China. We must follow guidelines and also apply common sense to at risk clinical environments. Consider COVID-19 infection possible in every patient. While priorities may change as rapid testing becomes available, these are our combined updated guidelines:
- Acute patients are our priority. COVID-19 should be sought in any patient needing emergency surgery by history, COVID-19 testing, recent CT chest (last 24h) or failing that CXR. Any patient undergoing abdominal CT scan must also have CT chest.
- Any patient currently prioritised to undergo urgent planned surgery must be assessed for COVID-19 as above and the current greater risks of adverse outcomes factored into planning and consent. Consider stoma formation rather than anastomosis to reduce need for unplanned post-operative critical care for complications.
- Full Personal Protective Equipment (PPE) should be used for laparotomy except perhaps when the patient is convincingly negative for COVID-19, but note that current tests maybe false negative. Full PPE includes wearing visors or eye protection. It is imperative to practise donning and doffing PPE in advance.
- Laparoscopy should generally not be used as it risks aerosol formation and infection. Chinese and Italian experience reflects this. SAGES have offered guidance. Advocated safety mechanisms (filters, traps, careful deflating) are difficult to implement. Consider laparoscopy only in extremely selected cases where the mortality benefit is substantially beyond doubt in the current situation.
- Use appropriate non-operative treatment of appendicitis or open appendicectomy.
- Treat acute biliary disease conservatively for now or with cholecystostomy.
- In theatre:
- Minimum number of staff in theatre
- Full protective PPE including visors for all staff in theatre
- Stop positive ventilation in theatre during procedure and for at least 20 minutes after the patient has left theatre
- Smoke evacuation for diathermy / other energy sources
- Patients are intubated and extubated in theatre – staff immediately present should be at a minimum.
- Risk situations in surgery also include:
- Approaching a coughing patient, for example, even if COVID-19 has not been diagnosed. Protection including eye shield is needed.
- Naso-gastric tube placement is an aerosol generating procedure (AGP). AGPSs are high risk. Full PPE is needed. Consider carrying out in a specified location.
- Only emergency endoscopic procedures should be performed . No diagnostic work to be done and BSG guidance followed. Upper GI procedures are high risk AGPs and full PPE must be used.
Updated Intercollegiate General Surgery Guidance on COVID-19 27th March 2020
This updated guidance will be subject to further amendment in the light of new national recommendations in relation to PPE and aerosol generating procedures. It should be noted that current advice from Public Health England in relation to positive flow ventilation in theatres should be followed and the previous text related to this issue has been removed.
Surgeons will continue to care for patients in the current crisis, especially emergencies. Patient care will be affected if staff become sick and leave work. This current document updates recent guidance for general surgery now further information has emerged from government, Italy and China. Consider COVID-19 infection possible in every patient. We must follow guidelines and also apply common sense to at risk clinical environments. Unfortunately, many patients will be disadvantaged by the current pandemic and increased risks apply to all patients. Teams will apply judgement based on local circumstances, resources and for some exceptional patients. While priorities may change as incidence increases and rapid testing becomes available, this is our current combined updated guidance for general surgery. This guidance is intended to aid development of consensus regarding regional and local approaches to treatment. It will be reviewed as regularly as possible but there will remain a great deal of uncertainty regarding the pandemic and you should update yourself from government and hospital resources also.
- Acute patients are our priority. COVID-19 should be sought in any patient needing emergency surgery: use history, COVID-19 testing, recent CT chest (last 24h) or failing that CXR. Any patient undergoing abdominal CT scan should also have CT chest. Current tests for COVID-19 may be false negative.
- Any patient currently prioritised to undergo urgent planned surgery must be assessed for COVID-19 as above and the current greater risks of adverse outcomes factored into planning and consent. Consider stoma formation rather than anastomosis to reduce need for unplanned post-operative critical care for complications.
- All theatre staff should use PPE during all operations under general anaesthetic whether by laparoscopy or laparotomy and infection control practices should be followed, as determined by local and national protocol. Those protocols advise on levels of Personal Protective Equipment (PPE) based on risk from proximity to potential viral load. When COVID-19 status is positive or uncertain, international experience recommends Full Personal Protective Equipment (PPE) be used for laparotomy but shortages prevent this in most areas and stratification is necessitated with lesser measures for low-risk cases. Full PPE is advised for positive or suspected patients and includes double layers of disposable gloves and gown, eye protection and FFP3 mask. It is imperative to practise sterile donning and doffing of PPE in advance. Procedural tasks are slower and more difficult when wearing full PPE. In low risk patients it may be pragmatic currently to use appropriately reduced measures, including a type 2R fluid resistant mask with visor and disposable gown and gloves as a minimum.
