Management of ophthalmic perioperative period during 2019 novel coronavirus disease(COVID -19) outbreak

Authors: Wang Xiaolei,Wang Zhen,Yao Chunlian, Li Shiying

 Department of Ophthalmology, First Affiliated Hospital, Army Medical University,  Chongqing 400038,China

Corresponding author: Li Shiying, Email: shiying_li@126.com

[Abstract] Objective To explore the perioperative management and infection prevention methods for acute eye diseases during the outbreak of 2019 novel coronavirus disease (COVID -19). Methods Since the COVID -19 was included in the Class B infectious diseases and was managed according to Class A infectious diseases in China, 127 patients who underwent ophthalmic surgery were enrolled at  Southwest Hospital/ Southwest Eye Hospital of Army Military Medical University from January 21 to February 19, 2020. The perioperative management according to the national epidemic prevention and control requirements was summarized, and the perioperative clinical management that should be taken during the epidemic prevention period were discussed. Results One hundred and twenty-seven patients underwent ophthalmic surgeries, including emergency surgery, daytime surgery and other surgeries for sight-threatening diseases. The methods of anesthesia included general anesthesia, local anesthesia and ocular superficial anesthesia. According to the national epidemic prevention and control requirements, epidemic screening for these patients and infectious managing measures were performed during the perioperative period, including the sterilization of relevant environment and equipments, the personal medical prevention and protection for medical staffs and patients, which help all the operations went smoothly and safely. There were no 2019-nCoV infection, surgical-relative infection, crossing infection and operation-related complications occurred. Meanwhile, there were not COVID -19-related infection events of medical staffs. The air sampling compliance rate in the operating room, ward, examination and other areas was 100%. Conclusions During the prevention and control period of the epidemic of COVID -19, strict adherence to the prevention and control measures can effectively ensure the smooth implementation of the operation and the perioperative safety of medical staff and patients.

[Key words] Corona virus disease-19; eye diseases/surgery; infectious management; perioperative period; opthalmology

Fund program: Chongqing Social and Livelihood Science Innovation Grant( cstc2017shmsA130100).

DOI:10.3760/cma.j.issn115989-20200224-00100

 

At the end of 2019, coronavirusinfection caused by COVID -19 (2019-nCoV) has caused spread at home and abroad widely, andattract the attention of the international community. The main transmission routes of 2019-nCoV are respiratory droplets and close contact transmission [1]. Studies have shown that the Sever Acute Respiraory Syndrom-coronavirus (SARS-CoV), which has a high homology with the 2019-nCoV genome, is transmitted by respiratory tract and may be infected by direct or indirect contact with  conjunctiva, nasal  or oral mucosa. During the outbreak of SARS in 2003, medical staff had increased the risk of infection because they were not equipped with goggles. It has been noted previously that SARS-CoV was detected in the tears of 3 patients with early onset (within 9d) by RT-PCR [2-4]. Based on this report, the study of COVID -19 patients found that conjunctivitis was the first symptom or the result of conjunctival sac virus nucleic acid test was positive [5-7]. Although studies have not definitively shown that mucous membranes or tissues of the eyes may be responsible for the transmission of COVID -19 virus, medical personnel may be at higher risk of infection due to close contact with patients during treatment. In addition, COVID -19 patients in the incubation period can also become the source of virus infection, so it is urgent for medical staff to protect themselves during clinical diagnosis and treatment of ophthalmology. In the course of diagnosis and treatment, especially perioperative period, it is very important for ophthalmologists to screen the patient’s condition, prevent cross-infection and strengthen personal protection. In this study, the perioperative protective management methods and other contents of patients undergoing surgical treatment in the ophthalmology department of First Affiliated Hospital, Army Medical University under the epidemic situation were summarized, which provided a theoretical basis for the smooth development of ophthalmic surgery during the pneumonia epidemic of COVID -19.

1 MATERIALS AND METHODS

1.1 general information

Researchers by cross-sectional study method, selection of February 19, 2020 January 21 solstice 127 cases in the army military medical university first affiliated hospital through ocular surgical patients, 59 patients, including emergency eye disease suffer from 26 patients with other diseases of the eye as well as on the first day (data collection) on January 21, during the surgery of 42 patients with eye diseases, and all ambulatory surgery patients surgery for 1 week in advance booking and completed all the preparation before surgery. There were 71 male and 56 female patients, with an average age of 45.6 years. Among them, 102 cases were local residents of chongqing and 25 cases were from other provinces or regions. All patients or guardians of the children were clearly aware of the process and purpose of all medical treatment projects and signed the informed consent.

