Lung Transplantation for Patients With COVID-19.

The COVID-19 pandemic has caused acute lung injury in millions of individuals worldwide. Some patients develop COVID-related acute respiratory distress syndrome (CARDS) and cannot be liberated from mechanical ventilation. Others may develop post-COVID fibrosis, resulting in substantial disability and need for long-term supplemental oxygen. In both of these situations, treatment teams often inquire about the possibility of lung transplantation. In fact, lung transplantation has been successfully employed for both CARDS and post-COVID fibrosis in a limited number of patients worldwide. Lung transplantation after COVID infection presents a number of unique challenges that transplant programs must consider. In those with severe CARDS, the inability to conduct proper psychosocial evaluation and pretransplantation education, marked deconditioning from critical illness, and infectious concerns regarding viral reactivation are major hurdles. In those with post-COVID fibrosis, our limited knowledge about the natural history of recovery after COVID-19 infection is problematic. Increased knowledge of the likelihood and degree of recovery after COVID-19 acute lung injury is essential for appropriate decision-making with regard to transplantation. Transplant physicians must weigh the risks and benefits of lung transplantation differently in a post-COVID fibrosis patient who is likely to remain stable or gradually improve in comparison with a patient with a known progressive fibrosing interstitial lung disease (fILD). Clearly lung transplantation can be a life-saving therapeutic option for some patients with severe lung injury from COVID-19 infection. In this review, we discuss how lung transplant providers from a number of experienced centers approach lung transplantation for CARDS or post-COVID fibrosis.

Strategy for the Practice of Spine Oncological Surgery During the Covid-19 Pandemic.

STUDY DESIGN: Case series. OBJECTIVE: For each of the most frequent clinical scenarios, the authors reached a consensus on how should be timing and indications be optimized to reduce risk while maintaining the expected outcomes under the Covid-19 pandemics. SUMMARY OF BACKGROUND DATA: The organization of health care has been changed by the Covid-19 pandemic with a direct impact on Spine Oncology Surgery. Emergency surgery is still a priority, but in case of spinal tumors it should be better defined which conditions require emergency treatment. METHODS: An expert panel with general spine surgeons, oncological spine surgeons, and radiation oncologists was formed to analyze the most frequent scenarios in spinal musculoskeletal oncology during Covid-19 pandemics. RESULTS: Spine metastases can be found incidentally during follow-up or can clinically occur by increasing pain, pathologic fracture, and/or neurological symptoms. Primary spine tumors are much more rare and very rarely present with acute onset. The first step is to suspect this rare condition, to avoid to treat a primary tumor as it were a metastasis. Most complex surgery, like en bloc resection, associated with high morbidity and mortality rate for the treatment of low grade malignancy like chordoma or chondrosarcomas, if intensive care unit availability is reduced, can be best delayed some weeks, as not impacting on prognosis, due to the slow growth rate of these conditions. The currently accepted protocols for Ewing sarcoma (ES) and osteogenic sarcoma must be performed for local and systemic disease control. For ES, after the first courses of chemotherapy, radiotherapy can be selected instead of surgery, during Covid-19, to the end of the full course of chemotherapy. In immunocompromised patients, (treated by chemotherapy), it is necessary to avoid contact with affected or exposed people. CONCLUSION: Even more than during normal times, a multidisciplinary approach is mandatory to share the decision to modify a treatment strategy. LEVEL OF EVIDENCE: 5.

Patients With COVID-19 Undergoing Cesarean Deliveries: Adapting the OR Suite and Perioperative Care to Prevent Transmission.

The novel coronavirus SARS-CoV-2 first appeared in Wuhan, China, in December 2019 and led to the Coronavirus Disease 2019 (COVID-19), which quickly spread globally. Protocols for surgical patients with COVID-19 were lacking, particularly for pregnant women undergoing cesarean deliveries. Perioperative nurses at Tongji Hospital in Wuhan retrospectively analyzed the perioperative nursing process, including OR preparation, intraoperative care, and OR cleanup, for women with COVID-19 undergoing cesarean deliveries. Preparation involved altering the layout of the surgical suite, educating staff members, providing personal protective equipment, and creating new in-house guidelines to help protect personnel and patients. This article describes how perioperative personnel strategized to prevent the transmission of COVID-19 in the OR and presents a multiple-case summary of six pregnant patients with COVID-19 who underwent cesarean deliveries at Tongji Hospital in January and February 2020.

