Reopening the Elective OR

As Phase 1 of the “Guidelines of Opening Up America Again” start to take effect, the aesthetic surgical practice is faced with the challenge of reopening the operating room in a way that keeps staff and patients safe.

To ease some of these anxieties, the American Society of Plastic Surgeons has created a comprehensive guide of best practices for restarting elective surgical procedures.

Before going back into the OR, ASPS suggests appraising the supplies available within your community and whether hospitals continuing to care for COVID-19 patients are well covered. It’s important to consider whether your use of personal protection equipment (PPE) and supplies will detract from the area’s ability to act in response to a potential coronavirus surge.

“Even if you plan outpatient procedures in off-site locations, this may be important in the event of an emergency or complication. In addition, critical resources may need to be diverted to local hospitals if a crisis situation exists,” according to ASPS guidelines.

Once the OR opens, the Centers for Medicare and Medicaid Services recommend prioritizing surgical care based on clinical needs.

“Providers should prioritize surgical/procedural care and high-complexity chronic disease management; however, select preventive services may also be highly necessary.”

Capi Wever, M.D., Ph.D., a facial plastic surgeon practicing in the Netherlands, suggests not operating on “those over 65 years old, are obese and ASA > 2,” to start.

Pe-Op Considerations

ASPS suggests adding updated language to surgical consent forms, or creating an entirely new form to address the potential risks of COVID-19.

“Consider either additional COVID-19 language in existing consents (or a separate consent) to address potential for exposure to COVID-19, limitations of testing and other mitigating measures, as well as the risk of undetected infection at the time of procedure leading to potential increased morbidity and mortality,” according to the guidelines.

Patients should be screened for COVID-19 as close as possible to the time of the surgery in an effort to lower the risk of exposure after the test is administered and before the procedure can take place.

However, Gary Linkov, M.D., a New York City-based facial plastic surgeon, says current available tests fall short in this area.

“Relying on testing (PCR test) will be challenging unless it can be done same day with a quick turnaround,” he says. “If the test is negative a few days prior, the patient could still have the infection the day of the surgery.”

Dr. Wever says that he is currently screening all of his patients “with PCR [tests] 48 hours prior to surgery and [then they’re] requested to self-isolate after the test.”

He acknowledges that false negatives do occur when using PCR tests. In response, his “team wears N95 masks and eye protection during intubation and extubation.”

In the OR

When discussing procedure and safety during surgery, Dr. Wever explains that there are two aspects that need to be understood, the safety of the patient and the safety of the team.

The more pressing risk, he says, is exposure from the patient to the team.

“The risk of patient-to-team contamination is likely the greatest during intubation, extubation and the immediate recovery period due to coughing,” he says. “It is also likely higher in rhinoplasty, given intranasal mucosal exposure.”

To help lower this risk, Dr. Wever has adjusted his approaches to intubation, extubation and rhinoplasty.

“Intubation is done with rapid-sequence inducation, after ample pre-oxygenation without positive pressure; a stylette or a videolaryngoscope is used to improve the likelihood of first-time success,” he says. “During extubation we perform deep extubation to reduce the likelihood of coughing.”

“For rhinoplasty, some adjustments have been made to reduce exposure to the intranasal mucosa. Tranexamine is used in the drip, to optimize bleeding control. After septoplasty is completed, epinephrine-soaked nasal packing and a pharyngeal tampon are used to avoid the need of suctioning.”

During intubation and extubation, know the aerosolization time based on air-exchange rate in the OR, ASPS suggests. Based on this time, minimize staff in the room.

To limit the likelihood of viral particles in the air, Dr. Linkov will be “using less unipolar cautery energy when working around the nose or mouth, and more bipolar to reduce the aerosolization of viral particles. Our anesthesia team will be moving away from endotracheal intubation and focusing primarily on laryngeal mask airway and nasal cannula.”

ASPS also suggests considering anesthesia tents and glidescopes, along with limiting the supplies in the room to only those required for each case to preserve sterilization.

Though many physicians will be using N95 masks during surgical procedures, Dr. Linkov says that some are opting to use a powered, air-purifying respirator (PAPR) for more protection. A PAPR filters out potential contaminants in the air by using a battery-operated blower to provide clean air through a tight-fitting respirator, a loose-fitting hood or a helmet.

However, shortages could affect the PPE available, Dr. Linkov says.

“[It] depends on availability of PPE from distributors such as Henry Schein and Mckesson, since that is where most surgeons shop for PPE,” he says.

Post-Op Considerations

ASPS recommends patients stick to a 7-day post-op social isolation period to reduce the incidence of new exposure of infection, excluding any needed post-op visits.

Dr. Wever is also considering the use of surgical masks for post-op patients during their time in the recovery-room.

To lower the risk even further, some physicians are considering virtual post-op appointments.

However, Dr. Linkov explains that “with surgical care, it is most helpful to see the patient and examine the wounds first-hand.”

Overall, Dr. Wever says that “communicating with your team and with your patients, and explaining what measures you have taken and why, is probably the best thing we can do. Be transparent.”

More on reopening the practice