CME is no longer available for this activity.
Release Information
Release Date: 4/9/2020
Expiration Date: 4/9/2023
You may claim CME credit after watching this video and answering a few short evaluation questions.
Disclosures
The following individuals disclosed financial relationships with ACCME-defined commercial interests prior to this activity.
The remaining planners and faculty had no relevant financial relationships with commercial interests.
| Name of Individual | Individual’s Role(s) in Activity | Name of Commercial Interest(s) | Nature of Relationship(s) | For What Role |
| Absun, Horacio | Faculty | Boston Scientific Olympus |
Honorarium Honorarium |
Consulting consulting |
| Mikami, Dean | Faculty/Planner | WL Gore | Honorarium | teaching |
| Schlachta, Chris | Faculty | Ethicon | honorarium | speaking |
| Spaniolas, Dino | Faculty | WL Gore Merck |
Honorarium Research |
speaking research support |
| Tsuda, Shawn | Course Chair/Moderator | Allergan Inc. Intuitive Surgical Inc. Endo Pharmaceuticals Inc. Covidien LP. |
Honoraria Honoraria Food and Beverage Food and Beverage |
Consulting and teaching Consulting and teaching Attended event Attended event |
Commercial Support
SAGES thanks the following companies for their generous educational grants in support of this activity:
- Conmed
- Ethicon
- Medtronic
Frequently Asked Questions (FAQ) for Surgical Care During the Covid-19 Pandemic
General Questions
Should we be testing every preoperative patient for COVID-19?
Yes, unless a true emergency, while infection rates in the region are high. Because of the high number of asymptomatic patients, symptoms should not guide testing.
If a patient is tested and COVID-19 negative, should we still practice enhanced precautions during surgery and endoscopy?
Yes, smoke evacuation techniques should still be utilized due to the risk of smoke inhalation. Due to the high risk environment and the concern for false negative results, full precautions should be utilized. If PPE is limited, however, standard precautions could be used in these patients.
What should we be wearing for eye protection in the OR?
Eye protection that prevents airborne particles to come into contact (full face shield, goggles)
Do you recommend performing all surgeries in negative pressure rooms?
Most operating rooms are constructed in a positive pressure fashion to protect the OR from airÂborne pathogens that may be present in adjacent areas. It is recommended to intubate and extubate patients in a Negative Pressure room and then transfer them to the OR. If you have a OR that has a Negative Pressure set up, then the entire procedure can be performed there. Be aware there may be increased risk for SSI in these environments.
When should we start elective surgeries again?
When approved by your hospital or surgical center to do so. If you are the decision maker, follow CDC recommendations and local health authorities to determine when the peak of the surge has passed. When your new admissions are declining and you have adequate space and resources, it is reasonable to restart in a controlled fashion.
What is the correct risk to quote a patient undergoing urgent surgery for contracting COVID-19?
The estimated risk is 0.45% if you have close contact with a COVID-19 positive individual in the hospital. Surgeons must also consider the prevalence of COVID-19 in their hospital, as many asymptomatic patients are exposed/ infected while inpatient, and the risk of exposure to asymptomatic carriers in their consent. This will vary across facilities “Active Monitoring of Persons Exposed to Patients with Confirmed COVID-19 — United States, January–February 2020. Rachel M. Burke, PhD1; Claire M. Midgley, PhD1; Alissa Dratch, MPH2; Marty Fenstersheib, MD; Thomas Haupt, MS4; Michelle Holshue, MPH5,6; Isaac Ghinai, MBBS6,7; M. Claire Jarashow, PhD8; Jennifer Lo, MD9; Tristan D. McPherson, MD6,10; Sara Rudman, MD; Sarah Scott, MD6,12; Aron J. Hall, DVM1; Alicia M. Fry, MD1; Melissa A. Rolfes, PhD. Morbidity and Mortality Weekly Report (MMWR) Weekly / March 6, 2020 / 69(9);245–246
Laparoscopy and Gas/Smoke Evacuation
Is laparoscopy currently contraindicated?
Laparoscopy is NOT contraindicated. Best practices should be implemented to filter smoke and CO2 and prevent the possibility of aersolization of viral particles.
If I normally perform a case (appendectomy, cholecystecomy) laparoscopically but can perform it open, should I do so in a COVID-19 positive or suspected patient?
Not necessarily. Procedures may be performed laparoscopically if they are within the normal practice of the surgeon and laparoscopy provides the optimal surgical outcome for the patient. In COVID-19 positive patients, all recommendations outlined in the SAGES Resources for Smoke and Gas Evacuation During Open, Laparoscopic, and Endoscopic Surgery should be followed. https://www.sages.org/resources-smoke-gas-evacuation-during-open-laparoscopic-endoscopic-procedures/
If our institution has no smoke evacuator with ULPA filters available, should we avoid laparoscopy?
