Preventive and Protective Management for Coronavirus Disease 2019 Patients Undergoing Emergent Cardiac Surgery
The coronavirus disease 2019 (COVID-19) pandemic has placed immense pressure on global health services, particularly in managing patients requiring emergent cardiac surgery. For patients confirmed or highly suspected of COVID-19 infection, non-operative treatment is preferred for stable cardiovascular conditions to minimize exposure. However, emergent cardiac surgery becomes necessary when the primary concern is life-threatening, and no alternative options exist. In China, optimized infection-control workflows, standard prevention measures, and hierarchical protection strategies have been widely adopted to minimize the risk of virus transmission and cross-infection. This article outlines a detailed perioperative management protocol for COVID-19 patients undergoing emergent cardiac surgery, emphasizing pre-operative, intraoperative, and post-operative measures.
Pre-operative Management
Identifying COVID-19 Infection During Cardiovascular Evaluation
For local patients, a detailed epidemiological history, temperature, and respiratory symptoms are assessed. Routine tests include a complete blood cell count and chest computed tomography (CT) scan. For suspected cases, a COVID-19 nucleic acid test is mandatory.
Patients confirmed or highly suspected of COVID-19 infection are referred only when local hospitals lack the necessary treatment capabilities, and the cardiovascular condition is life-threatening. Before referral, remote consultations are conducted to develop a treatment plan. Transportation occurs in dedicated negative-pressure vehicles with fully protected staff. Upon arrival, patients are admitted to the buffer zone of the emergency department.
Hierarchical Management of Cardiac Surgery
A multidisciplinary team, including cardiovascular surgeons, anesthesiologists, cardiologists, and infectious disease specialists, evaluates the patient. The team discusses COVID-19 infection status, the urgency of the cardiovascular condition, and potential non-surgical options. Emergent surgery is reserved for absolute life-threatening conditions without alternatives, such as acute Stanford Type A aortic dissection, acute coronary syndrome refractory to medication and percutaneous coronary intervention, infectious endocarditis with hemodynamic instability or embolism, unstable cardiac tumors with recurrent embolic events, and cardiac trauma.
Pre-operative Preparation
Once emergent surgery is indicated, the patient is admitted to an isolation ward, preferably a single-person room. Isolation wards have restricted access, and family visits are prohibited. Critically ill patients remain bedridden and wear masks.
Diagnostic evaluations for cardiovascular concerns are conducted immediately, with bedside testing preferred. All procedures, including echocardiography, follow Class III prevention protocols. Medical staff adhere to the “Technical Specifications for Hospital Isolation” and “Procedures for Putting on and Taking off Protective Equipment for Medical Staff” when entering or leaving isolation wards. Hand hygiene follows the “Standard for Hand Hygiene for Healthcare Workers” (WS/T313-2009). Isolation wards are cleaned according to “the Regulations of Air Purification Management in Hospital.”
Before surgery, the surgical team meets with representatives from anesthesia, operating room, respiratory, infectious disease, and medical offices to discuss the surgical plan. Necessary arrangements for medical supplies are made.
Management in Cardiac Surgery Operating Rooms
Preparation
- Surgery is conducted in an infection-customized room with negative pressure, air purification, and disinfection systems. The air-conditioning system is turned off. All medical staff undergo temperature checks.
- A “COVID-19” sign is displayed outside the operating room.
Medical Supply
- Disposable instruments, medications, and equipment are prepared in advance.
- The operating room is equipped with intercom and video surveillance facilities.
- Unnecessary items are removed. Immovable items are covered with protective cases to minimize contamination.
- Quick-drying hand disinfectants are preferred. Alternative disinfectants (chlorine, ethanol, hydrogen peroxide) are used for allergic staff. Chlorhexidine is ineffective against the novel coronavirus and is not recommended.
Patient Transportation
- Medical staff transferring patients wear Class III protection.
- A dedicated passage and elevator are used for surgical transfers, avoiding busy periods and routes.
Intraoperative Management
- Disposable instruments, equipment, and medical supplies are used whenever possible.
- The number of personnel involved is minimized. Strict personal disinfection is performed before surgery. Dedicated personnel handle material delivery. Indoor personnel do not leave the operating room during surgery, and outdoor personnel enter only after wearing protective equipment. Surgical supplies are prepared in advance to reduce personnel and equipment exchanges.
- All participants wear Class III protection. Surgeons and scrub nurses wear disposable sterile surgical gowns and two pairs of gloves. For surgeries exceeding four hours, diapers are provided. Medical staff with broken skin are excluded from the operation.
- Aseptic and safe manipulation principles are strictly followed to avoid occupational exposure. Alternative communication methods are used if protective equipment hinders verbal communication. Sharps injuries and contamination by patients’ blood and body fluids are avoided.
- The surgeon completes the Infectious Disease Report Form post-procedure.
Post-operative Management in the Operating Room
- ICU staff are notified in advance, and patients are transferred via a dedicated route.
- Reusable instruments are double-packed, labeled “COVID-19,” and disinfected separately.
- Air disinfection is performed according to infectious disease management requirements. Exhaust fan units and equipment surfaces are cleaned and disinfected.
- Surgical sheets and fabrics are disposed of as infectious waste.
- Pathological tissues are placed in double-layered yellow medical waste bags, sealed, and transported to the pathology department with clear notification. All medical waste follows the medical waste disposal process.
- Medical staff remove protective equipment in designated areas, with outer and inner layers removed in the operation room and buffer zone, respectively.
- In hybrid operating rooms, radiation protection and equipment disinfection are implemented.
- Quality control confirms the effectiveness of surface, air, and handler disinfection.
Management of Occupational Exposure
- Isolation is required for exposure or suspected close contact, followed by a 14-day medical observation and COVID-19 nucleic acid test.
- Mask slip-off: Gloves are changed or removed to adjust the mask. Protective equipment is removed following specifications, and personal hygiene is maintained.
- Damaged protective equipment: Staff leave the contaminated area, remove equipment, and perform personal hygiene. Exposure is assessed to determine the need for medical observation.
- Syncope: Staff assist the affected individual in leaving the contaminated area, remove protective equipment, and provide immediate treatment. Personal hygiene is maintained post-recovery.
Post-operative Management
After surgery, patients are transferred to a single-room isolation unit with negative pressure in the ICU. Medical staff wear Class III protection during non-invasive ventilation, tracheal intubation, tracheotomy, cardiopulmonary resuscitation, and bronchoscopy. Protective measures against droplet, contact, and air contamination are implemented. Disinfection of equipment, appliances, air conditioners, waste, and waste gas follows operating room requirements.
If the patient is stable with no pneumonia, fever, abnormal blood tests, or ground-glass opacity on chest CT, transfer to the recovery ward is considered. Before discharge, patients must meet both post-operative recovery and COVID-19 clinical recovery criteria.
This protocol aims to guide surgical teams in managing COVID-19 patients undergoing emergent cardiac surgery, ensuring patient safety and minimizing infection risks. It is not intended to replace institutional or local guidelines but to provide a framework for best practices in this evolving pandemic.
doi.org/10.1097/CM9.0000000000001012
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