Salvage Lobectomy to Treat Necrotizing SARS-CoV-2 Pneumonia Complicated by a Bronchopleural Fistula.

We report a case of necrotizing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia complicated by a bronchopleural fistula and treated by decortication and salvage lobectomy. Owing to the unknown characteristics of the underlying SARS-CoV-2 infection, treatment of the abscess and bronchopleural fistula was delayed. This may have resulted in further deterioration of the patient, with ensuing multiple organ dysfunction. Complications of SARS-CoV-2 pneumonia, such as a bacterial abscess and a bronchopleural fistula, should be treated as if the patient were not infected with SARS-CoV-2.

Challenges for Mesenchymal Stem Cell-Based Therapy for COVID-19.

The coronavirus disease 2019 (COVID-19) global pandemic continues and antiviral agents and vaccines are currently under investigation. Mesenchymal stem cell (MSC)-based therapy can be a suitable option for management of patients with COVID-19 at the urgent time of virus outbreak. Currently, MSCs are being explored against the novel infectious disease due to their therapeutic properties of anti-inflammation, immunomodulation and tissue repair and regeneration, albeit the precise mechanisms of MSC action toward COVID-19 remain unclear. To date, rigorous results from clinical trials using MSCs in human have been weakly positive. The pervasive uncertainty of using MSC therapeutic products as an effective combatant against COVID-19 requires rigorous resolution on several fronts, including MSC fate after infusion, safety issue, homing capability, and MSC resistance to the disease microenvironment. Focusing on these facets, a few important ones will be critically analyzed and addressed in this article for the development of safe and effective MSC-based therapies for COVID-19.

Spinal cord dysfunction after COVID-19 infection.

INTRODUCTION: We observed individuals affected by spinal cord dysfunction (SCD) after coronavirus disease 2019 (COVID-19). The aim of our report is to provide our initial experience with individuals experiencing SCD after COVID-19 in a referral center in Northern Italy, from February 21 to July 15, 2020. CASE PRESENTATION: We report on three men with SCD after COVID-19. Case 1, aged 69 years, experienced T10 AIS B paraplegia upon awakening due to spinal cord ischemia from T8 to conus medullaris, besides diffuse thromboses, 27 days after the onset of COVID-19 symptoms. Case 2, aged 56 years, reported progressive cervicalgia 29 days after COVID-19 onset associated with C3 AIS C tetraplegia. Magnetic resonance imaging (MRI) revealed a C4-C6 spinal epidural abscess (SEA) requiring a C3-C4 left hemilaminectomy. Case 3, aged 48 years, reported backache together with lower limb muscle weakness on day 16 after being diagnosed with COVID-19. Exam revealed T2 AIS A paraplegia and an MRI showed a T1-T7 SEA. He underwent a T3-T4 laminectomy. Prior to SCD, all three individuals suffered from respiratory failure due to COVID-19, required mechanical ventilation, had cardiovascular risk factors, experienced lymphopenia, and received tocilizumab (TCZ). DISCUSSION: To our knowledge, this is the first report of SCD after COVID-19. Based on our experience, we did not observe a direct viral infection, but there were two different etiologies. In Case 1, the individual developed spinal cord ischemia, whereas in Cases 2 and 3 SEAs were likely related to the use of TCZ used to treat COVID-19.

Safety and efficacy of tracheotomy for critically ill patients with coronavirus disease 2019 (COVID-19) in Wuhan: a case series of 14 patients.

OBJECTIVES: Coronavirus disease 2019 (COVID-19) is a global pandemic. Critically ill patients often require prolonged intubation for mechanical ventilation to support breathing; thus, the artificial airway must be managed by tracheotomy. Therefore, studies exploring appropriate and safe methods for tracheotomy that minimize the risks of nosocomial transmission are important. METHODS: A retrospective analysis of the clinical characteristics of 14 critically ill patients with COVID-19, who underwent bedside tracheotomy from March to April 2020 was conducted to summarize the indications for tracheotomy and key points related to personal protective equipment and surgical procedures. RESULTS: All 14 patients were diagnosed with COVID-19 and were critically ill. All tracheotomies were performed in the late phase of the infection course. The interval between the infection and tracheotomy was 33 days, and the median interval between intubation and tracheotomy was 25.5 days. The reverse transcription-polymerase chain reaction results of secretions from the operative incision and inside the tracheotomy tube were negative. Twelve patients improved after tracheotomy, with SpO2 levels maintained above 96%. One patient died of progressive respiratory failure; another patient died of uncontrolled septic shock. No medical staff who participated in the tracheotomy was infected. CONCLUSIONS: Tracheotomy in critically ill patients with COVID-19 who meet the indications for tracheotomy potentially represents a safer approach to manage the airway and help improve the treatment outcomes. A tracheotomy performed in the late phase of the disease has a relatively low risk of infection. Adherence to key steps in the tracheotomy procedure and donning adequate personal protection will help medical staff avoid infection.

