Surgery and Procedures in the Context of COVID-19

Comprehensive Peri-operative Infection Prevention and Resource-Stewardship Guideline

(Applicable during outbreaks of infection caused by COVID-19 and transmission of SARS‑CoV‑2)

1. PURPOSE AND AIMS

The purpose of this guideline is to provide a structured, evidence-based framework for delivering safe surgical and anesthetic care during a respiratory viral pandemic.

Primary Objectives

1. Protect the patient

   • Prevent peri-operative viral exposure

   • Reduce postoperative pulmonary complications

   • Ensure appropriate surgical prioritization

2. Protect healthcare workers

   • Reduce aerosol exposure

   • Standardize PPE utilization

   • Prevent intra-hospital outbreaks

3. Preserve critical resources

   • Ventilators

   • ICU beds

   • Oxygen supply

   • Personal Protective Equipment (PPE)

   • Workforce availability

4. Maintain essential surgical services

   • Save life

   • Preserve organ function

   • Prevent irreversible disease progression

2. SURGICAL PRIORITIZATION FRAMEWORK

During a pandemic surge, surgery is not stopped — it is stratified.

A. Emergency (Operate Immediately)

Conditions where delay results in death or permanent disability:

B. Urgent / Time-Sensitive (Operate within days–weeks)

C. Elective (Delay Until After Peak)

Examples:

• Hernia repair

• Cosmetic surgery

• Non-urgent endoscopy

• Joint replacement

• Benign masses

3. INFORMED CONSENT DURING PANDEMIC

Consent must specifically include:

• Risk of hospital-acquired viral infection

• Increased pulmonary complications

• Possible postoperative isolation

• Visitor restrictions

• ICU bed limitations

• Possibility of treatment modification due to resource scarcity

Consent may be obtained from:

• Patient

• Legal surrogate

• Emergency implied consent (life-saving situations)

4. OPERATING THEATRE DESIGNATION

Dedicated COVID Operating Theatre

All confirmed positive patients should be managed in a separate designated operating theatre:

Requirements

• Separate entry/exit pathway

• Negative pressure preferred

• Dedicated anesthesia machine

• Dedicated surgical instruments

• Dedicated donning/doffing area

5. IN-THEATRE PRACTICE PROTOCOL

Staffing

• Minimum personnel only

• No observers or students

• Fixed surgical teams if possible

Ventilation Control

• Positive pressure OFF during aerosol-generating procedures

• Resume after ≥20 minutes air exchange

• Negative pressure preferred

Airway Management (Highest Risk Phase)

Only most experienced anesthesiologist performs:

Energy Devices

Use smoke evacuation for:

• Diathermy

• Laser

• Ultrasonic devices

Reason: Viral particles may aerosolize in surgical smoke.

Post-operative Ventilation

Avoid elective postoperative ventilation where possible to preserve ICU resources.

6. PERIOPERATIVE SCREENING AND TESTING

Clinical Screening (All Patients)

Check for:

• Fever

• Cough

• Dyspnea

• Exposure history (last 7–14 days)

Laboratory Testing

• PCR test within 72 hours pre-procedure

• Self-quarantine after testing until surgery

• Emergency cases: treat as positive

7. PATIENT RISK CLASSIFICATION

8. PERSONAL PROTECTIVE EQUIPMENT (PPE)

Standard COVID PPE

• N95 respirator

• Eye protection (goggles/face shield)

• Gown

• Double gloves

Augmented COVID PPE

• PAPR/CAPR respirator

• Full gown

• Double gloves

• Eye protection

9. HIGH-RISK VS ULTRA-HIGH-RISK PROCEDURES

High-Risk Procedures

Aerosol likely but controlled:

• Thoracic surgery with lung isolation

• Bronchoscopy

• GI endoscopy

• Cardioversion

• Cesarean section with GA risk

Ultra-High-Risk Procedures

Direct airway aerosolization:

• Tracheostomy

• ENT airway surgery

• Nasopharyngeal procedures

• Rigid bronchoscopy

• Oropharyngeal surgery

Require Augmented PPE

10. OPERATIVE MANAGEMENT SCENARIOS

WHEN TESTING NOT AVAILABLE

D1 — Low-Risk Urgent

• N95 + shield

• Minimal staff

• 15-min entry delay after intubation

• 15-min exit delay after extubation

D2 — High-Risk Emergency

• Full PPE for all staff

• Augmented PPE for ultra-risk

• Continuous PPE use entire procedure

D3 — Symptomatic or Exposure

• Assume positive

• COVID ward post-op

• Leave intubated if needed

WHEN TESTING AVAILABLE

F1 — COVID Negative

• Standard OR protocol

F2 — COVID Positive Asymptomatic

• Full PPE

• Delayed entry/exit

F3 — Symptomatic Outpatient Positive

• Full PPE

• Minimal staff

F4 — Symptomatic Inpatient Positive

• Transfer to COVID unit post-op

11. POSTOPERATIVE MANAGEMENT

Patient Pathway

Staff Decontamination

1. Doff PPE in designated zone

2. Hand hygiene after each removal step

3. Shower recommended after high-risk exposure

Theatre Decontamination

• Chlorine disinfectant surfaces

• Air exchange ≥20 minutes

• Terminal cleaning

• Waste treated as infectious

12. CORE PRINCIPLE

This strategy protects:

• Patients

• Staff

• Hospital systems

• Community transmission chains