 

1.2 methods

1.2.1 management before surgery

1.2.1.1 epidemiological investigation of patients before admission before hospitalization, the patients were questioned in detail by trained medical personnel and their epidemiological history was recorded, including whether they had a history of close contact with people from the epidemic area or a history of travel to the epidemic area. All patients should have chest CT scan and blood routine examination. If the results are abnormal, the patients should be further screened, and the patients with fever, cough, diarrhea, vomiting and other upper respiratory infections and digestive tract symptoms should be excluded in time. The hospital adopted the “instrument for measuring patients in close contact with epidemic diseases” (public version) jointly established by the e-government office of the general office of the state council, the national health commission and China electronic science and technology corporation to evaluate patients and their families before entering the hospital. Without downloading the APP, the tested personnel scan the qr code on their mobile phone and input their name and ID number. They can assess the visual data related to the contact with confirmed or suspected COVID -19 patients within 14 days online, so as to conduct preliminary screening for the patients with 2019-ncov infection or close contact. After the patient and his/her family enter the hospital, follow the principle of one room per patient, minimize going out, must wear masks and so on. The medical staff will monitor the general condition of the patient at any time according to his/her nursing level and temperature.

1.2.1.2 patient escort management

During the prevention and control of COVID -19 in ophthalmology, the information registration form patient escort was established. Each patient only kept a fixed escort staff, and the head nurse of the nursing ward issued escort CARDS for the attendants and closely monitored them, and the attendants were only allowed to move in the patients’ ward. Escorts must wear masks, take daily temperature measurement, and cooperate with nurses to carry out epidemic prevention and control, health knowledge education and screening registration.

1.2.1.3 requirements for close treatment

Since all aspects of ophthalmic treatment and care are in close contact with patients, all operators wear disposable protective clothing and gloves, surgical masks, hats and eye protection devices as required by the hospital. When nurses on duty prepare contents before performing routine operation, including lacrimal duct irrigation and conjunctival sac irrigation, their heads need to add a face screen. When doctors use slit lamp microscope to examine patients, they need to add protective baffles modified by optical film, in order to prevent the virus transmission caused by patients’ secretions or pharyngeal droplets, so as to block the possibility of infection to medical staff from the transmission route. At the same time, the examination of patients’ fundus does not use direct ophthalmoscope, but adopts the method of slit lamp microscope combined with indirect ophthalmoscope. If it is clear that the patient must be examined, then the color fundus photography is taken. For the signing of informed surgical consent, it is necessary to contact only one patient at a time in a separate patient ward or in the patient reception room, so as to minimize the close contact between medical staff and patients.

1.2.2 intraoperative management

1.2.2.1 patient management

When the patient enters the operating room, a special nurse is required to inquire the patient’s previous medical history and contact history of the epidemic, take the patient’s temperature in time and check the CT images of lungs. If the patient is suspected or diagnosed with COVID -19, the operation should be canceled immediately. For the emergency patients, the operation should be conducted in the negative pressure operating room[8]. For patients who meet the surgical guidelines, they need to wear a disposable shoe cover and wear a mask after entering the operating room. When performing skin disinfection, the mask should cover the mouth and nose completely, while using adhesive tape to secure and seal the edge of the mask. As a result of eye operation, the patient is more conscious, so advise the patient to avoid coughing or sneezing during the operation.

1.2.2.2 management of medical personnel

Three-level protection mechanism should be established in the operating room, and doctors operating the operation and hand-washing nurses should implement three-level protection [9]. General anesthesia is needed for patients who cannot control themselves to cooperate with the operation and who are in poor general condition. The anesthesiologist adopts secondary protection and adds a face screen to the head and face to avoid the risk of infection during the endotracheal intubation. Other patients are operated under topical or superficial skin anesthesia to minimize systemic anesthesia. In the operating room, the nursing system is flexible to avoid the waste of personnel and protective materials. For the itinerant nurses, the second level of protection is adopted. The head nurse controls the operating room staff, up to 4 medical staff, and visitors are prevented from entering the operating room [10].

1.2.2.3 air and goods management

The frequency of air, surface sampling and bacterial detection should be increased from once a month to twice a month. The operation was fixed in the same operation room, and the disposable operation kit was used during the operation. Since the disinfectant is not disposable consumable during the operation, its repeated use may affect the imaging results of the microscope. Therefore, the disposable film is used to cover the main body of the microscope and only the eyepiece and objective lens are exposed.

