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.