- Laparoscopy is considered to carry some risks of aerosol-type formation and infection and considerable caution is advised. The level of risk has not been clearly defined and it is likely that the level of PPE deployed may be important. Advocated safety mechanisms (filters, traps, careful deflating) are difficult to implement. Consider laparoscopy only in selected individual cases where clinical benefit to the patient substantially exceeds the risk of potential viral transmission in that particular situation.
- Where non-operative management is possible (such as for early appendicitis and acute cholecystitis) this should be implemented. Appropriate non-operative treatment of appendicitis and open appendicectomy offer alternatives.
- In theatre:
- Minimum number of staff in theatre
- Appropriate PPE for all staff in theatre depending on role and risk
- Smoke evacuation for diathermy / other energy sources
- Team changes will be needed for prolonged procedures in full PPE
- Higher risk patients are intubated and extubated in theatre – staff immediately present should be at a minimum.
- Only emergency endoscopic procedures should be performed. No diagnostic work to be done and BSG guidance followed. Upper GI procedures are high risk AGPs and full PPE must be used.
- Consider the diagnosis and risk of COVID-19 in other situations in Emergency General Surgery settings and act accordingly. Presentations with intestinal symptoms occur and COVID-19 may present initially as an apparent post-operative complication. Naso-gastric tube placement may be an aerosol generating procedure (AGP). AGPSs are high risk and full PPE is needed. Consider carrying out in a specified location.
Following publication of Public Health England latest guidelines, the four Royal Surgical Colleges and the Association of Surgeons of Great Britain and Ireland, AUGIS and ACPGBI have revised their latest guidelines (last published on the 27th March 2020) to align with those of PHE and Health Protection Scotland. As a group, we have taken a lead on gathering information on best practice that Surgeons should follow in this difficult situation because our role is to protect and support the clinicians that we represent.
These guidelines also have the support of The Royal College of Radiologists. We welcome the updates from PHE and want to make sure that all guidance is aligned so that our Surgeons and practitioners working in theatre are clear about what they have to do to keep themselves, their patients and the general public safe.
Updated General Surgery Guidance on COVID-19 7th April 2020
The UK government released updated guidance on Personal Protective Equipment (PPE) on 2 April. This advice changes or clarifies guidance regarding the use of PPE in common general surgical settings including the ward, admission area, endoscopy and operating theatre and it is essential that you read it. A convenient summary table is also available. Following the advice is essential for your own safety, to protect your patients and family also, and to allow you to continue to treat patients during this crisis.
Consider the possibility of COVID-19 infection in every patient, follow national guidelines and apply common sense to at risk clinical environments. Unfortunately, many patients will be disadvantaged by the current pandemic and increased risks apply to all patients. Teams may have to apply judgement based on local circumstances, resources and for some exceptional patients. This guidance is intended to aid development of consensus regarding regional and local approaches to treatment. There will remain a great deal of uncertainty regarding the pandemic and you should update yourself from government and hospital resources also. The Colleges and other bodies have excellent resources on line.
1. Acute patients are our priority. COVID-19 should be sought in any patient referred acutely or needing emergency surgery: history, COVID-19 testing, and CXR can assist. Any patient undergoing an abdominal CT scan for acute pain as an emergency presentation should have a CT chest at the same time, unless CT chest previously performed within 24 hours. Current tests for COVID-19, including CXR and chest CT, may be false negative.
2. Any patient currently prioritised to undergo urgent planned surgery must have self-isolated and be assessed for COVID-19 as above.The current greater risks of adverse outcomes from possible COVID-19 infection after surgery should be factored into planning and consent. Consider stoma formation rather than anastomosis to reduce need for unplanned post-operative critical care for complications.
3. Operating theatres where Aerosol Generating Procedures (AGPs) are regularly performed are considered a higher risk clinical area and full PPE is advised where COVID-19 is possible or confirmed. General anaesthesia is an AGP. In line with PHE guidance, full PPE consists of disposable gloves and fluid repellent gown, eye/face protection and FFP2/3 mask. It is imperative to practise sterile donning and doffing of PPE in advance. Procedural tasks are slower and more difficult when wearing full PPE.
