Post-discharge after surgery Virtual Care with Remote Automated Monitoring-1 (PVC-RAM-1) technology versus standard care: randomised controlled trial.

OBJECTIVE: To determine if virtual care with remote automated monitoring (RAM) technology versus standard care increases days alive at home among adults discharged after non-elective surgery during the covid-19 pandemic. DESIGN: Multicentre randomised controlled trial. SETTING: 8 acute care hospitals in Canada. PARTICIPANTS: 905 adults (≥40 years) who resided in areas with mobile phone coverage and were to be discharged from hospital after non-elective surgery were randomised either to virtual care and RAM (n=451) or to standard care (n=454). 903 participants (99.8%) completed the 31 day follow-up. INTERVENTION: Participants in the experimental group received a tablet computer and RAM technology that measured blood pressure, heart rate, respiratory rate, oxygen saturation, temperature, and body weight. For 30 days the participants took daily biophysical measurements and photographs of their wound and interacted with nurses virtually. Participants in the standard care group received post-hospital discharge management according to the centre's usual care. Patients, healthcare providers, and data collectors were aware of patients' group allocations. Outcome adjudicators were blinded to group allocation. MAIN OUTCOME MEASURES: The primary outcome was days alive at home during 31 days of follow-up. The 12 secondary outcomes included acute hospital care, detection and correction of drug errors, and pain at 7, 15, and 30 days after randomisation. RESULTS: All 905 participants (mean age 63.1 years) were analysed in the groups to which they were randomised. Days alive at home during 31 days of follow-up were 29.7 in the virtual care group and 29.5 in the standard care group: relative risk 1.01 (95% confidence interval 0.99 to 1.02); absolute difference 0.2% (95% confidence interval -0.5% to 0.9%). 99 participants (22.0%) in the virtual care group and 124 (27.3%) in the standard care group required acute hospital care: relative risk 0.80 (0.64 to 1.01); absolute difference 5.3% (-0.3% to 10.9%). More participants in the virtual care group than standard care group had a drug error detected (134 (29.7%) v 25 (5.5%); absolute difference 24.2%, 19.5% to 28.9%) and a drug error corrected (absolute difference 24.4%, 19.9% to 28.9%). Fewer participants in the virtual care group than standard care group reported pain at 7, 15, and 30 days after randomisation: absolute differences 13.9% (7.4% to 20.4%), 11.9% (5.1% to 18.7%), and 9.6% (2.9% to 16.3%), respectively. Beneficial effects proved substantially larger in centres with a higher rate of care escalation. CONCLUSION: Virtual care with RAM shows promise in improving outcomes important to patients and to optimal health system function. TRIAL REGISTRATION: ClinicalTrials.gov NCT04344665.

Analysis of outcomes of emergency general and gastrointestinal surgery during the COVID-19 pandemic.

BACKGROUND: Few surgical studies have provided adjusted comparative postoperative outcome data among contemporary patients with and without COVID-19 infection and patients treated before the pandemic. The aim of this study was to determine the impact of performing emergency surgery in patients with concomitant COVID-19 infection. METHODS: Patients who underwent emergency general and gastrointestinal surgery from March to June 2020, and from March to June 2019 in 25 Spanish hospitals were included in a retrospective study (COVID-CIR). The main outcome was 30-day mortality. Secondary outcomes included postoperative complications and failure to rescue (mortality among patients who developed complications). Propensity score-matched comparisons were performed between patients who were positive and those who were negative for COVID-19; and between COVID-19-negative cohorts before and during the pandemic. RESULTS: Some 5307 patients were included in the study (183 COVID-19-positive and 2132 COVID-19-negative during pandemic; 2992 treated before pandemic). During the pandemic, patients with COVID-19 infection had greater 30-day mortality than those without (12.6 versus 4.6 per cent), but this difference was not statistically significant after propensity score matching (odds ratio (OR) 1.58, 95 per cent c.i. 0.88 to 2.74). Those positive for COVID-19 had more complications (41.5 versus 23.9 per cent; OR 1.61, 1.11 to 2.33) and a higher likelihood of failure to rescue (30.3 versus 19.3 per cent; OR 1.10, 0.57 to 2.12). Patients who were negative for COVID-19 during the pandemic had similar rates of 30-day mortality (4.6 versus 3.2 per cent; OR 1.35, 0.98 to 1.86) and complications (23.9 versus 25.2 per cent; OR 0.89, 0.77 to 1.02), but a greater likelihood of failure to rescue (19.3 versus 12.9 per cent; OR 1.56, 95 per cent 1.10 to 2.19) than prepandemic controls. CONCLUSION: Patients with COVID-19 infection undergoing emergency general and gastrointestinal surgery had worse postoperative outcomes than contemporary patients without COVID-19. COVID-19-negative patients operated on during the COVID-19 pandemic had a likelihood of greater failure-to-rescue than prepandemic controls.