1.2.2.4 environmental disinfection after operation

The operating room environment requires a full range of terminal disinfection, including the clean area and the office area. Disinfection frequency increased, specifically, the clean area corridor and auxiliary surgery room more than 4 times a day, the number of disinfection between the surgery room than the number of the day; The office area shall be sterilized once a day by air, twice by surface and ground.

For the disinfection work in the surgical room, the specific contents include (1) object surface disinfection instrument table, equipment, operation table, etc., the disinfectant is chlorine-containing preparation of 1000-20000 mg/L, the surface is wiped for 10-30 min, and then wiped with clean water. The floor of the operating room was sprayed with a chlorine-containing preparation of 2000-5000mg/L, and the floor was swept with clean water after 30 min. For dirt (patients’ blood, secretion, vomit, feces), etc., if less contamination by disposable material (cloth, cloth), dip in 5000-10000 mg/L oxygen disinfectant in addition, if for a large number of pollutants you will need to use disposable absorbent material to the reoccupy after completely covered the 5000-10 of 000 mg/L oxygen disinfectant pouring to water absorption material and maintains more than 30 min, clean up dirt in 1 000 mg/L again after chlorine disinfection disinfection, time is more than 30 min. (2) filter screen at return air inlet: spray or wipe with 1000 mg/L oxygen-containing disinfectant for 2 times, then wipe with clean water after 30 min, or soak the filter screen with 1000 mg/L chlorine-containing disinfectant for 30 min, then rinse with clean water. (3) treatment of transfer bed: remove and erect the mattress. The disinfection treatment of the object surface is the same as that of the operation. (4) treatment of medical waste: medical waste is sealed by double yellow garbage bag, and its outer packing is sterilized with 2000 mg/L chlorine-containing disinfectant. Package should be marked with information (category: infectious; Production department: ophthalmic operating room; Date of production: actual date; Special instructions: high risk), and centralized management of the treatment.

1.2.3 postoperative management

According to the standard of secondary protection, the medical staff shall conduct operations including eye point and replacement of excipients for the patients, and closely monitor the patient’s temperature and whether there are other clinical symptoms, including whether there is surgical fever or fever caused by other reasons. The prevention and control of the epidemic may affect the psychological feelings of some patients and increase their anxiety and tension. Therefore, the medical staff must closely observe the patients and timely comfort and psychological counseling. Due to road blockade and traffic control in some provinces and regions, patients discharged from the hospital need to be included in the medical care WeChat group according to the disease type, so as to ensure timely and uninterrupted answering questions for patients, so as to avoid patients coming to the hospital for treatment for many times.

 

2  RESULTS

2.1 screening results of instrument for close contacts before hospitalization

For the screening results of patients who passed the close contact measuring instrument before hospitalization, all of them had no “close contact”, so the operation in the hospital was more convenient and efficient, and the patients and their families had high acceptance and good compliance.

2.2 evaluation of chest CT image before surgery

There’re a total of 22 cases for 127 cases of patients with chest CT images show that abnormal, including pulmonarycalcifications in 2 cases, pulmonary hyperplastic lesions in 7 cases, hyaline grinding nodules 4 cases of inflammatory hyperplastic lesions (3 cases and accountability nodules in 1 case), nodular shadows in 2 cases, emphysema article 3 cases, 1 cases of fog shadow, shadow in 1 case, spot fuzzy shadows in 1 case, fiber oven in 1 case. However, none of the 22 patients had fever. After careful diagnosis and treatment in the respiratory department, they were excluded to have 2019-ncov, so there were no contraindations for eye surgery.

2.3 different surgical outcomes

All 127 patients completed the operation successfully, and there were no suspected or confirmed COVID -19 cases after rigorous examination. All operations are in accordance with the positive pressure laminar flow operating room operating conditions. In this process, a total of 59 patients underwent emergency surgery, including debridement and suture of ocular trauma, removal of foreign body, trabeculectomy/excision, ciliary body photocoagulation, scleral external buckling, vitrectomy and eye content extraction. A total of 26 patients underwent various eye diseases, including vitreous injection and trichiasis correction. A total of 42 patients underwent diurnal surgery, including phacoemulsification cataract extraction, pterygotomy, strabismus and ptosis correction.

2.4 operation completion under different anesthesia methods

A total of 18 of the 127 patients underwent surgery under general anesthesia, including 10 children under the age of 18 and 8 adults. A total of 54 patients were operated under local anesthesia and 55 patients were operated under surface anesthesia. For the operation of different eye diseases, its duration is between 20-120 min.

