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Surgery during global pandemics: Focus on prioritization and resource allocation
Pandemic disease is the spread of an illness across a vast geographic area, with a prevalence that transcends a singular country or continent, but extends across the entire globe. By comparison, an epidemic is the spread of an illness across a particular locality, region, or community. Human history features a well-documented record of pandemics; some of the most notable examples include the plague of Athens (430–427 bc ), leprosy (11th century), the Black Death (1350s), and the H1N1 influenza (1918–1919).
For more than 100 years, humanity has managed to avoid a pandemic as catastrophic as the H1N1 flu of 1918, which infected an estimated 500 million people and was responsible for millions of deaths. However, since that time, the world’s markedly increased population has encountered several major emerging infectious disease (EID) threats, including severe acute respiratory syndrome (SARS) (2003), Ebola (2004), H1N1 or swine flu (2009), and most recently, coronavirus disease 2019, also known as COVID-19. In today’s society, modern transportation capabilities allow travel across the globe in as little as 24 to 48 hours, connecting humans in an unprecedented way, while concurrently providing an opportunity for rapid and difficult-to-intercept spread of EIDs. When factoring this into the array of both known and unknown pathogens, it is not far-fetched to postulate that at any given time, the entire human civilization is only steps removed from a catastrophic zoonotic exposure leading to the next global pandemic.
In the face of this constant health security threat, the question of global pandemic preparedness must be answered. More specifically, it is critical to determine what practical historical lessons surgeons and other medical professionals should draw upon in order to adequately prepare for EID threats. Certainly, lack of adequate preparation is bound to result in fear and chaos; as noted by our contemporaries: “[F]or physicians and patients alike, COVID-19 has clouded every aspect of our lives with uncertainty, and the consequences of our suppressed panic and anticipatory dread are impossible to predict.” Thus, it is crucial that new policies, approaches, and strategies be implemented to not only blunt the impact of an emerging pandemic, but also minimize any disruptions to the provision of surgical care to patients, in both inpatient and outpatient settings.
The importance of “flattening the curve”
When considering the spread of both known and potential pathogens, the most critical factors to establish is how they are transmitted, the ease of transmission, as well as their virulence. Pathogens can spread via direct transmission through person-to-person contact (e.g., sexually transmitted diseases); droplets through coughing and sneezing (e.g., influenza, SARS-CoV-2); or via indirect transmission (e.g., measles—air, cholera—water, rhinovirus—fomites, black plague—animal carriers, or malaria—insect vectors). Certain viral-specific properties, including the particular strain, the inoculation titers, or the duration of time the virus can remain viable outside of the body, all factor into the level of infectivity. Exposure risks can be further modulated by how frequently a contaminated surface is utilized or contacted, the structural makeup of a fomite, the degree of ultraviolet (UV) light exposure, and indoor versus outdoor location, among other factors. Perhaps the most challenging trait of certain pathogens is the ability to propagate in an animal or insect reservoir before crossing over into a human host. Such diseases are referred to as zoonoses, and account for about 60% of infections known to affect humans, and approximately three out of every four novel diseases can be linked back to an animal/vector as the original carrier. Viruses like influenza, Nipah, Ebola, Zika, and SARS coronavirus (including SARS-CoV-2) originated in various animal hosts before being transmitted to humans. Unfortunately, there is no reliable way to determine in advance which zoonoses are capable of, or more likely to infect humans.
The introduction of a novel pathogen (e.g., one to which humans are neither naturally immune nor possess effective pharmacological therapies) can quickly lead to an out-of-control pandemic with associated high mortality rates, thus underscoring the importance of a reliable global surveillance system capable of early detection and outbreak containment. Depending on the mode of pathogen transmission, nonpharmacologic interventions (NPIs; e.g., handwashing, facial mask wearing, and social distancing) need to be employed to help “downmodulate the curve” of the outbreak or pandemic ( Fig. 1 ). This approach entails population-level education regarding specific measures that are effective in curbing the spread of the infection. It is important to note that NPIs can vary across different infectious agents and that frequent reassessment of NPIs being employed should be performed using evidence-based approaches. Overall, the ability to effectively downmodulate the curve saves lives. However, there can be nontrivial nonmedical (e.g., economic) trade-offs at the societal level.
