Abstract
The coronavirus disease (COVID-19) SARS-CoV-2 virus epidemic continues to exhibit a sporadic onset trend due to the continuous variation of the novel coronavirus. However, the psychological impact of the pandemic persists. It is crucial to reflect on our experiences to better prepare for future large-scale infectious diseases. During outbreaks of infectious diseases, patients may still require orthopaedic surgery. It is crucial to prioritize the safety of medical staff and establish procedures to ensure their protection. However, with the implementation of a series of standardized operational protection procedures, orthopaedic surgeons can safely perform their duties without the risk of contracting COVID-19. There is no doubt that the orthopaedic occupational exposure protection process and perioperative management plan for global infectious diseases, such as COVID-19, require a standardized summarization process and a narrative review.
Introduction
The coronavirus disease (COVID-19) SARS-CoV-2 virus has been mutating since its outbreak in December 2019. As the Omicron variant continues to spread and become the dominant strain in many countries, it presents new challenges for the prevention and control of COVID-19. 1 However, with our expertise and knowledge, we are confident in our ability to tackle these challenges and mitigate the impact of this variant. SARS-CoV-2 not only invades the respiratory system but also causes injuries to other organs in severe cases, such as the kidneys, liver, heart, coagulation system and gastrointestinal tract.2–7 Research has unequivocally shown that Omicron significantly increases the risk of transmission compared with early primary strains. 8 Due to its high contagiousness, the disease may persist for an extended period as an epidemic develops. Orthopaedic surgery may be required by an increasing number of patients in these specific groups. It is crucial to prevent occupational exposure to COVID-19 during surgery. The prevention strategy is based on the guidelines for the prevention and control of the novel coronavirus issued by the National Health Commission of China, as well as the experience of frontline experts in various infectious disease hospitals. Furthermore, this can be used as a guide for future protection and perioperative management in the face of sudden infectious diseases, which can make us less confused.
Orthopaedic surgery and occupational exposure during COVID-19
With the global spread of novel coronaviruses, the normalization of epidemic prevention and control has entered a new phase. Therefore, in the face of the sudden spread of infectious diseases similar to the COVID-19 pandemic, occupational exposure protection and perioperative management will remain a long-term issue. In orthopaedics, emergency surgery is required to treat conditions such as open injuries, joint dislocations and acute lumbar disc herniations. The onset of this type of disease is acute and the symptoms and signs are obvious. Delayed treatment will cause more serious harm to patients, such as serious complications such as open fractures, which can lead to infection and even endanger patients’ lives if not treated in time. Therefore, during the normalization of epidemic prevention and control in COVID-19, how to meet the medical needs of society and how to perform medical services such as surgery safely and effectively will place higher demands on the existing diagnosis and treatment process and protective measures of orthopaedics. During the COVID-19 pandemic, we performed emergency orthopaedic surgery on 21 patients. Based on the existing research and a lot of clinical experience, this paper proposes the countermeasures to safely perform orthopaedic surgery during a sudden epidemic of an infectious disease. 9
A questionnaire survey was undertaken among 421 medical staff at Beijing Ditan Hospital, Capital Medical University, Beijing, China in order to analyse the factors affecting occupational exposure by multiple linear regression. Our investigation showed that 24 of 421 (5.7%) medical staff had occupational exposure to COVID-19. Among these, staff with a college education, junior professional title, 1–2 years of work experience, doctors and outpatients had a relatively high level of occupational exposure. In addition, the survey found that sex, intensive care work, use of diapers, facial pressure ulcers, participation in surgery or invasive operations were the risk factors for occupational exposure of medical staff in isolation wards and operating theatres. Supervising and training nursing staff to use protective equipment appropriately, and doing a good job in monitoring and controlling occupational exposure can greatly reduce the risk of infection of medical staff. 10
Preoperative preparation and protection
Choice of operation time