Easy-to-use electrocautery smoke evacuation device for open surgery under the risk of the COVID-19 pandemic.

OBJECTIVE: This study was performed to introduce an easy method of surgical smoke evacuation for patients with confirmed or suspected COVID-19 undergoing emergency surgery. METHODS: An easy, inexpensive, protective, and practical surgical smoke evacuation device/system was developed and is herein described. RESULTS: The use of this surgical smoke evacuation device/system in open surgery is convenient and effective. It allows for easy, economic, useful, and protective surgical smoke evacuation. CONCLUSIONS: COVID-19 infection causes direct mortality and morbidity, and its incidence has recently increased. Protection from electrosurgery-related smoke is recommended particularly during the current pandemic. This surgical smoke evacuation device/system is easy to use and provides a convenient and effective method of smoke evacuation during both open surgery and all cauterization interventions.

Removal of Remdesivir's Metabolite GS-441524 by Hemodialysis in a Double Lung Transplant Recipient with COVID-19.

Remdesivir has reported efficacy against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in vitro and in vivo Drug-drug interactions limit therapeutic options in transplant patients. Remdesivir and its metabolite GS-441524 are excreted principally in urine. In intensive care unit (ICU) settings, in which multiple-organ dysfunctions can occur rapidly, hemodialysis may be a viable option for maintaining remdesivir treatment, while improving tolerance, by removing both remdesivir's metabolite (GS-441524) and sulfobutylether ß-cyclodextrin sodium (SEBCD). Additional studies may prove informative, particularly in the evaluations of therapeutic options for coronavirus disease 2019 (COVID-19).

The Aftermath of COVID-19 Lockdown- Why and How Should We Be Ready?

INTRODUCTION: Severe acute respiratory syndrome, coronavirus 2 (SARS-COV 2) has inexplicably and irreversibly changed the way of neurosurgery practice. There has been a substantial reduction in neurosurgical operations during the period of lockdown. The lockdown might be the most effective measure to curtail viral transmission. Once we return to the normalization of the lifestyle, there will be a backlog of unoperated pending cases along with the possibility of further spread of the coronavirus. METHODS: We reviewed the available literature and protocols for neurosurgical practice in different geographic locations. We drafted a consensus statement based on the literature and protocols suggested by the World Health Organization (WHO) and various professional societies to prevent the spread of SARS-COV2 while streamlining the neurosurgical practice. RESULTS: The consensus statement suggests the patient triage, workflow, resource distribution, and operational efficacy for care providers at different stages of management. The priority is set at personal protection while ensuring patients' safety, timely management, and capacity building. We performed a detailed subsection analysis for the management of trauma and set up for COVID-free hospitals for simultaneous management of routine neurosurgical indications. In this time of medicolegal upheaval, special consent from the patients should be taken in view of the chances of delay in management and the added risk of corona infection. The consensus statements are applicable to neurosurgical setups of all capacities. CONCLUSION: Along with the glaring problem of infection, there is another threat of neurosurgery emergency building up. This wave may overwhelm the already stretched systems to the hilt. We need to flatten this curve while avoiding contagion. These measures may guide neurosurgery practitioners to effectively manage patients ensuring the safety of caregivers and care seekers both.

Neurosurgical activity during COVID-19 pandemic: an experts' opinion from China, South Korea, Italy, the USA, Colombia, and the UK.

