Features of the Management of Surgical Patients in the Context of the Covid-19 Pandemic

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The appearance of SARS-CoV-2 in the Chinese city of Wuhan affected the life of the entire planet [1]. The pandemic revealed the imperfection of world medicine, and not only in the issue of the inferiority of medical knowledge. According to WHO, the number of confirmed cases of COVID-19 exceeded 35 million, and the number of deaths amounted to 770 thousand cases, and this data sets new records every day [4]. According to the decree of the Government of the Russian Federation No. 66 of January 31, 2020, SARS-CoV-2 is included in the list of diseases that pose a danger to others, along with particularly dangerous infections [6].

SARS-CoV-2 is an aggressive enveloped RNA virus of the family Coronaviridae, genus Betacoronavirus. The virus is stable in the external environment, maintaining its properties on a solid surface at room temperature up to 3, in a liquid environment – up to 7, in the environment at a temperature of +4°From – to 14 days [5]. SARS-CoV-2 is highly contagious and is able to enter the human body through the covers of the upper respiratory tract, stomach and intestines, i.e. by airborne droplet, airborne dust and contact transmission routes.

To date, the tropism of SARSCoV-2 to human cells expressing angiotensin converting enzyme-2 (angiotensin converting enzyme, ACE2) and transmembrane glycoprotein CD147 has been described. The main target of SARS-CoV-2 is considered to be ACE2-positive cells, which, in addition to pneumocytes, include some cells of the intestine, kidneys and liver [8, 9]. Angiotensin converting enzyme-2 is expressed in the endothelial layer of the vascular wall of arteries and veins [19, 20]. Once in the body, SARS-CoV-2 penetrates into ACE2-positive cells, where it begins to replicate. In the blood, the viral nucleocapsid penetrates into the cell via a receptor-mediated bond, followed by viral RNA replication [19, 20]. Cytokines are released. Interleukins 1β and 6 in COVID-19 can cause thrombocytosis and hyperfibrinogenemia [21]. Their release leads to the development of interstitial inflammation, endothelial damage and activation of coagulation, in the pathogenesis of which a key role belongs to the tissue factor, which is released by monocytes, as well as damaged or activated, due to the action of cytokines, endothelial cells. As a result, thrombin is formed, which leads to thrombosis of the alveolar capillaries [19, 22, 31]. The coagulation profile of patients with COVID-19 shows hypercoagulation, which suggests thrombosis under the influence of coronavirus infection in both congestive areas of veins and arteries, and in the capillary bed [22]. There is a decrease in the activity of phagocytosis, which prolongs the phase of inflammation, slows down the growth of blood vessels, reduces the proliferation and migration of cells, inhibits the synthesis of collagen, reduces the resistance of tissues to infection. Together, SARS-CoV-2 changes the functioning of the body, leading to severe damage to the lung and nervous tissues, and severe thrombotic complications [23]. The development of a viral infection in the body reduces the protective abilities of the immune system, can lead to an exacerbation of chronic diseases, the activation of "dormant" foci of infection, the development of violations of the water-electrolyte balance. The most common complication of COVID-19 is viral pneumonia, which to a greater or lesser extent leads to a decrease in the oxygenation of body tissues. The course of the disease can be so aggressive that the consequences described above occur despite the ongoing anticoagulation therapy [23, 24, 25, 26].

