General guidelines

1. Establish a communication channel between the department of surgery and the hospital board of directors, with daily reports about the department and the hospital.

2. Consider a 14-day shift followed by a 14-day break period according to the incubation period of the disease.

3. The usual work of the department will be lower due to the decrease in the normal activity. The surgeon without an assigned activity or who has finished it should remain at home to reduce exposure and infection and should be available for any emergency. This distribution should be coordinated by the person designated to such task.

4. All the staff members should receive practical training in donning and doffing of personal protective equipment (PPE) as established in each center. Recomendaciones para equipos de salud | Argentina.gob.ar

5. Working areas, offices and lecture halls must be well ventilated, keeping the safe distance between doctors and with the rest of the hospital staff.

Elective surgery

▪ Elective non-oncological surgeries should be canceled, and cancer surgeries should be prioritized (weighting COVID-19 mortality against cancer mortality, especially in high-risk patients)

Hospitalization

1. Ward rounds: Keep all the protective measures established by the Preventive Medicine Department of each hospital.

2. Healthcare staff should always wear surgical face masks and use gloves in patients with suspected COVID-19 or with respiratory symptoms.

3. Inpatient care of COVID-19 patients: Only one surgeon must evaluate an inpatient following the protective measures established by the corresponding entity.

4. All the patients hospitalized with a surgical condition and respiratory symptoms

will wear a surgical mask and will be reported to the Preventive Medicine Department.

5. A strict record should be kept of all staff members who have been in contact with a patient who has tested POSITIVE and should be reported to the Occupational Medicine or Preventive Medicine Department.

Outpatient/ambulatory cases

1. Each case should be reviewed by the surgeon in charge before postponing it, and each cancer case should be individually assessed according to the guidelines of each center.

2. Patients with cancer diseases will be treated bearing in mind all the measures. The physician/ surgeon must wear a mask and keep great distance from the patient and family members during the interview. Only one family member is recommended in the interview.

3. Tables and keyboards should be cleaned and disinfected.

Duty shifts

1. In view of the reduction of the ordinary activity of the emergency services, the working hours of the staff on duty will be assigned; each sick leave in the list of the staff on duty and in the contingency list will be checked every day. Each service will have a list of the staff on duty and a parallel contingency list per week.

2. Consider taking food and beverages to the emergency department and if possible and disinfect the common areas and emergency equipment with aerosol spray.

Recommendations for the surgical management of COVID-19 patients

Emergency surgeries cannot be delayed or canceled; they must always be guaranteed, considering the general recommendations in coordination with the authorities of each healthcare center. The main goal is to preserve vital healthcare activity while protecting our patients and healthcare workers.

▪ As in other settings involving patients with highly communicable diseases or very high case fatality rates, appropriate personal protective equipment and masks should be required at each facility. Limit the number of medical professionals necessary for surgery who must be those better trained and with the greatest experience.

▪ Preoperative testing is not indicated for all the patients with emergency surgical conditions (but the possibility of testing would be advisable). Routine testing for COVID-19 is recommended for all suspected cases with the symptoms described in the literature (respiratory symptoms, fever, dyspnea, abnormal chest X-ray and anosmia and ageusia in the early stage of the disease). Extra-respiratory symptoms are not common and non-specific (nausea, vomiting, epigastric pain) while hepatotoxicity related to the treatments used is exceptional. Gastrointestinal symptoms, especially diarrhea and nausea, may precede the respiratory symptoms and may have a worse prognosis due to an increase in viral load and complications. Gastrointestinal symptoms mimicking surgical conditions, similar to acute pancreatitis, have been reported, even in the absence of respiratory symptoms. We must carefully check that this clinical information has been collected, and if not, we must get it during the first interview with the patient.

▪ In case of emergency surgery on a confirmed or suspected COVID-19 patient, it is recommended to have a dedicated operating room for COVID+ patients with the specific protective measures required. In suspected patients with surgical conditions that cannot be delayed and in the absence of rapid testing, consider the patient as a positive case and fellow the corresponding recommendations: Recomendaciones para equipos de salud | Argentina.gob.ar

▪ When possible:

- avoid exposure to aerosols to prevent infection,

- limit the number of surgical staff in the operating room,

- avoid endotracheal intubation and general anesthesia,

- the surgical team (surgeon, assistant/s, scrub nurse) should net enter the operating room until the endotracheal tube has been placed,

- googles and N95 respirators should be used even in negative COVID-19 patients.

▪ The USUAL SURGICAL INDICATIONS SHOULD NOT BE CHANGED unless determined by a context of patient load (in review). Each decision should be individualized and based on a definitive diagnosis. In those patients with suspected or documented SARS-CoV-2 infection, the need for intervention should be very rigorously considered with evaluation of the clinical impact due to the infection.

The surgical technique should not be modified, but we can consider:

- Surgical approach: determine the RISK/BENEFIT ratio in the use of the LAPAROSCOPIC APPROACH in patients with SARS-COV-2 INFECTION requiring EMERGENCY SURGERY. If the laparoscopic approach is decided:

- the individual PROTECTION protocol must be strictly observed,

- devices to FILTER released CO2 should be used,

- The LOWEST PNEUMOPERITONEUM PRESSURE should be used if it does not compromise the exposure of the surgical field,

- avoid placing COVID+ patients in the Trendelenburg position for a long period to prevent adverse effects on the cardiopulmonary function,

- LIMIT the continuous use of POWER SOURCES on certain areas to minimize aerosolization, and complete exsufflation is recommended before removing the trocars.

- Surgical technique: Achieve the MAXIMUM POSSIBLE BENEFIT with the SMALLEST SURGICAL GESTURE TO MINIMIZE THE PROBABILITY OF POSTOPERATIVE COMPLICATIONS.

- High-risk anastomoses should be minimized.

-The surgery must be performed by the MINIMUM NUMBER OF OPERATORS.

-The most experienced surgeon should be the leader of the surgical team to minimize risks, complications, and time of exposure in the operating room.

* The patient with suspected or confirmed or COVID-19 infection must be evaluated by a single professional before surgery, using adequate PPE. Although there is no clear evidence, it seems that postoperative complications are more common in these patients.

*Polytrauma patients should be managed in a dedicated room and the staff should use the corresponding PPE. In case a dedicated room is not available, it is advisable to use the same room to manage these patients. Due to the epidemiological context, all polytrauma patients should be considered as COVID+ patients; thus, all the individual protective measures should be followed throughout the entire process of care: transportation for imaging, to the operating room or to the intensive care unit. The members of the trauma team assigned for the initial care should be limited in the current situation.

DO NOT ENTER THE OPERATION ROOM WITH PERSONAL ITEMS (MOBILES, KEYS, STAMPS, ETC.)

See attached chart