COVID Surgical Algorithm for OR Utilization 2020-2021
I wrote this algorithm in February of 2020 at the beginning of the pandemic. The goal is and was to continue operating with a calculation of the risk on a patient by patient basis including the urgency and necessity of surgical intervention. Fundamentally, we need to know the risk of disease transmission. To accomplish this, we might think of a infectious patient in six categories.
Two categories are considered high risk which include fulminant infection and active carriers. These disease states likely portend the greatest risk of infection to the surgeon and associated operating room personnel.
Intermediate categories include those patients who tested positive and are now convalescent hosts who have two negative PCR tests, and no symptoms for greater than two weeks. Also included in this category are undetermined hosts who are symptomatic without a known exposure but present with symptoms. In certain cases, a negative PCR may be reported as a false negative which still represents some risk to the surgical team.
Lastly, two low risk categories include the likely negative who may have had a known exposure >14 days prior to requiring surgical intervention as well as presumed negative patients who have a negative PCR test, no known exposure, no symptoms, and have been largely social distancing compliant.
Other items to consider in this algorithm include the use of hydrogen peroxide to prepare the oral cavity, oropharynx, nose and nasopharynx. As it is considered that the coronavirus colonizes the nasopharyngeal tissues prior to disseminated infection as well as in those who are considered asymptomatic carriers. Coronavirus species are uniquely susceptible to hydrogen peroxide when directly exposed.
"Hydrogen peroxide is produced physiologically by oral bacteria and plays a significant role in the balance of oral microecology since it is an important antimicrobial agent. In the epithelial cells, the enzyme superoxide dismutase catalyzes a reaction leading from hydrogen peroxide to the ion superoxide. The induced oxidative stress stimulates a local innate response via activation of the toll-like receptors and the NF-κB. Those kinds of reactions are also activated by viral infections. Virus-induced oxidative stress plays an important role in the regulation of the host immune system and the specific oxidant-sensitive pathway is one of the effective strategies against viral infections. Therefore, nose/mouth/throat washing with hydrogen peroxide may enhance those local innate responses to viral infections and help protect against the current coronavirus pandemic."
"The effect of H2O2 on adenovirus types 3 and 6, adenoassociated virus type 4, rhinoviruses 1A, 1B, and type 7, myxoviruses, influenza A and B, respiratory syncytial virus, strain Long, and coronavirus strain 229E was studied in vitro, using different H2O2 concentration and timec of exposure. H2O2 in a 3 percent concentration inactivated all the viruses under study within 1--30 min. Coronavirus and influenza viruses were found to be most sensitive. Reoviruses, adenoviruses and adenoassociated virus were relatively stable. H2O2 is a convenient means for virus inactivation"
Additional research may help facilitate the actual risk of transmission in the various categories listed above.