SAGES

Reimagining surgical care for a healthier world

Notes from the Battlefield – April 6, 2020

by

Corona Virus Global Surgical Collaborative (CVGSC)*
An initiative sponsored by SAGES in collaboration with EAES, AEC, KSELS, and ELSA

Re-sterilization of N-95 masks

Given the shortage of PPE around the globe, much effort has been placed in extending the life of N95 masks ( https://www.sages.org/n-95-re-use-instructions/ ). The FDA has now approved at least two systems for sterilization of N95 masks which will likely be of significant impact while we await for a larger production of new masks. Both systems use vaporized hydrogen peroxide. The below links are informational of the systems that to our knowledge are currently approved.

Closing the backdoor

Many of the healthcare efforts are concentrated at the hospital’s front door, screening patients for COVID symptoms and triaging all patients to areas of the hospital according to their potential of having the disease. From the European experience, it became evident that there is a need to control the spread of the virus originating from the assumed “clean areas” within the hospital. While in an ideal situation all patients coming to a hospital be tested for Covid-19, it is currently occurring only at very few institutions. Despite prior recommendations, the testing of all patients undergoing surgery ( https://www.sages.org/notes-from-the-battlefield-march-30-2020/ ) is still not uniformly practiced because continuing limitations in availability of testing and quick turnaround time. Regular screening of patients in the “clean areas” is therefore essential for early identification and isolation of newly infected cases. This is better done through a formal process. EAES and SAGES have created a Standard Operating Procedure (SOP) document that may be of assistance.

Can the “cytokine storm” be curtailed?

SARS-CoV-2 infection induces an excessive and aberrant host immune response that is associated with an acute respiratory distress syndrome characterized by the plasma increase of many cytokines: the so-called “cytokine storm”. The use of anti IL 6 medications, traditionally used in bone marrow transplant patients, may offer potential benefit:

    • Chinese researchers (Xiaoling Xu1, Mingfeng Han, Tiantian Li et al. Effective Treatment of Severe COVID-19 Patients with Tocilizumab. ChinaXiv: 202003.00026v1) treated 21 patients with severe or critical COVID-19 pneumonia with Tocilizumab obtaining a reduction in oxygen requirement (15/20), a resolution of CT lesions (19/21), a normalization of lymphocyte count (10/19), a reduction of C-reactive protein levels (16/19), leading to hospital discharge (19/21) with an average hospitalization duration of 13.5 days. These results are considered by the Chinese authors to be very positive and lead to the design of a randomized trial (Tocilizumab vs control) which will include approximately 190 patients and is expected to reach the planned accrual by mid-May 2020.
    • In Italy a national study is being conducted on the use of Tocilizumab which has already enrolled 300 patients. In particular, in Pavia University Hospital were 30 patients have been treated with non-homogeneous results.
    • The FDA has approved a randomized, double-blind, placebo-controlled phase III clinical trial to evaluate the safety and efficacy of intravenous (IV) Tocilizumab (Actemra) plus standard of care in hospitalized adult patients with severe coronavirus disease 2019 (COVID-19) pneumonia. Timing of administration of the medication may play a role in the variability of the observed results.

Corona Virus in the Gastrointestinal Tract

Covid-19 virus is known to mainly effect the respiratory system. However, there is rapid cumulative information that up to 29% of patients develop gastrointestinal symptoms. Viral RNA and viable virus have been identified in stools. The risk of contamination trough a fecal-oral route is not well known but the potential risk of the GI tract being a source of contamination is evident. Gastrointestinal surgeons and endoscopists should be aware and be vigilant about the possibility when performing endoscopic procedures, procedures were the bowel is entered or divided and during TATME and TEM procedures. Appropriate PPE should be used.

Follow-up on the good news from Italy

On our last week’s report, we stated that despite being too early to make any conclusions, there have been some signs that the slope of COVID-19 new cases in Italy may be starting to slow down and that Italian epidemiologists feel it is the result of the strict social isolation measures. This week it seems clear that indeed the peak is passing in Italy. Spain is now also experiencing positive results from social isolation measures which continue to look as the best preventive measure to emphasize, and possibly the only definite intervention currently available to overcome this epidemic.

Participants:

Drs. Horacio Asbun (Lead), Mohammed Abu Hilal, Jaap Bonjer, Nicolas Demartines, Nader Francis, Ho-Seong Han, Davide Lomanto, Salvador Morales, Andrea Pietrabissa, Aurora Pryor, Christopher Schlachta, Patricia Sylla, Eduardo Targarona, Suthep Udomsawaengsup

Other Surgical Societies/leaders are welcome to participate in future discussions. Please contact SAGES Executive Director, Sallie Matthews at sallie@sages.org if interested in being considered for participation.

*GENERAL DISCLAIMER:  

The following is intended to provide our members with information arising from the experience of our colleagues from Europe and Asia who experienced the pandemic first.  While the information provided is from very reliable sources, it is NOT evidence based data, since there was no time to test its validity on scientific grounds. It is merely an attempt to share practical advice based upon prior experience and current knowledge.

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