Pediatric Surgery in India amidst the Covid -19 pandemic - best practice guidelines from Indian Association of Pediatric Surgeons.

INTRODUCTION

The Executive Committee of the Indian Association of Pediatric Surgeons (IAPS) 2020 suggested guidelines for best practices for the pediatric surgeons of India in May 2020. The same was circulated and put on the IAPS website as a general guideline to be followed.[1] With changing times, the guidelines by the Indian Council of Medical Research (ICMR) and the Department of Health of the Government of India have been evolving; these guidelines here may serve as an outline of the standard operating procedures to be followed by the pediatric surgeons to lessen the morbidity and mortality of the patients as well as the health-care workers associated with delivering care at this hour of crisis. The hospital guidelines should be followed for admission and infection control policies, personal protective equipment (PPE), and COVID testing.

Since 80% of the diagnosed cases of COVID as on this date are asymptomatic, we have to consider all surgical patients and their parents and caregivers as potential carriers (ICMR April 20, 2020).

It is suggested that all patients taken up for surgery should be tested for COVID. A detailed history and contact tracing of the mother and father should be done. In ideal circumstances and availability of testing, the parents may also be tested for COVID, especially if they have any history of symptoms or they belong to a red or contained zone; as they would be living and visiting the baby during inpatient stay. All inpatient antenatal mothers should be tested for COVID. Recently, vertical transmission, possibly also transplacental and in utero, has also been documented, and all newborns should be treated with all due precautions.[2]

COVID TESTING

The ICMR has led the country in the testing for COVID. A cumulative total of 30,041,400 samples have been tested up to August 16, 2020.[3]

Currently, the following tests are available for COVID testing:[4]

Real-time polymerase chain reaction (RT-PCR) is the gold standard test for COVID-19 and should be used as the frontline test wherever available. The average time taken for this test is around 4–5 h. Ninety tests can be done at one time. However, it requires a specialized laboratory and cannot be performed at every district level

The TrueNat and cartridge-based nucleic acid amplification test systems have also been deployed for the diagnosis of COVID-19 in view of the availability of customized cartridges. These are available even in remote districts and primary health center level. The testing time is 30–60 min, but only 1–4 samples can be tested in one run, limiting the maximum number of tests to 24–48/day. They have minimal hazard as the viral lysis buffer that comes with the COVID-19 cartridges inactivates the virus, the system is closed, and there is minimum sample handling

Rapid point-of-care (PoC) antigen detection test can be interpreted with the naked eye and is a promising tool for quick diagnosis of SARS-CoV-2 in remote areas. The assay has been developed by SD Biosensor. It has very high specificity with moderate sensitivity. It is now recommended to use Standard Q COVID-19 Ag detection test as a PoC diagnostic assay for testing in the containment zones as well as in hospitals in combination with the gold standard RT-PCR.[4]

PEDIATRIC SURGERY CONSULTATION

Selective physical consultation for routine cases can be done with due precautions of mask, headgear, gown, and gloves. Gloves to be changed for each patient or hands to be washed with soap and water if papers touched with hand

Use the telemedicine and teleconsultation wherever available and consult your patients online for normal surgical problems and follow-up till situation improves. The Board of Governors in supersession of the Medical Council of India framed and published the Telemedicine Practice Guidelines, enabling Registered Medical Practitioners to Provide Healthcare Using Telemedicine on March 25, 2020.[5] These have been endorsed by the Ministry of Health and Family Welfare (MoHFW), have been prepared in partnership with the National Institution for Transforming India Aayog, and are available on the MoHFW website. These guidelines have been widely adopted in various government institutions and hospitals across the country including All India Institute of Medical Sciences, New Delhi. Telemedicine in the COVID era can prove extremely beneficial being cost-effective and enabling rural patients to seek timely good medical advice without the need to travel long distances for obtaining consultation and treatment. Telemedicine reduces the inconvenience to family and caregivers including social factors, apart from preventing the spread of COVID infection. The availability of patient records online enables patient prescriptions to be more reliable and accurate.[6] Written documentation increases the legal protection of both parties. However, the existing individual hospital policies and recommendations should be adhered to, in order to safeguard the medicolegal implications

Antenatal counseling for surgical anomalies may be done by tele/video/physical consultation. If physical consultation is done, only the mother should be allowed in the consultation chamber. Any discussion with the gynecologist or genetic specialist can be done telephonically to minimize patient visits. The crucial decision of continuation of pregnancy or medical termination should be done timely by the parents

Social distancing, restricting the attendants to one, patient/attendant masking, and hand hygiene measures should be adhered to

The child should be held in a restrained position so that he or she does not touch any surroundings. The child should also wear a mask

In referral or transfer from other centers, please discuss with the referring physician in detail about the contact details, overseas travel history of the patient or family members, known contact with COVID-positive patients, zone of origin/stay (red/orange/green), and presence of respiratory symptoms.