Notable pandemics since the early 1900s: The argument for ongoing vigilance
Influenza
Seasonal influenza, commonly referred to as the flu, is typically seen from October to May in the United States. The 2018–2019 flu season saw approximately 35,520,883 cases and 34,157 deaths, while during 2017 to 2018, there were approximately 44,802,629 cases with 61,099 deaths, illustrating the significant population impact of influenza. The 1918 H1N1 (i.e., “Spanish flu”) pandemic is among the most devastating EID events of the past 150 years, with >50 million people killed and difficult-to-measure downstream global aftereffects that likely extended for years, if not decades. Today, the most commonly identified influenza strains are H1N1 and H3N2. Among these two strains, H3N2 typically targets individuals > 65 years of age (65% of cases) and is associated with a greater risk of coinfections, as compared to H1N1, which has a greater tendency to affect younger patients (ages 15–64 comprise 52% of cases) and is linked to greater incidences of pneumonia, acute respiratory distress syndrome (ARDS), and longer intensive care stays.
In the late 1950s, a new strain (H2N2) influenza pandemic caused approximately 2 million deaths worldwide, followed by the novel H3N2 pandemic in the late 1960s, causing 1 million deaths. The most recent H1N1 (i.e., swine flu) pandemic occurred in 2009 to 2010, with nearly 61 million people testing positive within the United States and an estimated 151,700 to 575,400 mortalities on a global scale. Although considered a novel strain, it had close similarities to the 1918 H1N1 pandemic virus. The latter phenomenon was believed to have played some role in the immunity seen in many individuals over 65; a defense not afforded to the younger population.
In surgical patients, the presence of H1N1 is believed to compound the problems of what would otherwise be considered routine diagnoses and procedures. Published data are scarce; however, multiple case reports suggest that coexisting H1N1 infection may substantially impact patient outcomes related to admissions for common surgical emergencies. On average, H1N1 has an incubation period of 2 to 7 days. Cases of H1N1 confirmed using real-time reverse transcription polymerase chain reaction (rRT-PCR) were thought to have worse outcomes across a variety of scenarios (appendicitis, cutaneous infection, traumatic brain injury, and bowel obstruction). More data are required to determine the validity of these assumptions. Current evidence that supports H1N1 is susceptible to antiviral therapies such as oseltamivir (Tamiflu) and zanamivir. Furthermore, the influenza vaccine offers effective acquired active immunity after a single dose in those 10 years of age and older, with a second dose recommended for those under 10 years old.
Human immunodeficiency virus (HIV)
HIV, the virus that causes AIDS, was found to be circulating within the borders of the United States for at least 12 years before AIDS was initially identified in 1981. Data from 2018 estimates approximately 37.9 million individuals are currently infected with HIV/AIDS worldwide, with a suspected 1.7 million new cases each year. About 1 in 7 of the presumed 1.1 million individuals infected in the United States are not even aware that they have contracted the disease. The effects of HIV on the provision of surgical services were profound, including mandatory testing of blood products, increased barrier precautions during surgical procedures, and postexposure prophylaxis and testing.
In response to HIV, numerous strategies were developed to enhance the protection and safety of both patients and medical staff, specifically recognizing that procedural specialties such as general surgery and its various subspecialties were at an increased risk of exposure through potential scalpel lacerations, needlesticks, or direct contact with open wounds. After universal precautions for HIV were introduced by the Centers for Disease Control and Prevention (CDC) in 1987, all blood and bodily fluids were considered potentially infectious with HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), or other bloodborne pathogen regardless of whether or not the patient’s status is known. Preventing direct contact with these substances remains the primary means of reducing patient-to-provider exposure in the health care setting. In 2013, the CDC outlined procedures to follow in the event of occupational exposure, defining health care personnel (HCP) as anyone employed or volunteering at a health care facility who could be potentially exposed to patient blood or bodily fluids through direct or indirect contact. Double gloving decreases the chance of a needlestick exposure and allows for quick removal of extravasated blood from the affected area. During invasive procedures, the use and handling of blades and needles should be minimized, optimizing the use of items such as electrocautery and staplers. Minimally invasive laparoscopic surgery should be performed whenever possible. In situations requiring a lymph node biopsy, fine-needle aspiration (FNA) or computed tomography–guided biopsies should supersede open techniques, with an open lymph node biopsy done only if further information is required.