When treating patients with suspected or confirmed COVID-19, it is crucial to consider the patient’s tolerance and the duration of the treatment. For patients with severe or critical COVID-19, it is recommended to provide treatment in a designated ward with fixed operating conditions. The primary objective for these patients should be to save their lives. The scope of the operation is limited to life-saving measures, such as emergency procedures for abdominal organ injuries, uncontrollable bleeding and craniocerebral injuries.11–14 Diagnosis and treatment should be prioritized based on the patient’s condition during an epidemic. Operations can be categorized as selective, limited or emergency, depending on the patient’s needs. Strict perioperative protective measures must be implemented for operations on patients above the emergency level. Step-by-step procedures should be followed for sub-emergency and time-limited operations, taking into account the epidemic control situation. Surgery for other patients should be considered only after the isolation period. During the high-risk period of an epidemic, selective operations must be suspended. Organizing such operations after the primary response to public health events in the area has been alleviated is highly recommended.15–17
Establish a three-level protection system
For Level I protection, surgeons must wear surgical hats, masks, clothes, medical gloves and face shields. For Level II protection, in addition to the items required for Level I, surgeons must wear N95 or higher grade surgical masks, waterproof surgical clothes and either face shields or goggles. Waterproof boot covers and shoe covers are also mandatory. Surgeons must wear Level II protection as a minimum requirement. Additionally, they should consider using a positive pressure head cover with an electric air supply filter respirator to further enhance their self-protection. This decision should be based on the specific needs of the surgery and the security capacity of the medical unit.
Ward management, protection and disinfection
To ensure the safety of all individuals involved, it is imperative to strictly enforce the ‘one person, one room’ principle for all COVID-19 patients or those suspected of having the virus who enter the isolation ward. Before entering the ward, medical staff are required to take and report their own body temperature and to take routine protective measures, including wearing surgical caps, surgical masks (N95 and above), waterproof surgical clothing, surgical gloves and a face shield or goggles, as well as waterproof boot covers and shoe covers. Adhering to these guidelines will showcase our competence and expertise in preventing cross-infection. It is crucial to consider that asymptomatic carriers of COVID-19 can spread the virus. Therefore, it is highly recommended that all patients in areas with a severe epidemic be treated as potential suspected cases. Medical staff in the ward must use three-level protection when managing high-risk patients, such as those with acute and severe cases, by placing them in single rooms and prohibiting unnecessary visits. 18 Suspected patients must be immediately isolated in a single room and undergo COVID-19 diagnosis and troubleshooting. They must then be transferred to the designated COVID-19 ward. The ward must conduct rounds with three-level protection. Latex gloves should be worn when coming into contact with the patient’s blood, body fluids, secretions, excrement, vomit, or pollutants, and disinfection must be carried out. 19 Research has shown that SARS-CoV-2 can be effectively inactivated by various methods, including ultraviolet radiation, heat and fat solvents such as 56 °C for 30 min, 75% ethanol by volume, peracetic acid, chlorine-containing disinfectants (such as 84 disinfectant) and chloroform. 20
Selection of operation methods
Patients with COVID-19 should receive minimally invasive treatment to reduce operating time. It can significantly reduce the risk of occupational exposure of medical staff involved in the operation. Surgeons should select experienced senior physicians who can save patients’ lives, solve their basic problems and preserve their functions. Regardless of the surgical method, it is very important to control the operation time, reduce soft tissue injury, blood loss and complications. 11 During the operation, the standard negative pressure laminar flow operating room should be selected for the operation. It must have the design of “three areas and two channels”. The three areas include clean area, potential area and contaminated area. The two channels include patient and medical staff channels. Multidisciplinary consultation should take place before surgery, relevant investigations should be actively improved, and cross-infection should be prevented by strict pre- and postoperative disinfection in the operating theatre.11,19 Risk assessment should be carried out for all personnel involved in surgical treatment and personal protective equipment of different levels should be fully prepared. Protective equipment includes the following: surgeons wearing disposable full-face surgical caps, medical protective masks (N95 and above), surgical scrubs, disposable protective surgical clothing, disposable impermeable isolation surgical clothing, face shield or goggles, at least double layer latex gloves and waterproof boot covers and shoe covers.