SURGICAL TRIAGE GUIDELINES

Surgery should be performed only if delaying the surgery will increase morbidity, increase the chance of later hospital admission, or increase chances of complication later on. One should refer all serology-positive patients and suspected COVID patients to a COVID-19 designated treatment center.

OPERATIVE PROCEDURE LIST

Table 1 lists all the common conditions managed by a pediatric surgeon, though it is not meant to be comprehensive. The list has been modified from the American Association of Pediatric Surgeons to include many conditions commonly seen in India and also include pediatric urology and neurosurgery.[7] A recent study has shown a high concentration of virus in the peritoneal fluid which tested positive on RT PCR even with 10 times dilution.[8] There are also reports of not getting any evidence of positivity from the peritoneal fluid.[9] However, surgeons should be cautious when undertaking decision laparotomy. There are now efforts to resume elective surgeries slowly depending on the incidence of prevailing infection.

Table 1

Triage of pediatric surgery and pediatric urology operative procedure list

Condition	Indication for Intervention/ Procedure
Emergency cases
Life-threatening congenital anomalies	Esophageal atresia with or without tracheoesophageal fistula
	Congenital diaphragmatic hernia
	Intestinal atresia
	Meconium cyst/peritonitis
	Colostomy/anoplasty for anorectal anomalies
	Colostomy/ileostomy for Hirschsprung’s disease (not improving with bowel irrigations
	Vaginostomy for infantile hydrocolpos/hydrometrocolpos
	Large ovarian cyst causing respiratory distress/possibility of torsion
	Ruptured meningomyelocele without neurological deficits
	Raised intracranial tension for hydrocephalus
Necrotizing enterocolitis	Confirmed/suspected perforation/intestinal ischemia
Intestinal obstruction	Incarcerated inguinal hernia
	Infantile hypertrophic pyloric stenosis
	Intussusception (reduction not amenable to radiographic reduction or failed reduction)
	Peritonitis due to any cause
	Malrotation
	Volvulus - gastric/midgut/sigmoid
	Intestinal perforation
	Intestinal gangrene
Trauma	with uncontrolled hemorrhage or penetration
	Sexual assault with perineal injury
Vascular compromise	Testicular torsion
	Ovarian torsion
	Limb ischemia from trauma or iatrogenic
Acute appendicitis	Perforative/gangrenous/nonresponse to Ochsner-Sherren regimen
Appendicular abscess	Drainage
Psoas abscess	Drainage
Severe urinary obstruction requiring diversion procedures	Pigtail insertion for pyonephrosis
	Vesicostomy
	Ureterostomy
	Percutaneous nephrostomy
Posterior urethral valve	Fulguration
Tracheostomy	For stridor, FB trachea
FB removal	Trachea, bronchus, esophagus, sharp FB in stomach or intestines, soft-tissue FB
Cellulitis, abscess	Incision/incision and drainage
Liver abscess	Pigtail catheter insertion
Massive GI bleed	Upper or lower GI bleed for scopy/balloon
Esophageal stricture	Esophageal dilatation (no gastrostomy)
Dysphagia due to corrosive injury	Gastrostomy
Paraphimosis	Reduction
Phimosis with urinary retention	Dorsal slit/circumcision
Any other life-threatening surgical conditions
Urgent
Empyema thoracis	Intercostal drainage
Biliary atresia	Kasai portoenterostomy
Symptomatic inguinal hernia	Repair
Oncology	A biopsy for establishing the diagnosis
	Oncologic complications requiring surgical intervention like - airway obstruction, intestinal or urinary tract obstruction
	Surgery if chemotherapy not feasible or not indicated. (However, supra-major cases involving major vessels or extensive resections, etc., should be avoided)
	Surgery if chemotherapy completed and lesion operable
Gastric outlet obstruction	Gastrostomy
Pyocele/mucocele of gallbladder	Cholecystectomy/ERCP stenting
DJ stent - long duration/causing recurrent UTI	Removal
Symptomatic urethral stricture	Dilatation
Meatal stenosis	Dilatation/meatotomy
Phimosis with back pressure changes	Dorsal slit/circumcision
Ureteric stones with hydroureteronephrosis	DJ insertion
Pelviureteric junction obstruction with rapid fall in function or symptomatic	Pyeloplasty
Colostomy complications - prolapse, bleeding	Redo colostomy or colostomy closure may be required.
Undescended testis	If nonpalpable, and nearing 1 year ageIf palpable, can wait till 15 months age, depending on the distance of the patient’s residence from the hospital and residence in containment area
Ureterocele with obstructive symptoms	Cystoscopic deroofing
Other similar urgent cases, where surgical delay is likely to affect the child
Elective cases to be avoided
Asymptomatic hernia-inguinal/umbilical	Repair
Hydrocele persisting beyond 2 years age	Repair
Anorectal malformation already on colostomy	Definitive repair
Hirschsprung’s disease following diversion	Reconstruction
Enterostomy for any indication	Closure
Branchial cleft cyst/sinus	Excision
Thyroglossal duct cyst	Excision
Undescended testis <11 months age	Orchiopexy
Splenomegaly due to hematologic disease	Splenectomy
Asymptomatic choledochal cyst	Excision
Lung lesion/empyema	Thoracotomy
Asymptomatic pelviureteric junction obstruction with preserved function	Pyeloplasty
Vesicoureteric reflux	Deflux/ureteric reimplantation
Any other surgical procedure, where the child is unlikely to be affected by delaying the surgical intervention