During the admission of a surgical patient to the hospital, it is necessary to pay due attention to the collection of anamnesis, with an emphasis on the list of drugs used by them, to clarify whether the patient is taking the anticoagulant drugs prescribed to him, how long ago the coronavirus infection was transferred in order to assess the risk of thromboembolic complications. The most common symptoms of COVID-19 are fever, cough, shortness of breath, as well as fatigue, headache, and muscle soreness [32, 46]. The manifestation of the disease may begin with extrapulmonary manifestations, in particular, with gastrointestinal symptoms [10, 11]. A meta-analysis of more than 4 thousand patients showed that approximately 17.6% of patients had symptoms of gastrointestinal disease, including 9.2% – pain, 12.5% - diarrhea, and 10.2% - nausea and / or vomiting [12]. These symptoms are often the only manifestations of COVID-19 and may require a thorough differential diagnosis with surgical pathology [10, 11]. For a more reliable diagnosis of the modern available instrumental methods of research, it is most preferable to use computed tomography. High interest in terms of differential diagnosis is given to diagnostic laparoscopy. However, some authors recommend open, rather than laparoscopic, operations, as they believe that laparoscopy increases the risk of infection of personnel [13, 14]. One of the symptoms of COVID-19 is venous thrombosis of the lower extremities [23]. Due to changes in the endothelium of the vascular wall under the influence of the "cytokine storm" and the high risk of thrombosis in patients who have undergone COVID-19, it is necessary to be more cautious in terms of thromboembolic complications during surgery, which raises the question of the need for preoperative duplex scanning of the vessels of the lower extremities. A number of researchers recommend that personalized anticoagulant thromboprophylaxis be followed in outpatient patients with COVID infection, hospitalized patients, and patients in the early postoperative period [28].

It is necessary to remember about the possibility of re-infection, admission of the patient to a surgical hospital in the incubation period of the disease. Surgical interventions during this period can cause a violation of cell-mediated immunity, one of the main mechanisms that control viral infections [44, 45]. The literature also describes cases when patients operated on within a month after infection with COVID-19 developed a severe form of coronavirus disease in 75% of cases [33, 38].

In the context of the COVID-19 pandemic, the practice of providing surgical care is rapidly changing, due to the mobilization of beds, medical and nursing staff. The possibility of using dressing rooms and operating rooms is limited, including due to the need to use artificial ventilation devices in intensive care units. The changes lead to a revision of the procedures for providing specialized surgical care in order to concentrate forces and resources for the treatment of patients with COVID-19. The number and complexity of the work of medical personnel in operating rooms and dressing rooms is reduced, as the entire surgical team, including anesthesiologists, is forced to use additional personal protective equipment (masks, safety glasses and overalls), which complicate the performance of professional duties [18, 39].

One of the problems faced by the health care system was the suspension of planned surgical interventions, which can lead to an increase in chronic diseases, an increase in the number of emergency surgical interventions [33, 34, 35, 36, 37].

The question of choosing the method of surgical intervention in a patient with COVID-19 remains relevant. Performing surgical interventions in patients with COVID-19 in the incubation period and with a mild degree of lesion in an infectious hospital does not lead to an increase in the duration of inpatient treatment and the frequency of complications [47, 50].

A number of authors point to a high risk of infection of personnel during endoscopic surgical interventions through the spread of infected smoke aerosol generated by the pneumoperitoneal gas stream and formed during tracheal intubation[18, 27, 31, 39, 40, 41, 48, 49]. The literature also draws attention to the possibility of developing respiratory failure against the background of pulmonary fibrosis in patients with a history of CT-3 and CT-4 viral pneumonia when performing laparoscopic operations using pneumoperitoneum [32]. Other authors prefer to use the laparotomy method for both diagnostic and therapeutic purposes [42, 43]. It is necessary to take into account the increased risk of infection of personnel when opening the intestinal wall in infected patients, since a number of studies have confirmed the presence of infection in the contents of the stool [16, 17, 18, 47]. To reduce the risk of infection, it is recommended to minimize communication between staff, use disposable protective material, reduce the number of people in the operating room, etc. [11, 15, 27].

Many patients with COVID-19, first of all, suffer from the blood clotting system, there are coagulation disorders that mimic other systemic coagulopathies. A significant proportion of severe patients develop, sometimes undetected, venous and arterial thromboembolic complications. Thrombotic microangiopathy is usually caused by a pathologically enhanced interaction between platelets and the vascular wall. Changes in coagulation associated with COVID-19 suggest the presence of a hypercoagulation status, which may increase the risk of thromboembolic complications [31]. Immobilization and vascular damage are other factors that increase the risk of thrombosis, which in turn will complicate the course and treatment of surgical patients with COVID-19.