BACKGROUND: More than a million and a half people are infected worldwide with more than 90,000 casualties. The ongoing COVID-19 pandemic is radically altering both socio-economic and health care scenarios. METHODS: On April 4th, 2020, at 13:30 CET, a webinar was broadcasted, organized by Global Neuro and supported by WFNS. Expert neurosurgeons from six different countries (China, Italy, South Korea, the USA, Colombia, and the UK) reported on the impact of the COVID-19 pandemic on their health care systems and neurosurgical activity. RESULTS: The first part focused on the epidemiology until that date. The USA were the most affected State with 450,000 cases, followed by Italy (140,000 cases and 19,000 casualties), China (83,305 cases and 3345 have died), South Korea (10,156 cases with 177 casualties), the UK (38,168 cases and 3605 deaths) and Colombia (1267 cases and 25 deaths). The second part concerned Institution and staff reorganization. In every country all surgical plans have been modified. The third part was about neurosurgical practice during the COVID-19 pandemic. The fourth and last part touched upon how to perform safe surgery and re-start after the pandemic. CONCLUSIONS: In general, the pandemic scenario was presented as a thought-provoking challenge in all countries which requires tireless efforts for both maintaining emergency and elective neurosurgical procedures.

The nose lid for the endoscopic endonasal procedures during COVID-19 era: technical note.

BACKGROUND: COVID-19 pandemic has disrupted the global health systems worldwide. According to the tremendous rate of interhuman transmission via aerosols and respiratory droplets, severe measures have been required to contain contagion spread. Accordingly, medical and surgical maneuvers involving the respiratory mucosa and, among them, transnasal transsphenoidal surgery have been charged of maximum risk of spread and contagion, above all for healthcare professionals. METHOD: Our department, according to the actual COVID-19 protocol national guidelines, has suspended elective procedures and, in the last month, only three patients underwent to endoscopic endonasal procedures, due to urgent conditions (a pituitary apoplexy, a chondrosarcoma causing cavernous sinus syndrome, and a pituitary macroadenoma determining chiasm compression). We describe peculiar surgical technique modifications and the use of an endonasal face mask, i.e., the nose lid, to be applied to the patient during transnasal procedures for skull base pathologies as a further possible COVID-19 mitigation strategy. RESULTS: The nose lid is cheap, promptly available, and can be easily assembled with the use of few tools available in the OR; this mask allows to both operating surgeon and his assistant to perform wider surgical maneuvers throughout the slits, without ripping it, while limiting the nostril airflow. CONCLUSIONS: Transnasal surgery, transgressing respiratory mucosa, can definitely increase the risk of virus transmission: we find that adopting further precautions, above all limiting high-speed drill can help preventing or at least reducing aerosol/droplets. The creation of a non-rigid face mask, i.e., the nose lid, allows the comfortable introduction of instruments through one or both nostrils and, at the same time, minimizes the release of droplets from the patient's nasal cavity.

Emergency cesarean section performed in a patient with confirmed severe acute respiratory syndrome Coronavirus-2 -a case report.

BACKGROUND: Since the first case of severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2) occurred in Wuhan in December 2019, the virus has spread globally. The World Health Organization declared the virus outbreak a pandemic on March 11, 2020. On January 19, 2020, a 35-year-old woman who returned from China was confirmed as the first SARS-CoV-2 infected case in Korea. Since then, it has spread all over Korea. CASE: We report the first case of a SARS-CoV-2 positive woman delivering a baby through cesarean section at 37+6 weeks of pregnancy in the Republic of Korea. CONCLUSIONS: This case suggested that negative pressure operating room, skillful medical team, and enhanced personal protective equipment including N95 masks, surgical cap, double gown, double gloves, shoe covers, and powered air-purifying respirator are required at the hospital for safe delivery in such a case.

Methods for a Seamless Transition From Tracheostomy to Spontaneous Breathing in Patients With COVID-19.

The COVID-19 pandemic has profoundly affected health care delivery worldwide. A small yet significant number of patients with respiratory failure will require prolonged mechanical ventilation while recovering from the viral-induced injury. The majority of reports thus far have focused on the epidemiology, clinical factors, and acute care of these patients, with less attention given to the recovery phase and care of those patients requiring extended time on mechanical ventilation. In this paper, we review the procedures and methods to safely care for patients with COVID-19 who require tracheostomy, gastrostomy, weaning from mechanical ventilation, and final decannulation. The guiding principles consist of modifications in the methods of airway care to safely prevent iatrogenesis and to promote safety in patients severely affected by COVID-19, including mitigation of aerosol generation to minimize risk for health care workers.