ERCP: Endoscopic retrograde cholangiography, GI: Gastrointestinal, FB: Foreign body, UTI: Urinary tract infection

The pediatric surgical and pediatric urological cases can be triaged into

Emergency which should be done during this period as the delay can be life threatening

Urgent, which can be done during this period as delays of days to weeks may be detrimental to the child

Elective cases to be avoided till the pandemic resolves as delay will result in minimal patient risk.

As resumption of normal elective procedures evolves, the surgeons should first incorporate urgent cases along with the emergency cases and then see the effect it has on the incidence of COVID infections and morbidity.

ADVICE ON PERSONAL PROTECTIVE EQUIPMENT

N95 respirator with eye protection and headgear full-body gown with plastic apron inside is recommended[10]

PPE donning and doffing should be as per standard protocols in designated area

PPE disposal and proper sanitization postprocedure as per hospital protocol

All accidental/negligent violation of PPE protocol should be reported without fail.

PERSONAL HYGIENE

Frequent use of hand sanitizer and/or disposable gloves

Clean your cell phone frequently before, during, and after patient care activities with alcohol rub. Cell phones may be used while kept in a Ziploc bag during work activities. It is better not to carry the phone or any documents in patient care areas. Shoe covers should be worn while in wards and taken off after leaving the ward

Keep car keys in an isolated place. Leave office keys in car

Change clothes and bathe within hospital if facilities are available and again upon arrival home

Minimize physical contact with family members and wash hands frequently

Clean hard surfaces at home with an effective disinfectant solution (e.g., 60% alcohol).

OPERATIONAL TECHNOLOGY INFRASTRUCTURE

The air conditioning is a major concern. Attempts should be made to make it a negative pressure area with proper filtration and air exchanges as per the norms of the hospital.

Minimize the use of monopolar diathermy as there is a potential risk of viral spread through the fumes. Constant suction should be used whenever monopolar diathermy has to be used.

LAPAROSCOPY (OPTIONAL AS PER HOSPITAL/DEPARTMENT GUIDELINES)

Many studies have shown increased risks with laparoscopic procedures in this pandemic, but conclusive evidences are not yet available. Laparoscopic and thoracoscopic procedures have potential to generate aerosolized viral particles which can spread in operating room atmosphere under increased pressure. Thoracoscopy has a much higher chance and hence should be completely avoided. The precautions for laparoscopy are mentioned here with the view that one may need to resume laparoscopy when the guidelines and pandemic conditions allow. One may refer to the Society of American Gastrointestinal and Endoscopic Surgeons and the Indian Association of Gastrointestinal Endosurgeons guidelines for more details.[1112]

The following precautions need to be taken if at all one decides to go for laparoscopy.