Smoke and gas evacuation through ULPA filters is recommended during laparoscopy. In a COVID-19 positive patient or PUI, it is especially important. However, if resources do not allow for safe filtering of smoke and gas, every effort should be made to mitigate the risk of spread to OR staff, including consideration for non-surgical management, or open surgery with minimal use of energy devices.
Is there evidence that COVID-19 is present in gases released from laparoscopy?
No, all precautions described are based on the assumption that this virus shares properties documented previously in other viruses.
What smoke evacuators are recommended?
Please refer to the SAGES RESOURCES FOR SMOKE & GAS EVACUATION DURING OPEN, LAPAROSCOPIC, AND ENDOSCOPIC PROCEDURES: https://www.sages.org/resources-smoke-gas-evacuation-during-open-laparoscopic-endoscopic-procedures/
Should we be doing robotic surgery?
Robotic surgery can be performed as long as all recommendations that apply to laparoscopic surgery are followed, including use of a smoke evacuator with an ULPA filter and dessufflation of the pneumoperitoneum with a filtered system. Special care should be taken to clean robotic surgeons’ and patient-side consoles with alcohol-based cleaners to avoid surface-transmission.
Can we use the Airseal system?
Yes but there are specific instructions to follow. Please refer to these documents. https://www.sages.org/wp-content/uploads/2020/03/CONMED-AirSeal-SAGES-Response.pdf, https://www.sages.org/wp-content/uploads/2020/03/CONMED-Insufflation-Recommendations.pdf, https://www.sages.org/wp-content/uploads/2020/03/CONMED-Smoke-Evacuation-Recommendations.pdf, https://www.sages.org/wp-content/uploads/2020/03/CONMED-Insufflation-Recommendations-Wall-Chart.pdf
Where can I find out if our hospital’s smoke evacuation system is adequate for filtering the virus?
Check with hospital maintenance and the manufacturer’s website. You can also call the industry representative directly.
What is the recommendation for suction devices used during procedures?
Please refer to the SAGES RESOURCES FOR SMOKE & GAS EVACUATION DURING OPEN, LAPAROSCOPIC, AND ENDOSCOPIC PROCEDURES: https://www.sages.org/resources-smoke-gas-evacuation-during-open-laparoscopic-endoscopic-procedures/
Can gases be filtered through a drainage canister containing bleach?
This has been used in certain parts of the world. There are no studies looking to its effectiveness in killing viral particles as the escaping smoke and CO2 is being bubbled through the bleached solution. Although, it would be intuitive that any viral particle that gets in contact with the surrounding bleach solution should be disinfected, we do not know about the viral particles in the middle of the bubbles that do not contact the bleach solution.
N95 Respirators
Should the OR staff wear N95 respirators in every surgical case?
If there is sufficient PPE to do so, for patients who are positive, under investigation, symptomatic, or questionable, all OR staff should wear N95’s. If the patient is negative and asymptomatic, N95’s can be optional, keeping in mind there is a significant false negative rate of current tests, and that asymptomatic spread is still possible.
If the SARS-Cov-2 virus is smaller than the 0.3 microns that N95 respirators are rated for, will N95 respirators protect the wearer from the virus?
Yes. Nanoparticles mainly travel by Brownian motion and are effectively captured within the N95 filter via mechanical and electrostatic forces. Technical explanations: 1) https://multimedia.3m.com/mws/media/376179O/nanotechnology-and-respirator-use.pdf ; 2) https://www.irsst.qc.ca/media/documents/PubIRSST/R-754.pdf
How many times can the N95 respirator be re-used without re-sterilization?
If stored properly, the CDC suggests 5 uses as the maximum for N95 masks
Can I use a KN95 mask?
While authentic KN95 masks are similar in efficacy to the US NIOSH N95 mask, unfortunately there are a high number of counterfeit versions circulating the market (the FDA delayed the emergency use authorization of KN95 masks due to high concern for counterfeits). Importantly, there are multiple types of filtering facepiece respirators from various countries that are also similar to US NIOSH N95 masks that have temporarily been allowed by the CDC under an Emergency Use Authorization. The list can be found here: https://www.cdc.gov/niosh/npptl/respirators/testing/NonNIOSH.html
What is the best method for storing an N95 mask?
Any storage method must allow the respirator to fully dry. It can be hung on a hook without contacting other objects, laid flat on a paper towel, or placed in a breathable container such as a paper bag. When handling the mask, avoid touching the inside or the outside.
Energy Devices
Why is it recommended I minimize the use of electrosurgery during procedures?