The protection of medical workers during operation anaesthesia
Anaesthetists must use three-level protective equipment and arrange operations in independent negative pressure operating rooms. Visitors are strictly prohibited. Simple anaesthesia, such as local anaesthesia or nerve block, should be the first choice, followed by intraspinal anaesthesia. If general anaesthesia is absolutely necessary, measures must be taken to prevent patient secretion pollution. When using general or monitored anaesthesia, a disposable filter must be placed between the tracheal intubation and respiratory circuit to reduce pollution. This ensures protection against patient body fluids and secretions, as well as aerosol pollution during tracheal intubation and sputum suction. Before induction, two pieces of moist gauze are placed over the nose and mouth to provide oxygen and 100% pure oxygen is administered to ensure complete and independent breathing. Endotracheal intubation is performed by the anaesthesiologist with the help of an assistant. Once intubation is complete, the disposable equipment must be disposed of in the designated waste bin and should not be removed from the operating room. A closed suction system was used. Extubation of the tracheal tube must be performed under conditions of adequate analgesia to prevent choking. All operators must wear protective gear, including medical-grade masks (N95 or higher), protective eyewear, surgical gowns and positive-pressure headgear or helmets, to minimize exposure.18,21
Intraoperative protection
During the operation, medical staff must strictly adhere to the three-level protection standard. They must wear personal protective equipment (PPE), which includes disposable surgical hats, surgical masks (N95 and above), waterproof surgical clothes, double-layer surgical gloves, a face shield or goggles, as well as waterproof boot covers and shoe covers. Apply positive pressure ventilation, such as positive pressure head masks or helmets, and use a high-power suction device during the operation to reduce the gas and blood splashing produced by electrode burning tissue. To prevent sharp injuries, such as those caused by acupuncture, and cross-infection from occupational exposure,18,22 cooperation during the operation is crucial. Additionally, to prevent the spread of COVID-19, it is recommended to hang signs indicating the presence of infected patients on the door of the operating room. During the operation, indoor personnel should remain in the operating room, and outdoor personnel should only enter the infection operating room if absolutely necessary. The operating room medical staff consists of skilled surgeons, diligent hand washing nurses, experienced anaesthesiologists and reliable itinerant nurses.
Personal protective equipment service regulations
When entering a potentially polluted area from a clean area, there are seven steps to follow for wearing PPE with confidence. These include hand washing, wearing hats, wearing medical protective masks (N95 and above, with an air leakage test), wearing protective surgical clothing, wearing boot covers, wearing shoe covers and wearing a face shield or goggles. To enter the pollution area, follow these steps: wash your hands in seven steps, wear sterile surgical gloves, put on waterproof surgical clothing, wear sterile surgical gloves again, and prepare for the operation. Maintaining a sterile environment is crucial to prevent contamination.
Follow procedures for removing PPE carefully. Perform hand hygiene before entering a potentially contaminated area. Remove shoe covers, waterproof surgical clothing and outer gloves simultaneously. Then, perform hand hygiene again and remove the face shield or goggles. Finally, perform hand hygiene again before entering the potentially contaminated area. Dispose of the articles in special dirt containers after use. To ensure safety and prevent contamination, it is imperative to follow these steps before entering the cleaning area: perform hand hygiene, remove protective clothing and boot covers, remove medical protective masks and remove hats. Once these steps have been completed, confidently proceed to the cleaning area and proceed with bathing, changing clothes and exiting the area.