All pneumoperitoneum should be safely evacuated from the port attached to the filtration device before closure, trocar removal, specimen extraction, or conversion to open procedure[11]

If Hasson method is used to place the first port, it should be properly fixed to the skin to minimize air leak

The placed ports should not be used to evacuate smoke or desufflation during the procedure where possible

During desufflation, all escaping CO2gas and smoke should be captured with an ultrafiltration system and desufflation mode should be used if available. If desufflation feature is not available, be sure to close the valve on the working port that is being used for insufflation before the flow of CO2on the insufflator is turned off.[11] Without taking this precaution, contaminated intra-abdominal CO2can be pushed into the insufflator when the intra-abdominal pressure is higher than the pressure within the insufflator

The patient should be flat, and the least dependent port should be utilized for desufflation

Specimens should be removed once all the CO2gas and smoke is evacuated

Surgical drains should be placed only if absolutely necessary

Suture closure devices that allow for leakage of insufflation should be avoided. The fascia should be closed after desufflation

Intraoperatively, filters are recommended to remove smoke and particulate matter including viruses. Viruses are known to transmit through the surgical smoke. Currently, two filters, namely ultra-low particle aspirator and high-efficiency particle aspirator, are capable of clearing the virus particles.[11] An alternative or an additional method is attaching the suction apparatus through a chest drainage bottle or bag containing hypochlorite solution at the base so that the sucked air goes through the solution

Energy source usage should be minimal as they generate smoke. Aerosolization of viral and bacterial RNA/DNA may occur during the use of energy devices. The mechanism is different; rather than gas moving over fluid, it results from pyrolysis of tissues, an inherently destructive process.[11] The various energy sources lead to different sizes of particles, electrocautery, and LASER having the smallest, hottest particles and ultrasonic devices larger, cooler particles. Hence, minimal use and short bursts are advised

The current best practice is to use a multilayered approach, which includes proper ventilation, appropriate PPE, and smoke evacuation devices with a suction and filtration system (among other standard safety precautions).

HISTOPATHOLOGY SPECIMEN

Operative specimens should be sent in sealed double leak-proof specimen bags/containers

The specimen should be completely immersed in 10% buffered formalin (for small biopsies, formalin should be ten times the volume of the tissue and big specimens should be at least double the volume of the tissue)[13]

All specimens as well as histopathology requisition forms should be labeled properly with patient details and clearly marked regarding the status of COVID-19 (negative, suspected, positive, or not tested)

The requisition forms should not be handled with contaminated gloves or contaminated with blood, bodily fluids, or any infective material

The personnel who transport these specimens should be aware/trained in safe handling practices and should be wearing masks and gloves

Frozen sections should be avoided during the duration of pandemic.

POSTOPERATIVE CARE

Minimal hospital stay should be planned. The removal of drains, catheters, dressings, and stitches should be explained to the parents. Surgical neonates should be provided expressed breast milk from the mothers when feasible to provide them with immunity from the breast milk. Rooming-in and kangaroo care should be considered as early as possible. In case the mother is a COVID suspect, masking and hand hygiene should be followed with sanctity. Although fortunately, the incidence of COVID in children is <2% of the total infections and that too mostly mild cases, appropriate precautions should be taken to prevent infection.[14] Most children acquire infection from close contact with adults in family clusters.[14] The families should be counseled about appropriate means of prevention in the hospital as well as at home.

DOCUMENTATION

Apart from usual operative documentation, the full names of the patient, parents, and relatives present during the admission with their contact details and addresses.

The full names and contact details with addresses of complete anesthetist team, surgeon team, nurses and technicians, and supportive staff should be mentioned. The operation theatre location and the exact, time the patient was brought in and shifted out should be noted in records.

PEDIATRIC SURGERY TRAINING

With COVID set into our daily routine and with a probability of remaining for the next few months or a year, the training of residents has to undergo adaptation according to the changing scenarios. Online classes with virtual teaching should be adapted as a routine, and senior teachers should share their experience more generously with younger colleagues and new students. Simulation models should be developed and used for training and teaching. There are already existent models for many pediatric surgical conditions both for open and laparoscopic repair such as infantile hypertrophic pyloric stenosis, tracheoesophageal fistula, congenital diaphragmatic hernia repair, and posterior sagittal anorectoplasty. Video-recorded surgical procedures can be discussed with the students.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.