Surgical Outcomes During COVID-19 Pandemic.

BACKGROUND: In December 2019, an outbreak of a novel coronavirus (COVID-19) occurred in China and became pandemic in March 2020. Patients undergoing surgery are a vulnerable risk of COVID-19 exposure/infection. The aim of the study was to determine the characteristics and outcomes of patients undergoing surgery during the COVID-19 pandemic in a third level reference hospital in Mexico. METHOD: IRB approved observational study (prospectively collected database) of general and surgical oncology procedures from 04/20-08/20. Patients preoperative data and surgical cases registered. COVID-19 detection was a combination of polymerase chain reaction swab and chest computed tomography. Primary endpoints were: 30 d surgical mortality and complications, including COVID-19 infection during hospitalization. RESULTS: 193 patients were included (mean age: 53.9 years, 63.7% female). 52.8% procedures were performed by surgical oncology. 42.4% developed a complication with 8.3% mortality. COVID-19 infection was 11.3% (n = 22). Postoperative morbidity (81.3 vs. 37.4%, p = 0.0001) and mortality (27.3 vs. 5.8%, p = 0.0001) was higher in COVID-19 (+) patients. Factors associated with COVID-19 infections were sex, functional status, preoperative sepsis and ventilation, renal failure and dialysis (univariate analysis) and sepsis and renal failure (multivariate analysis). COVID-19 infection was associated with respiratory complications (54.5 vs. 2.9%), surgical site infection (27.3 vs. 10.5%), postoperative transfusions (59.1 vs. 31.6%), renal failure (54.5 vs. 8.2%), sepsis (68.2 vs. 22.2%), reintervention (22.7 vs. 7.6%), readmission (18.2 vs. 4.1%), and death (27.3 vs. 5.8%) (p <0.05). CONCLUSION: Postoperative morbidity and mortality in COVID-19 patients is high. Surgical procedures should be thoughtfully reviewed with a plan to minimize scheduled operations.

Impact of COVID-19 on surgical emergencies: nationwide analysis.

BACKGROUND: The COVID-19 pandemic has had a major impact on healthcare in many countries. This study assessed the effect of a nationwide lockdown in France on admissions for acute surgical conditions and the subsequent impact on postoperative mortality. METHODS: This was an observational analytical study, evaluating data from a national discharge database that collected all discharge reports from any hospital in France. All adult patients admitted through the emergency department and requiring a surgical treatment between 17 March and 11 May 2020, and the equivalent period in 2019 were included. The primary outcome was the change in number of hospital admissions for acute surgical conditions. Mortality was assessed in the matched population, and stratified by region. RESULTS: During the lockdown period, 57 589 consecutive patients were admitted for acute surgical conditions, representing a decrease of 20.9 per cent compared with the 2019 cohort. Significant differences between regions were observed: the decrease was 15.6, 17.2, and 26.8 per cent for low-, intermediate- and high-prevalence regions respectively. The mortality rate was 1.92 per cent during the lockdown period and 1.81 per cent in 2019. In high-prevalence zones, mortality was significantly increased (odds ratio 1.22, 95 per cent c.i. 1.06 to 1.40). CONCLUSION: A marked decrease in hospital admissions for surgical emergencies was observed during the lockdown period, with increased mortality in regions with a higher prevalence of COVID-19 infection. Health authorities should use these findings to preserve quality of care and deliver appropriate messages to the population.

COVID-19 pandemic did not affect emergency theatre patient demographic and length of stay in the first phase of UK countrywide lockdown in a district general hospital.

INTRODUCTION: We aim to identify any changes in outcome for patients undergoing nonelective surgery at the start of the UK pandemic in our district general hospital. This was a single-centre retrospective cohort review of a UK district general hospital serving a population of over 250,000 people. METHODS: Participants were all patients undergoing a surgical procedure in the acute theatre list between 23 March to 11 May in both 2019 and 2020. Primary outcome was 90-day postoperative mortality. Secondary outcomes include time to surgical intervention and length of inpatient stay. RESULTS: A total of 132 patients (2020) versus 141 (2019) patients were included. Although overall 90-day postoperative mortality was higher in 2020 (9.8%) compared with 2019 (5.7%), this difference was not statistically significant (p=0.196). In 2020, eight patients tested positive for COVID-19 either as an inpatient or within 2 weeks of discharge, of whom five patients died. Time to surgical intervention was significantly faster for NCEPOD (National Confidential Enquiry into Patient Outcome and Death) code 3 patients in 2020 than in 2019 (p=0.027). There were no significant differences in mean length of inpatient stay. CONCLUSIONS: We found that patients were appropriately prioritised using NCEPOD classification, with no statistically significant differences in 90-day postoperative mortality and length of inpatient stay compared with the 2019 period. A study on a larger scale would further elucidate the profile and outcomes of patients requiring acute surgery to generate statistical significance.