Coronaviruses—from middle east respiratory syndrome to COVID-19
When Middle East Respiratory Syndrome Coronavirus (MERS-CoV) emerged in April 2012, it spread through 25 countries, including parts of the Middle East, areas of neighboring Northern Africa and Europe, before it began to taper off. Although the MERS-CoV never reached pandemic proportions, the approximately 35% lethality of this particular coronavirus strain was substantial. This was comparable to the approximately 30% lethality of smallpox, arguably one of history’s deadliest diseases. The MERS-CoV is also highly infectious. In one report, a single patient was documented to transmit MERS-CoV to 11 people (6 medical providers, 5 patients or visitors), 2 of whom were health care workers (HCWs) that died shortly after coming in contact with the patient. The time of exposure for those that acquired the virus ranged from as little as 1 to 2 minutes up to 8 hours. In terms of acuity, nearly 81% of infected patients required tracheal intubation. Moreover, patient with preexisting conditions, such as advanced age, tobacco use, obesity, diabetes, cardiovascular diseases, chronic respiratory disorders, malignancy, renal failure, immunosuppression (including transplantation), and hepatic cirrhosis appeared to have predilection toward mortality after contracting MERS-CoV, with mortality increasing as the number of preexisting conditions rose.
The presence of MERS-CoV in postsurgical patients adds further complexity to the hospital course of those who are already at increased risk of perioperative complications. A case series described an outbreak in a cardiac surgical ward that ultimately lead to deaths of five out of six infected patients, all of whom had no preprocedural signs or symptoms of MERS-CoV. Given what is known regarding the effects of the virus in the presence of comorbidities, including various forms of cardiovascular disease and tobacco use, one can speculate that MERS-CoV and mortality were linked. Much has been learned about containment strategies, with relevant experiences from the SARS, MERS, and Ebola virus disease outbreaks over the past two decades. These lessons learned will prove helpful in containing future pandemics.
In December 2019, Wuhan, China, became ground zero for what would become the coronavirus disease 2019 (COVID-19) pandemic, associated with SARS-CoV-2 virus. This pandemic is likely the single greatest international health security threat since the 1918 H1N1 pandemic, spreading swiftly among travelers, close contacts of infected individuals, and members of the community. SARS-CoV-2, a novel betacoronavirus, was identified in January 2020 as the seventh known human coronavirus and third novel coronavirus to emerge within the past 17 years (including both SARS-CoV and MERS-CoV). The SARS-CoV-2 appears to spread primarily via droplet particles and requires contact points with external mucosal surfaces (i.e., the mouth, nose, eyes, or upper aerodigestive system). There is also early evidence of fecal-oral and fomite transmission. It is believed to be twice as lethal in men as in women. COVID-19 infection has an incubation period between 5.1 and 6.4 days and takes an average of 11.5 days (95% confidence interval 8.2–15.6 days) to show symptoms in the majority (97.5%) of symptomatic individuals. However, as many as half of those infected can remain asymptomatic, supporting the hypothesis that there is active asymptomatic transmission.
Most of those affected by COVID-19 experience mild to moderate acute symptoms, including fever, malaise, cough, and/or dyspnea, that usually resolve within a week. In addition, a wide array of heterogeneous symptoms has been described, and more importantly, some patients may be relatively asymptomatic before experiencing interspersed periods of severe symptoms, and there are also cases of gradual progression of symptoms that linger before worsening. Despite its appearance in the majority of cases, fever is not always present in early illness and among older patients. In the highest acuity cases (8%–15%), patients may deteriorate into respiratory distress with acute inflammatory response and multisystem failure including encephalopathy, acute cardiac injury, and renal failure, contributing to an intensive care mortality of 14% to 66%, depending on patient-specific factors. Severe infection is infrequent among younger patients, but deaths in children and adolescents have occurred (e.g., infants less than 1 year of age have higher morbidity and mortality). Obesity and comorbid conditions increase risk in this group as well.
Of importance, COVID-19 can have significant extrapulmonary complications, including venous and arterial thromboembolic events in more than 30% of SARS-CoV2-positive patients, despite use of systemic prophylaxis (low-molecular-weight heparin). In one relatively small sample of COVID-19 patients, up to 36% were noted to have VTE on imaging, demonstrating the high prevalence in this disease. Complications included acute pulmonary embolism (PE, approximately 80%), deep-vein thrombosis (DVT), ischemic stroke, myocardial infarction, (MI) or systemic arterial embolism. Although the exact mechanism of this prothrombotic state is unclear, it has been suggested that coagulation activation, endothelial dysfunction, abundant inflammation, hypoxia, immobilization, and diffuse intravascular coagulation all may contribute. Despite the lack of definitive, high-level evidence, it may be prudent to closely monitor COVID-19 patients for fibrinogen, PT, and PTT, as well as to consider increased dosing or frequency of venous thromboembolism (VTE) prophylaxis to prevent increased levels of procoagulant factors such as fibrinogen and factor VIII, similar to strategies employed in postoperative bariatric surgery patients.
