Access thebmj.com - The BMJ logo

Delivering time critical complex major surgery in a covid protective environment

The cardiac and thoracic units of St Bartholomew’s Hospital have developed covid-19 protective protocols that have enabled us to carry out over 120 consecutive emergency and urgent major cardiac and thoracic operations since March, including through the peak of the pandemic. In these patients, as far as we are aware, there has been no covid-19 related morbidity or mortality. Overall mortality was <2% in keeping with pre-covid-19 practice. These protocols which are published on the Society for Cardiothoracic Surgery (in Great Britain and Ireland) website are being adopted by cardiothoracic units in the UK and abroad.1

The pandemic has caused severe disruption to the National Health Service in the United Kingdom. Following suspension of all elective surgery the ability to maintain services for life saving and time critical operations became a priority. As part of the NHS England response to the Level 4 national emergency, a Pan London Emergency Cardiac Surgery (PLECS) service was initiated to deliver emergency and urgent cardiac surgery across London. St Bartholomew’s Hospital serves as the hub with surgery provided at two delivery sites (St Bartholomew’s Hospital and Harefield Hospital). At the same time, as part of the reorganisation and prioritisation of cancer surgery across London St Bartholomew’s Hospital continues to perform emergency and time-critical thoracic surgery. 

The outcomes of new covid-19 infection in patients undergoing complex major surgery, including cardiac and thoracic are poor.2,3 Therefore establishing and maintaining a covid-19 protective environment is essential. We aim to avoid operating on patients with ongoing covid-19 infection and ensure it does not develop postoperatively. Emergency patients with unknown covid-19 status require special consideration. We developed targeted protocols to achieve these aims.1 Two important aspects of these protocols involve screening of all patients before and on arrival in our unit and isolation of those patients with unknown covid-19 status. Screening consists of clinical history, two throat swabs,4 lymphocyte count, LDH and ferritin levels5 and if these indicate low probability of covid-19 infection – a computed tomography (CT) chest scan.6 The routine use of bronchoalveolar lavage (BAL) intraoperatively guides post-operative management especially in the covid-19 unknown emergency patient.7 All operations have been carried out with theatre staff wearing full personal protective equipment (PPE). Clinical care with respect to PPE and patient contact has at all times followed Public Health England recommendations. 

Prior to the introduction of these protocols, in keeping with other units, we experienced significant covid-19 related complications including mortality. We therefore aimed our protocols firstly to avoid admitting and operating on covid-19 positive patients and secondly to be able to isolate covid-19 status unknown patients. The addition of BAL swabs taken at the time of intubation significantly increases the accuracy of delineating covid-19 status compared to upper respiratory swabs.7

Our cardiac experience includes nine emergency aortic dissections who were operated with unknown covid-19 status. Emergencies and other urgent complex cardiac procedures were inter-hospital transfers. All major lung cancer resections have been admitted from home and all (except one chest wall resection-reconstruction) have been minimally invasive (VATS or Robotic). 

Since the introduction of our protocols on the 27 March 2020 we have operated on over 120 consecutive patients requiring cardiac and thoracic surgery and have not identified anyone who has developed covid-19 postoperatively. Although resource intensive, these protocols provide a framework to continue to perform surgery irrespective of urgency or complexity, through the pandemic.

Resumption and recovery of activity to include elective operations will need to ensure patient safety and restoration of confidence, by limiting risks to those solely related to the surgical procedure. Consideration will need to be given to align covid-19 protocols to the complexity of the procedure and the capability of delivery sites to provide the necessary infrastructure.

Stephen Edmondson, Consultant Cardiothoracic Surgeon, Chief of Surgery and Chairman of the Clinical Board in Surgery, St Bartholomew’s Hospital, London, United Kingdom.

Martin T. Yates, Specialist Registrar in Cardiothoracic Surgery, St Bartholomew’s Hospital, London, United Kingdom.

Kelvin Lau, Consultant Thoracic Surgeon, St Bartholomew’s Hospital, London, United Kingdom.

Rakesh Uppal, Professor of Cardiac Surgery. St Bartholomew’s Hospital, London, United Kingdom.

Jonathan Lambourne, Consultant in Infectious Diseases and Microbiology, St Bartholomew’s Hospital, London, United Kingdom.

Claire Rathwell, Consultant in Anaesthesia and Critical Care, St Bartholomew’s Hospital, London, United Kingdom.

Competing interests: none declared.

References:

  1. Hussain A, Balmforth D, Yates MT, Lopez-Marco A, Rathwell C, Lambourne J, Roberts N, Lall K, Edmondson S. The Pan London Emergency Cardiac Surgery service: Coordinating a response to the COVID-19 pandemic. J Card Surg. 2020; 35(7): 1563-9
  2. Li Y, Peng S, Li L et al. Clinical and Transmission Characteristics of Covid-19 – A Retrospective Study of 25 cases from a  Single Thoracic Surgery Department. Curr Med Sci 2020; 40(2): 1-6
  3. Lei S, Jiang F, Su W et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID  – 19 infection. EClinicalMedicine 2020: 100331
  4. Wolfel R, Corman VM, Guggemos W et al. Virological assessment of hospitalized patients with COVID-2019. Nature 2020
  5. Rodriguez-Morales AJ, Cardona-Ospina JA, Gutierrez-Ocampo E et al. Clinical, laboratory and imaging features of COVID-19: A systematic review and meta-analysis. Travel Medicine and Infectious Disease 2020.
  6. Ai T, Yang Z, Hou H, et al. Correlation of chest CT and RT-PCR testing in coronavirus disease 2019 (COVID-19) in China: a report of 1014 cases. Radiology 2020; DOI:10.1148/radiol.2020200642
  7. Chen C, Gao G, Xu Y et al. SARS-CoV-2 Positive Sputum and Feces after Conversion of Pharyngeal Samples in Patients with COVID-19. Ann Intern Med 2020 DOI: 10.7326/M20-0991