Pain distraction during awake low anterior resection and Cuddle Delivery initiative for inpatient: frugal procedural options to support surgery in the COVID-19 era.

OBJECTIVE: Since minimally invasive surgery and general anesthesia are both aerosol-generating procedures, their use became controversial during the outbreak of coronavirus disease 2019 (COVID-19). Moreover, social distancing resulted in serious psychological consequences for inpatients. This case report investigates pain distraction during awake laparotomy, as well as new possibilities for emotional postoperative support to inpatients. PATIENTS AND METHODS: A 72-year-old man affected by middle rectal adenocarcinoma underwent lower anterior resection plus total mesorectal excision under combined spinal-epidural anesthesia. A 3D mobile theatre (3DMT) was intraoperatively used for pain distraction. A postoperative "Cuddle delivery" service was instituted: video-messages from relatives and close friends were delivered daily to the patient through the 3DMT. Emotional correlations were investigated through a clinical interview by the psychologist of our Hospital. RESULTS: Intraoperative, as well as postoperative pain, resulted well-controlled: visual analogue scale (VAS) ≤3. Conversion to general anesthesia and postoperative intensive support/monitoring were unnecessary. The "Cuddle delivery" initiative positively fed our patient's mood and attitude, strengthening his bond to life. CONCLUSIONS: During pandemic, awake laparotomy under loco-regional anesthesia may be a crucial option in delivering acute care surgery to selected patients when intensive care beds are unavailable. Our procedure introduces potential ways to optimize this approach.

Awake laparotomy: is locoregional anesthesia a functional option for major abdominal surgeries in the COVID-19 era?

OBJECTIVE: Over the ongoing pandemic of coronavirus disease 2019 (COVID-19), the demand for critical care beds among medical services has rapidly exceeded its supply. Elective surgery has comprehensively been drastically limited and allocating intensive care beds to emergency cases or to high risk scheduled elective cases has become an even more difficult task. Here we present our experience which could help to handle undelayable surgical procedures during this emergency. PATIENTS AND METHODS: In 2019, eight patients (4 men, 4 women) with a mean age of 88 years, needing emergency abdominal surgery underwent awake open surgery at our Department of Surgery. All of them were identified as fragile patients at preoperative evaluation by the anesthesiologist. In all cases, locoregional anesthesia (spinal, epidural or combined spinal-epidural anesthesia) was performed. Intraoperative and postoperative pain has been monitored and regularly assessed. RESULTS: None of the patients was intubated. Mean operative time was 80 minutes (minimum 30 minutes, maximum 130 minutes). Intraoperative and postoperative pain were both well controlled. None of them required postoperative intensive care support. No perioperative complications were observed. CONCLUSIONS: Based on our preliminary case series, awake open surgery has resulted feasible and safe. This approach has allowed to perform undelayable major abdominal surgeries on fragile patients when intensive care beds were not available. Surely, it represents a helpful alternative in the COVID-19 era. A streamlining of workflows would fast-track both fragile patients management, as well as healthcare workers' tasks and activity.