Additional complications seen in COVID-19 patients include altered mental status and encephalopathy in elderly patients (potentially related to exacerbation of preexisting cerebrovascular disease) and a variety of other neurologic complications (e.g., encephalitis, acute hemorrhagic necrotizing encephalopathy, acute transverse myelitis, Guillain-Barré syndrome, and meningitis) affecting patients who are older than 60 years of age. Of importance, there is increasing evidence that myocardial injury and arrhythmias may be more common in COVID-19 patients, likely a multifactorial and heterogeneous phenomenon. Renal and metabolic complications may also occur, from acute renal failure to rhabdomyolysis presenting as extremity weakness and pain accompanied by a substantial increase in creatinine kinase and urine myoglobin. Although individuals under the age of 18 tend to have relatively mild manifestations of COVID-19, there are concerns regarding Kawasaki-like syndrome seen in a small percentage of younger patients. New information about SARS-CoV-2 is evolving continually, and our understanding of this complex disease is likely to evolve in the near future.
Impact of pandemic phase on surgical practice and services
Regardless of whether we are examining the local or the international context, the impact of pandemics on surgical practice is profound. From a logistical operations perspective, a pandemic can be compared to a fast-approaching hurricane. Consequently, the initial response may consist of a reactive “brace for impact” plan. Surgeons, allied health care personnel, and administrators should engage in early and proactive drafting of an emergency response, complete with appropriate patient acuity triage, resource allocation, diagnostic screening/testing, personal protective equipment (PPE), as well as efficient and safely modified operating room (OR) workflows.
The impact of a pandemic on a broad range of surgical diseases, from elective hernia operations, to oncologic resections, to urologic functional surgery, to coronary artery bypass grafting, can result in significant delays to definitive care. Therefore, surgeons should expect late, and much more complex, presentations of surgical diseases that ordinarily are subject to primary prevention (e.g., strangulated hernia, advanced malignancy, post–myocardial infarction coronary disease).
Preparedness and emergency reorganization of surgical services
Resilience of health care systems during pandemics will be largely dependent on preparedness, structural readiness, protocolized approaches, and successful implementation of reorganization of various services, including surgical services. Consideration should be made for clear and transparent ways to distinguish and separate infected and noninfected patients. Resources permitting, this patient flow potentially includes dedicated infectious disease-positive radiology suite (CT scanner, x-ray machines, etc.), hospital floors, and ORs. In addition, reorganization and redistribution of surgical equipment, venues, and staff members may also be required. If a large surge of critically ill patients occurs, nonessential or elective surgeries will likely be canceled, freeing up ORs, anesthesia equipment, and postoperative recovery areas as overflow space for intensive care. Since critical care training is an integral part of most surgical training programs in the United States, surgeons or trainees with critical care experience can thus be repurposed to intensive care management.
Management of elective surgeries during a pandemic
“Elective surgery” is a term that is inherently ill defined, but most consider elective procedures to be either nonessential or nonemergent. General perioperative recommendations and guidelines during COVID-19 have been issued by numerous governmental and specialty organizations across the globe. Although a uniform definition of an elective procedure is somewhat heterogeneous, and each patient should still be evaluated individually, it is generally agreed upon that surgical services that are nonessential or time critical should be deferred to a later date when acute pandemic phases subside. During the COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS) announced that all elective surgeries, including all nonessential surgical, medical, and dental procedures, should be delayed, with guidance provided to surgeons regarding specific circumstances and options. A proposed framework in evaluating elective surgery during the pandemic includes reviewing national, state, local, and society guidelines and ensuring surgeon compliance; leveraging “content experts” within an institution (e.g., surgeons, administrators, infectious disease specialists, ethics committees) for decision making; considering current and projected resource needs and allocations; as well as the awareness of national, regional, local, and patient needs. Of importance, even during a pandemic, ethics deem that certain lifesaving procedures must be performed, including oncologic, transplant, and trauma/emergency surgery. Certainly, although available resources may not permit the conduct of all elective operations, appropriate prioritization should ensure that cases with greatest urgency are able to proceed.
Management of emergency surgeries during a pandemic
With regard to emergency surgeries during pandemics, the two main goals of safety and prevention must be prioritized. The primary consideration in management is whether postponement of surgery is at all possible. If a true surgical emergency is present (e.g., hemodynamically unstable patient, peritonitis with sepsis), surgical management is required, but key precautions must be taken. These precautions include limiting staff to the smallest number possible with proper PPE, as well as a designated OR with adequate equipment. Recommendations specific to the most common surgical emergencies are as follows.
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