Postoperative management and disinfection/sterilization
For all medical staff involved in the operation, according to the COVID-19 suspected and confirmed patients’ condition and virus nucleic acid test results, whether the operation process is strictly implemented with tertiary protection and whether there is accidental exposure, the expert team will decide whether the operating staff can apply for exemption from isolation after evaluation, otherwise, the medical observation shall be carried out for 7 days and 3 days of home health monitoring, during the observation period, if there is any abnormality, and seek medical advice.
With regard to the operating theatre, after the operation, the operating room staff closes the laminar flow and air supply, uses the peroxide acetic acid or hydrogen peroxide spray to seal the disinfection for 1–2 h, but may also use an ultraviolet ray to disinfect; the floor is cleaned with chlorine preparation disinfection (routine is 84 disinfectant) for 30 min, followed by mopping with water; the instrument table, equipment, operating platform and all surfaces are cleaned with chlorine preparation disinfection (routine is 84 disinfectant) for 10–30 min, followed by wiping down with water. Try to reduce the contamination on the floor. If there is contaminated liquid or blood on the floor or surfaces, wipe it with 2000 mg/l of effective chlorine disinfectant (generally 84 disinfectant). After negative pressure or infection theatre disinfection, contact the infection management department for surface and air sampling testing and use only after acceptable test results are confirmed. 23
With regard to the surgical instruments, use a double-layered yellow medical waste bag, seal it with tape, stick a ‘COVID-19’ eye-catching label on the outside and place it separately according to the specifications of the disinfection supply room: first disinfect, then clean, then sterilize. The instrument must be placed in a closed container, labelled on the outside, sent to the central supply room and handed to the receiving staff face to face. Treatment method: the chlorine-based disinfectant 1000–2000 mg/l can be used for 30–45 min; chlorine-based disinfectant 5000–10000 mg/l should be used for ≥60 min if there is obvious contamination, and all items should be immersed below the liquid level, disinfected first, and then treated in the order of cleaning, drying, packaging and sterilization. 23
Transfer of COVID-19 surgical patients and disinfection/sterilization
The members of the transport team should take three-level protection and transport the patients to the entrance of the operating room by negative pressure stretcher. They should then lay a large one-time use sheet onto the operation docking car, connect the special or negative pressure stretcher car to connect the patients to the negative pressure operating room, and move the patients to the operating bed; then they should sterilise the operation docking car, special or negative pressure stretcher car and move to the door of the operating room for standby. Anaesthesia and resuscitation are performed in the operating room after the operation, and after the patient is fully awake, the mobile nurse and the operating doctor will move the patient to the special or negative pressure stretcher car and the operation docking car, disinfect the wheels at the door of the operating room, and the mobile nurse will transfer the patient to the door of the operating room, hand them over to the transfer team, who will transfer the patient to the isolation ward and hand them over to the ward nurse. Ensure that the patient’s different lines are handled with care during transport to prevent leakage and cross infection. The mobile nurse will send the operation docking car, special or negative pressure stretcher car back to the negative pressure operation room, and use the chlorine-containing disinfectant (1000 mg/l or 5000 mg/l) to mop the floor from the operation room lobby to the operation room; and use the chlorine-containing disinfectant (1000 mg/l or 5000 mg/l) at the same time to wet wipe and disinfect the car body and vehicle mattress. Then they should use hydrogen peroxide spray fumigation and disinfection for 2 h, wash with clean water and clean the surfaces of the object until the sampling culture is qualified. 24
Conclusion
As the COVID-19 epidemic continues, increasing numbers of patients need orthopaedic surgery, so the prevention of occupational exposure during surgery has become the most important concern for surgeons. The current authors focused on COVID-19 epidemiology, clinical manifestations and diagnosis, preoperative preparation, choice of operation and anaesthesia, protection of all kinds of personnel during surgery, management of operating theatres and instruments after surgery. According to the control guidelines issued by the National Health Protection Committee of China and combined with the experience of frontline experts, this current review suggests management and protection strategies for orthopaedic surgery in patients with COVID-19.