2.5 infection control

There was no infection or operation-related complications in the affected area of the patients after the operation, and no medical staff was infected. The days of air sampling reaching the standard in the operating room, ward and inspection areas were 100%.

2.6 identification and management of perioperative patients’ lesions

The body temperature of a child with congenital glaucoma (1 year and 9 months old) was found to be elevated and the highest value was 39℃ on the 1st day before the operation. The parents of the sick child indicated that there was no contact history of the epidemic, indicating that the child had diarrhea, the number of stool 10 times/day, the stool was watery, yellow and smelly. Subsequently, it was detected by fecal routine and binomial virus. Routine blood test showed that the white blood cell count of the child was 21.66×10 /L, and the disease was diagnosed as acute upper respiratory tract infection and diarrhea after consultation with the pediatrician. The children were given ceftazidine injection with intravenous drip, montmorillonite powder for oral antidiarrheal treatment and ibuprofen suspension cooling. After 4 days of stable body temperature, trabeculectomy was performed under general anesthesia.

 

3  DISCUSSION

COVID -19 is a respiratory disease with long incubation period, strong infectivity and easy to endanger the life of patients [11]. However, during the epidemic of COVID -19, the medical staff should pay enough attention to the protection of their safety. The infection of some patients may be related to nosocomial transmission [12-13]. At present, whether the 2019-nCoV virus can cause eye infection in patients, and whether its transmission route includes the eye surface and other issues are the focus of ophthalmologists. At present, COVID -19 pneumonia with conjunctivitis has been found in patients, whose clinical symptoms are conjunctival congestion, and painful eyes, foreign body sensation, tears, exosome increase and other eye characteristics. Ophthalmological medical workers may also come into contact with COVID -19 patients with conjunctivitis as the first symptom [14]. The researchers demonstrated the ability to collect tears or conjunctival swabs and use second-generation sequencing as an adjunctive diagnostic modality for COVID -19 patients. Because second-generation sequencing requires a high level of laboratory skills and high operational ability of technicians, it is difficult to widely promote it in a short period of time [6]. At the same time, during the COVID -19 outbreak, routine surgery should be delayed in order to protect patients and medical workers. In this study, we studied 42 patients who had received preoperative examination and preparation 1 week in advance for ambuscular surgery. Other types of surgery were emergency surgery or more serious surgery. Under the condition that the condition permits, it is necessary to follow the procedures of ambulatory surgery. Therefore, it is particularly important to do a good job in the safety screening and protection of perioperative patients. This study shows that centralized management of patients and their families in hospitals can effectively reduce the risk of 2019nCoV and related in-hospital infection[15]. Due to the long incubation period of COVID -19, patients and their families may conceal the true condition and epidemic history for their own interests. They often rely on clinical experience and intuitive judgment to judge the condition, and lack accurate, objective and credible quantitative evaluation indicators. At the same time in order to improve the effectiveness of public health events patients triage and accuracy, we use the close contacts measuring instrument for the patient and family to assess the pre-hospital, countries withNational Health Commission (NHC), ministry of transport, railway corporation and the civil aviation administration support aspects of data resources, to prevent the patient and family to treat eye diseases and possible to hide the history or exposure history, worthy of clinical popularization and application. Early COVID – 19 patients with chest CT imaging findings of multiple small patch and interstitial changes, and then develop into double multiple ground glass shadow or infiltrative lung shadow [1], in this study included 5 cases of patients with a similar image, but the respiratory consultation are ruled out COVID – 19, and cases of infection has not been found in the follow-up after discharge, hints if you encounter such a situation in the clinical work don’t too much panic, should do well in personal protection, relying on the scientific spirit and scientific method, calm to deal with it. Reference for undergraduate medical staff in the fight against SARS and the prevention and control experience, in the process of ebola haemorrhagic fever ward and outpatient service and the various parts of the operating room family at that time made the “COVID – 19 during the SARS period of infection control case” only foresee risk exists, actively take effective preventive measures, to safety as the center, always keep a clear mind, to reduce the spread of virusand the occurrence of complications and adverse events. However, ophthalmology is prone to some prominent problems, such as insufficient attention, lack of effective early screening means, etc. How to further improve the ideological awareness, standardize the protection means, strengthen the protection equipment, and maintain the goal of zero infection, which is worth further discussion and consideration.

Conflict of interest: the authors of this study have no conflict of interest.

 

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