30-Day postoperative COVID-19 outcomes in 398 patients from regional hospitals utilising a designated COVID-19 minimal surgical site pathway.

INTRODUCTION: Postoperative pulmonary complications and mortality rates during the COVID-19 pandemic have been higher than expected, leading to mass cancellation of elective operating in the UK. To minimise this, the Guy's and St Thomas' Hospital NHS Foundation Trust elective surgery hub and the executive team at London Bridge Hospital (LBH) created an elective operating framework at LBH, a COVID-19 minimal site, in which patients self-isolated for two weeks and proceeded with surgery only following a negative preoperative SARS-CoV-2 polymerase chain reaction swab. The aim was to determine the rates of rates of postoperative COVID-19 infection. METHODS: The collaboration involved three large hospital trusts, covering the geographic area of south-east London. All patients were referred to LBH for elective surgery. Patients were followed up by telephone interview at four weeks postoperatively. RESULTS: Three hundred and ninety-eight patients from 13 surgical specialties were included in the analysis. The median age was 60 (IQR 29-71) years. Sixty-three per cent (252/398) were female. In total, 78.4% of patients had an American Society of Anesthesiologists grade of 1-2 and the average BMI was 27.2 (IQR 23.7-31.8) kg/m2. Some 83.6% (336/402) were 'major' operations. The rate of COVID-19-related death in our cohort was 0.25% (1/398). Overall, there was a 1.26% (5/398) 30-day postoperative all-cause mortality rate. Seven patients (1.76%) reported COVID-19 symptoms, but none attended the emergency department or were readmitted to hospital as a result. CONCLUSION: The risk of contracting COVID-19 in our elective operating framework was very low. We demonstrate that high-volume major surgery is safe, even at the peak of the pandemic, if patients are screened appropriately preoperatively.

Retrospective analysis of the first 50 emergency/elective surgical cases in terms of mortality and morbidity in CoVid-19 Pandemic Hospital in Istanbul.

2019-nCoV currently named SARS-CoV-2 is a highly pathogenic Coronavirus identified in Wuhan China in December 2019. Turkey declared the first case relatively late compared to Asian and European countries on March 11, as the first SARS-CoV-2 infection in Turkey. In this study, we aimed to determine patients' outcomes in 50 surgeries done in the incubation period of SARS-CoV-2 in our hospital. METHODS: We retrospectively analyzed the clinical data of 50 patients who underwent surgeries during the incubation period of CoVid-19 at Istinye University Gaziosmanpasa Medical Park Hospital in Istanbul, from March 2 to April 11, 2020. RESULTS: The age of 50 patients range was 21 to 73, and the median age was 43.32 (64%) patients were women. The median length of hospital stay is 2.6 days (1-21). Operations at various difficulty levels were also performed on patients with co-morbidities. No complication or mortality was observed except for 1 patient, and the ICU requirement of that patient was also due to high energy trauma. CONCLUSION: Although contrary claims have been made in various studies; it is the primary duty of us surgeons to operate CoVid-19 positive/suspicious patients safely and without any contamination, and on the other hand, to continue their operations without victimizing negative patients. In this pilot study, we would like to emphasize with necessary and adequate measures these can be achieved. KEY WORDS: CoVid-19, SARS-CoV-2, Surgery.

A single-centre observational cohort study to evaluate volume and severity of emergency general surgery admissions during the COVID-19 pandemic: Is there a "lockdown" effect?

INTRODUCTION: The COVID-19 pandemic has led to changes in NHS surgical service provision, including reduced elective surgical and endoscopic activity, with only essential emergency surgery being undertaken. This, combined with the government-imposed lockdown, may have impacted on patient attendance, severity of surgical disease, and outcomes. The aim of this study was to investigate a possible 'lockdown' effect on the volume and severity of surgical admissions and their outcomes. METHODS: Two separate cohorts of adult emergency general surgery inpatient admissions 30 days immediately before (February 16, 2020 to March 15, 2020), and after UK government advice (March 16, 2020 to April 15, 2020). Data were collected relating to patient characteristics, severity of disease, clinical outcomes, and compared between these groups. RESULTS: Following lockdown, a significant reduction in median daily admissions from 7 to 3 per day (p < 0.001) was observed. Post-lockdown patients were significantly older, frailer with higher inflammatory indices and rates of acute kidney injury, and also were significantly more likely to present with gastrointestinal cancer, obstruction, and perforation. Patients had significantly higher rates of Clavien-Dindo Grade ≥3 complications (p = 0.001), all cause 30-day mortality (8.5% vs. 2.9%, p = 0.028), but no significant difference was observed in operative 30-day mortality. CONCLUSION: There appears to be a "lockdown" effect on general surgical admissions with a profound impact; fewer surgical admissions, more acutely unwell surgical patients, and an increase in all cause 30-day mortality. Patients should be advised to present promptly with gastrointestinal symptoms, and this should be reinforced for future lockdowns during the pandemic.