4. Laparoscopy is considered to carry some risks of aerosol-type formation and infection and considerable caution is advised. The level of risk has not been clearly defined and the level of PPE deployed may be important. Advocated safety mechanisms (filters, traps, careful deflating) can be difficult to implement. The smoke plume at laparotomy from coagulating instruments may also not be without some risk. Given the current requirement to protect staff and other patients, a safety-first approach is needed.
– Consider laparoscopy only in selected individual cases where clinical benefit to the patient substantially exceeds the risk of potential viral transmission to surgical and theatre teams in that particular situation.
– Where non-operative management is possible and reasonable (such as for early appendicitis and acute cholecystitis) this should be implemented. Appropriate non-operative treatment of appendicitis and open appendicectomy offer alternatives. Some gall bladder operations can be reasonably deferred for several weeks. Commissioning advice from AUGIS on gallstone disease can be helpful in assessing urgent cases that cannot be deferred.
5. In theatre:
– Minimum number of staff in theatre
– Appropriate PPE for all staff in theatre depending on role and risk
– Smoke evacuation for diathermy / other energy sources
– Team changes will be needed for prolonged procedures in full PPE
– Higher risk patients are intubated and extubated in theatre – staff immediately present should be at a minimum.
6. Only emergency endoscopic procedures should be performed. Routine diagnostic work should be avoided and BSG guidance followed for urgent cases. Upper GI procedures are high risk AGPs and full PPE must be used.
7. Consider the diagnosis and risk of COVID-19 in other situations in Emergency General Surgery settings and act and use PPE accordingly. Presentations with intestinal symptoms occur and COVID-19 may present initially as an apparent post-operative complication. Naso-gastric tube placement may be an aerosol generating procedure (AGP). Also, although chest compressions with CPR are not normally considered aerosol generating, compression patients often splutter and cough so full PPE in these instances should also be considered. AGPs are high risk and full PPE is needed. Consider carrying out in a specified location.
The College has released an update to the intercollegiate guidance, now updated from the 30th May:
- With the UK peak in COVID-19 admissions reportedly past, some of the steps in our previous guidance might now be modified, depending on local circumstances. Key local factors will be background infection rate, maintaining cold sites for elective surgery, availability of PPE, testing capabilities and ability to stream patients. The Associations, Colleges and NHS have produced guidance on re-starting surgery which is available on their websites.
- Data are emerging to guide us about postoperative risks. When major surgery is carried out in COVID-positive patients, whether diagnosed peri-operatively or post-operatively, the risks appear to be substantial.
- On the other hand, early reports suggest that elective major surgery may be carried out with acceptable risks in selected groups of self-isolated and swab negative cancer patients with perioperative care taking place in a COVID-cold environment. These apparent early successes come from areas with separate elective hospitals. Best practice in maintaining relatively COVID-cold sites has yet to be precisely defined. It is likely that staff and patient testing, good bed management, attention to patient flow and footfall, and allocation of staff, where feasible, to either hot or cold sites will all play a role.
- Two streams of patients are emerging and must be separated on basis of potential infection risk:
- Elective patients (isolated for 14 days, screened with questionnaire and tested by throat swab within 72 hours of surgery) undergoing surgery in a COVID-cold site.
- Acute patients whose status is unknown and who are therefore a potential risk to themselves and others. In EGS patients undergoing CT abdomen and pelvis for diagnostic purposes, assessment should include CT chest unless equally reliable and rapid alternative testing methods are locally available.
- The need persists for us to consider safety of all healthcare personnel, resource priorities, and infection rates in addition to the outcome of the individual patient.
- The risks of viral infection and dissemination from surgical smoke plume are unknown but there is concern about uncontrolled release of pressurised gas in laparoscopic surgery and use of electrocautery and other devices in open surgery. Proponents of laparoscopy during COVID-19 highlight potential risks and need for risk mitigation strategies including use of technological protection and enhanced PPE.
- Units have cautiously re-established laparoscopy where all criteria are met, theatre teams are satisfied with safety and skill set and most importantly, where the team consider that the benefits outweigh the risks in their local set up.
- A recent review indicates that greater caution continues to be needed with emergency surgery in terms of safety, diagnosis, and optimal treatment choices.
- As we progress through the phases of the COVID-19 pandemic, further information will continue to emerge and inform practice. The continued use of adequate PPE remains essential.
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