For the prevention of thrombosis, it is advisable to use low-molecular-weight heparin (HMG) [28, 29], which is explained by a number of its positive properties in comparison with unfractionated heparin: a lower risk of bleeding, which is especially important during surgical interventions; the use of HMG is rarely complicated by heparin-induced thrombocytopenia; HMG has an anti-inflammatory effect [28].

Low molecular weight heparin may be more preferable for use in hospitalized patients who are already in critical condition due to a shorter half-life, the possibility of intravenous or subcutaneous use, and a lower degree of drug interaction compared to oral anticoagulants. The use of NMH in combination with glucocorticosteroids can reduce vascular damage and restore blood circulation at the level of microcirculation.

The course of the wound process is associated with high bleeding of tissues, in some cases requiring blood transfusion correction, which puts a personalized approach to each patient in the first place. The selection of anticoagulants or antiplatelet drugs for surgical patients with COVID-19 is recommended taking into account their potential interaction with other drugs used.

Patients with COVID-19 who have thromboembolic complications or suspected thromboembolic disease in the absence of vascular scanning should be treated with therapeutic doses of anticoagulants, according to the standards of care for patients without COVID-19. At the moment, there is not enough data to recommend "for" or "against" the appointment of therapeutic doses of antithrombotic or thrombolytic agents to hospitalized patients.

The use of hyperbaric oxygenation (HBO) can also be used to treat patients with COVID-19. HBO has, among other things, a pronounced antimicrobial and antiviral effect, which minimizes drug consumption and is of particular importance during coronavirus infection. Even a short-term improvement in oxygenation is a powerful stimulus to activate immune responses, which leads to a decrease in the concentration of toxic products, a decrease in shortness of breath, and an improvement in overall well-being. Numerous clinical and experimental studies, including randomized trials, demonstrate the important role of HBO in the course of revascularization processes in the wound, stimulation of granulation formation and acceleration of epithelialization.

A special place in the treatment of surgical patients with severe forms of COVID-19 is occupied by the problem of nosocomial infection. Due to the use of a wide range of antibacterial drugs in bacterial complications of the course of COVID-19, it is necessary to rationally and personally approach the choice of medicines from this group in the surgical hospital for patients who have suffered a coronavirus infection in order to prevent the development of antibiotic resistance [32].

In addition, the treatment developed to date for medium-severe and severe forms of infection caused by the SARS-CoV-2 coronavirus has a sharply negative impact on the processes of wound regeneration. The standards for the treatment of pneumonia caused by the SARS-CoV-2 coronavirus include glucocorticosteroids, the use of which disrupts the healing processes, decompensates concomitant diseases (diabetes mellitus, hypertension) [32]. Taking systemic steroids is associated with a number of possible side effects and complications. Although it is unclear to what extent they may manifest themselves when infected with COVID-19, any patient who is scheduled for steroid therapy should be examined for the risk of developing venous thromboembolism, reactivation of mycobacterial or other infection, risk of gastrointestinal bleeding, hyperglycemia with possible development of steroid-induced diabetes, volume overload and other symptoms, especially for people aged 80 years and older, patients with HIV and severe liver disease. In such groups, the possibility of using steroids should be considered separately for each case.

With regard to the use of NSAIDs in patients with COVID-19, not enough studies have been conducted to assess the full picture of the complications caused and the long-term consequences of their use. NSAIDs, in particular ibuprofen, can also increase the expression of APF2, which, in theory, can promote the penetration of the virus into the body's cells [29]. The use of this group of drugs may contribute to the erased manifestation of clinical symptoms [29].

Thus, based on our own experience and literature data, we can formulate the main approaches to the management of surgical patients in the context of the COVID-19 pandemic:

• When treating patients, it is necessary to take into account the increasing complexity of the work of medical personnel, which is due, among other things, to the use of additional personal protective equipment.

* Ensure that not only the instruments but also all equipment are thoroughly cleaned and disinfected to prevent the spread of SARS-CoV-2.

* It is necessary to review the timing of surgical care in order to concentrate the forces and resources to help patients with COVID-19. Surgeons should make the most of operating room hours and treat them as a scarce resource. It is necessary to give preference to low-risk surgical interventions that minimize the likelihood of postoperative complications that require treatment in the intensive care unit.