Mortality and pulmonary complications in patients undergoing upper extremity surgery at the peak of the SARS-CoV-2 pandemic in the UK: a national cohort study.

INTRODUCTION: This study reports the 30-day mortality, SARS-CoV-2 complication rate and SARS-CoV-2-related hospital processes at the peak of the first wave of the pandemic in the UK. METHODS: This national, multicentre, cohort study at 74 centres in the UK included all patients undergoing any surgery below the elbow at the peak of the UK pandemic. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The secondary outcomes were SARS-CoV-2 complication rates and overall complication rates. A clinician survey relating to SARS-CoV-2 safety processes was carried out for each participating centre. RESULTS: This analysis includes 1093 patients who underwent upper limb surgery from the 1 to 14 April 2020 inclusively. The overall 30-day mortality was 0.09% (1 pre-existing SARS-CoV-2 pneumonia) and the mortality of day case surgery was zero. Most centres (96%) screened patients for symptoms prior to admission, only 22% routinely tested for SARS-CoV-2 prior to admission. The SARS-CoV-2 complication rate was 0.18% (2 pneumonias) and the overall complication rate was 6.6% (72 patients). Both SARS-CoV-2-related complications occurred in patients who had been hospitalised for a prolonged period before their surgery and a total of 19 patients (1.7%) were SARS-CoV-2 positive. CONCLUSIONS: The SARS-CoV-2-related complication rate for upper limb surgery even at the peak of the UK pandemic was low at 0.18% and the mortality was zero for patients admitted on the day of surgery. Urgent surgery should not be delayed pending the results of SARS-CoV-2 testing. Routine SARS-CoV-2 testing for day case upper limb surgery not requiring general anaesthesia may be excessive and have unintended negative impacts.

Trauma of major surgery: A global problem that is not going away.

Globally, a staggering 310 million major surgeries are performed each year; around 40 to 50 million in USA and 20 million in Europe. It is estimated that 1-4% of these patients will die, up to 15% will have serious postoperative morbidity, and 5-15% will be readmitted within 30 days. An annual global mortality of around 8 million patients places major surgery comparable with the leading causes of death from cardiovascular disease and stroke, cancer and injury. If surgical complications were classified as a pandemic, like HIV/AIDS or coronavirus (COVID-19), developed countries would work together and devise an immediate action plan and allocate resources to address it. Seeking to reduce preventable deaths and post-surgical complications would save billions of dollars in healthcare costs. Part of the global problem resides in differences in institutional practice patterns in high- and low-income countries, and part from a lack of effective perioperative drug therapies to protect the patient from surgical stress. We briefly review the history of surgical stress and provide a path forward from a systems-based approach. Key to progress is recognizing that the anesthetized brain is still physiologically 'awake' and responsive to the sterile stressors of surgery. New intravenous drug therapies are urgently required after anesthesia and before the first incision to prevent the brain from switching to sympathetic overdrive and activating secondary injury progression such as hyperinflammation, coagulopathy, immune activation and metabolic dysfunction. A systems-based approach targeting central nervous system-mitochondrial coupling may help drive research to improve outcomes following major surgery in civilian and military medicine.

Surgical Critical Care at the Epicenter of the COVID-19 Pandemic.

The number of deaths and infected people by Corona-19 virusin 2020 around the world is alarming and numbing at the same time. It almostdifficult to remember when the world was normal, although it just started fewmonths ago. Our world and everything around have changed, our surgical practicehas changed, our life has changed, but Intensive Care Units (ICU)in WestchesterMedical center in Valhalla, NY, continue to care for the sickest of thesickest. But this time, different disease with different prognosis. Everycritical care specialist, every surgery resident and surgical critical carefellow, are COVID-19 doctors. As I round in the ICU, I imagine myself in one ofthose beds that I could have been few weeks ago. Now, fully recovered fromCOVID-19, and coming back to work is a real treat. Yet, I still have morequestions than answers.