To decrease the amount of smoke generated that may aerosolize the virus
Is it safe to use ultrasonic devices?
If an ultrasonic device must be utilized, it should be done so for the briefest times and duration possible, as this device can create aerosols. All pneumoperitoneum clearance precautions should be meticulously practiced.
What is the evidence that the COVID-19 virus, or any viral particles, exist in smoke plume generated from energy devices?
While there is no published data on SARS-CoV 2 being transmitted through smoke plume currently, there are many published studies on other viral particles being transmitted throughout smoke plume and infecting OR personnel. Here are a few studies. 1. Human papillomavirus DNA in surgical smoke during cervical loop electrosurgical excision procedures and its impact on the surgeon. Zhou Q, Hu X, Zhou J, Zhao M, Zhu X, Zhu X. Cancer Manag Res. 2019 Apr 29. 2. Electrosurgical smoke: a real concern. Chowdhury KK1, Meftahuzzaman SM, Rickta D, Chowdhury TK, Chowdhury BB, Ireen ST. Mymensingh Med J. 2011 Jul;20(3):507-12. 3. The Dangers of Electrosurgical Smoke to Operating Room Personnel: A Review. Bree K, Barnhill S, Rundell W Workplace Health Saf. 2017 Nov;65(11):517-526.
Education
Do you have recommendations for simulation-based activities (FLS) during the COVID-19 pandemic?
The SAGES FLS, FES, and FUSE programs have been placed temporarily on hold during the pandemic. Simulation activities that do not violate social distancing principles can be continued. Home practice on single surgeon simulators is ideal.
Should medical student and resident teaching be paused during the COVID-19 pandemic?
SAGES recommends that the fewest personnel necessary to safely complete the procedure be present in the operating room. Learners who are not critical participants to the operation should not be present.
Critical Care and Mechanical Ventilation
When do we consider performing tracheostomies on COVID-19 patients?
That will be answered in a future webinar. AAST is publishing their recommendations soon.
What are strategies we can use if our facility is running low on our normally used sedatives and narcotics?
Consider alternatives to your usual protocol. Some strategies include: 1) Rotating sedatives for each patient based on side effect profile as well as time course in their clinical presentation. For instance, patients can start on propofol, transition to a benzodiazepine before propofol toxicity ensues, then be weaned to precedex when it comes close to extubation ; 2) using multiple sedatives concurrently to lower the dose needed for each one ; 3) Alternatives such as ketamine, volatile anesthetics in the OR, etc.
Can we use BiPAP to avoid mechanical ventilation or to support a patient after extubation?
Yes, if necessary, but with great caution given the potential to spread virus in a pressurized manner. The positive pressure may spread the virus further around. There are some who advocate that it is safe. http://www.covid-bopapinfo.com
Telehealth
Will SAGES be advocating for telemedicine reimbursement and universal telemedicine licensure?
Yes , SAGES, ACS and AMA will all be advocating for Telehealth. It is therefore important for SAGES members to be active members of both ACS and AMA. ACS helps provide financial leverage in advocacy. The more AMA members we have in SAGES the more representation we have in AMA.
Is Zoom HIPAA compliant?
Zoom can be configured to be fully HIPPA compatible with multilayered security with encryption. Zoom can integrate fully with EHR(EPIC). Can launch a video directly from application’s Telehealth workflows. See https://zoom.us, Zoom for healthcare June 2019
Is telemedicine okay for surgeons to use given that physical examination is not possible?
Yes, both time and E/M (Medical decion making) can be used for Telehealth. It a good idea to always use time in the documentation. It is also important to document 1. History and Physical exam from focused to expanded to comprehensive. Self reported weight, Vitals from devices such as blood pressure machines and video of incision are all examples of objective findings. ; 2. Medical decision making with the spectrum of straightforward to complex should be documented.; and 3. Presenting issue from minor to severe should also be documented. New patients need three out of three of these components while established patients need only two out of three. Always remember to include any objective findings you can and always include Time.
How do you bill a telehealth visit if no physical examination can be documented?
See Above
What are the required components of a telehealth visit for coding and billing purposes?
See Above
Can phone calls be used if the provider or patient do not have access to a telehealth platform?
Telephone calls can be used but this is audio only and not Telehealth. This likely will not be reimbursed by CMS and only by some private insurers. In the documentation make sure to include time, why the telephone visit was needed and that the patient did not have the technology or equipment needed for Telehealth.
What should we be doing about physically signing consent forms – paper or electronic – in the interest of safety
Written consents are preferable but during the pandemic verbal consent with documentation after is acceptable. The goal should be to have a form the patient signs with their paperwork at their visit.