* It is necessary to use remote consultations to correct the treatment of patients, discuss problematic issues and develop patient management tactics. It is advisable to use a tracking and feedback system for treated patients, which will allow remote monitoring of their condition after early discharge, and prompt notification of the possibility of face-to-face admission.

* Programs of face-to-face monitoring of treated patients, including those aimed at conducting scientific research and medical examinations of patients, should be suspended.

* Treatment regimens should be reviewed to reduce the number of visits by medical staff. It is recommended to prescribe drugs for oral or subcutaneous administration, as an alternative to drugs with intravenous administration. Medical personnel should minimize any contact with the patient's biological tissues and fluids.

• In the treatment of patients, it is necessary to take into account the probability of a significant decrease in the oxygenation of soft tissues, the body's defenses, the development of water-electrolyte balance disorders, exacerbation of chronic diseases, and the activation of "dormant" foci of infection. Reducing the activity of phagocytosis, prolonging the phase of inflammation slows down the growth of blood vessels, reduces the proliferation of epithelium and cell migration, inhibits the synthesis of collagen, reduces the resistance of tissues to infection, which leads to a lengthening of all phases of the wound process, slow wound healing.

* In surgical diseases, it is necessary to take into account the mutual negative impact of viral infection, pneumonia and surgical pathology, especially in patients of older age groups, with severe concomitant diseases, overweight, and endocrine pathology.

* The treatment of the wound process is negatively affected by the use of glucocorticosteroids, which often disrupt the healing processes, decompensate concomitant diseases (diabetes mellitus, hypertension).

* It should be borne in mind that the use of low-molecular-weight heparins often leads to the development of a number of problems, in particular, increased severity and increased duration of bleeding.

* The use of complex antibiotic treatment regimens and the widespread use of antiseptics lead to the formation of resistant bacterial varieties that, in the form of biofilms, heat up in wounds, on ventilator systems, catheters, and drains, forming a permanent focus of resistant bacterial infection and increasing the risk of sepsis.

About the authors

Anton Petrovich Ostroushko

N.N. Burdenko Voronezh state medical University

Email: antonostroushko@yandex.ru
ORCID iD: 0000-0003-3656-5954
SPIN-code: 9811-2385

Ph.D., associate Professor of the Department of General surgery of N. N. Burdenko Voronezh state medical University

Russian Federation, Voronezh, Russian Federation

Maria Valeryevna Aralova

Voronezh State Medical University. N.N. Burdenko "of the Ministry of Health of Russia.

Email: Mashaaralova@mail.ru
ORCID iD: 0000-0003-4257-5120
SPIN-code: 8115-2155

PhD, head. department of ambulatory surgery

Russian Federation, 151 Moskovskii Ave.,Voronezh, 394036, Russian Federation

Svetlana Sergeevna Menshikova

Voronezh State Medical University named after N. N. Burdenko

Author for correspondence.
Email: MenshikovaSS@yandex.ru
ORCID iD: 0000-0002-4706-0276
SPIN-code: 4299-9889
Russian Federation, 10 Studencheskaya str., Voronezh, Russia, 394036

Andreev Alexander Alexeevich

N.N. Burdenko Voronezh State Medical University.

Email: sugery@mail.ru
ORCID iD: 0000-0002-5242-6105
SPIN-code: 1394-5147
http://vrngmu.ru/academy/personnel/889/

Ph.D., Professor of the Department of General Surgery, Deputy Director of the Institute of Surgical Infections for Research of N.N. Burdenko Voronezh State Medical University.

Russian Federation, 394036, Russia, Voronezh, Studencheskaya str.

Aleksandr Anatolevich Glukhov

N.N. Burdenko Voronezh State Medical University.

Email: glukhov-vrn@yandex.ru
ORCID iD: 0000-0001-9675-7611
SPIN-code: 3821-2175

doctor of medical Sciences, Professor, head of the Department of General surgery, Voronezh state medical University N. N. Burdenko

Russian Federation, 394036, Russia, Voronezh

References

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