Nosocomial SARS-Cov-2 transmission to cardiovascular surgery
patients and healthcare personnel in Spain
Although cardiac surgical volumes have decreased worldwide, the need to
continue to offer surgery, despite the coexistence of SARS-COV-2 within
the hospital and beyond, becomes evident.
Preliminary reports of outcomes of thoracic surgery (25) and a variety
of other surgical interventions points at a dramatic increase of
postoperative mortality outside prediction. Although not reported, most
likely COVID-19 has further negative impact in postoperative outcomes
after cardiovascular surgery.
Transmission of SARS-COV-2 to HCW and nosocomial infection to healthy
patients remain an undesired possibility (26, 27). Currently, there are
no proven therapies to treat COVID-19 disease or to prevent its
development once infection is acquired. Thus, it all comes down to
develop a defensive line by means of extended measures.
In May 2020, a voluntary survey exploring the impact of the current
pandemic was circulated amongst cardiovascular surgeons in Spain. Data
from 13 university associated public healthcare centers offer a snapshot
during the first pandemic wave. All those but one were appointed as
regional COVID-19 referral institutions. Several aspects have been
universal such as a steep decrease in the departmental activity with
almost exclusive delivery of urgent or emergency operations. In 80% of
centers cardiovascular surgery ICUs admitted COVID-19-infected patients.
Around 50% relocated their cardiac surgery patients to other units
creating a newly design clean path for surgical patients away from
COVID-19 cases.
Concerning preparation for the pandemic, around 20% of colleagues felt
that their institutions failed in providing enough timely information
regarding the developments. In fact, more than 80% of personnel
undertook the necessary training to face COVID-19 cases after the
admission of the first infected patients. Around 40% felt that their
institutions did not provide them with enough PPE as deemed necessary by
the Centers for Disease Control and Prevention (CDC) (mostly referring
to the lack of FFP2 or FFP3 at any point outside the ICU environment).
In terms of surveillance of cardiovascular surgery personnel health
status, most of the 13 responders carried regular COVID-19 swabs to
surgeons. However, it is known that to a greater extend throughout Spain
screening to HCW at the peak pandemic (sometimes even with symptoms
suggesting SARS-Cov-2 infection) was not offered. Notably, newly
admitted patients facing cardiac surgery had swab testing
preoperatively. In 2/13 (15%) centers cardiac surgeons were relocated
to ICU primary physician positions whilst the other centers had their
ICUs managed mainly by anesthesiologists. Four out of 13 (30%) of
centers had at least one staff cardiovascular surgeon infected with
SARS-CoV-2 and 2/13 (15%) had at least one trainee infected during at
the time of the survey. About anesthesia personnel dedicated to cardiac
surgery 5/13 (38%) centers had infected colleagues. In summary, the
rate of infected healthcare cardiovascular surgery personnel has not
been anecdotal, although difficult to attribute entirely to in-hospital
infections. The suspicion is that the majority may have been infected at
workplace -State of Alarm was declared - despite a significant
decrease of surgery volume thus pointing at cross-contamination between
personnel.
The impact of SARS-CoV-2 in patients undergoing cardiac surgery has not
been minor. Although hard to distinguish from nosocomial acquisitions vs
community-acquired disease (before admission) almost half of centers
performed surgery in at least one COVID-19 patient (range 1-10) since
the pandemic was declared. The observed mortality in this sample ranged
from 9% to 60%, once COVID-19 affects a patient undergoing
cardiovascular surgery. Important to mention, the transplant activity
decreased significantly (number of offers also decreased) with some
centers formally closing the program temporarily under the threat of a
potential negative impact of infection on transplant patients.
In view of the above mentioned, when facing a surgical emergency it
seems wise to adopt further protective measures despite the absence of
COVID-19 symptoms or exposure to known cases. The proposal is extending
preoperative evaluation to other laboratory tests such as ferritin,
C-reactive protein and pay attention for the presence of leukopenia.
Such abnormal tests and/or pulmonary infiltrates -beyond pulmonary
edema- should raise SARS-CoV-2 suspicion and motivate full PPE and FFP3
mask use. If there are no laboratory or imaging data suggesting the
presence of SARS-CoV-2, the use of FFP2-3 and a regular surgical mask on
top seems advisable during this pandemic (for protection from patients
and for protection from/of other HCW nearby). The reason to wear a
regular surgical mask on top of a valved high-filtering mask is that HCW
can be asymptomatic carriers and we should protect our surrounding
colleagues from ourselves (valved-FFP3 masks do not offer protection to
those in close contact). In addition, a delay of 30 minutes since
intubation to operating room access - for those not involved with the
airway procedure - seems advisable if not wearing full PPE (28, 29). All
measures and efforts need to be in place to avoid cross-contamination of
secondary patients or HCW. Some of those measures have been adopted by
Spanish centers and remain now.
In our opinion, the use of surgical masks alone in the hospital during
this pandemic either inside or outside the operating room seems
questionable and unsafe. Mortality and complications arising from a
negative - direct or indirect - impact of the pandemic amongst
cardiovascular diseases has also been reported in Spain (18). The need
to increase the practice of cardiovascular surgery to regular volume is
inevitable and necessary despite SARS-CoV-2 is expected to remain in the
population until general immunity is acquired or an effective vaccine
available. For this reason, a change in paradigm of conventional
protective measures seems necessary at multiple ends (30) and
particularly true as we are currently seeing a new escalation of
SARS-CoV-2 cases across the country. We are in a critical moment with
the need of a roadmap to resume elective surgery without putting the
patients and ourselves at further risk. Preoperative extended screening
including swab tests, routine laboratory tests (including ferritin,
D-dimer and leucocyte count) and chest X-ray obtained 2-3 days prior to
an elective procedure, have become routine practice in Spain to help
decrease the risk of postoperative mortality, complications and
in-hospital transmissions of SARS-CoV-2.