Two-drape closed pocket technique: minimizing aerosolization in mastoid exploration during COVID-19 pandemic

Aerosol containment device design considerations and performance evaluation metrics

BACKGROUND

Spurred by the Coronavirus infectious disease 2019 pandemic, aerosol containment devices (ACDs) were developed to capture infectious respiratory aerosols generated by patients at their source. Prior reviews indicated that such devices had low evidence of effectiveness, but did not address how ACDs should be evaluated, how well they should perform, nor have clearly defined performance standards. Towards developing design criteria for ACDs, two questions were posed: 1) What characteristics have guided the design of ACDs? 2) How have these characteristics been evaluated?

METHODS

A scoping review was performed consistent with PRISMA guidelines. Data were extracted with respect to general study information, intended use of the device, device design characteristics and evaluation.

RESULTS

Fifty-four articles were included. Evaluation was most commonly performed with respect to device aerosol containment (n = 31, 61%), with only 5 (9%), 3 (6%) and 8 (15%) formally assessing providing experience, patient experience and procedure impact, respectively. Nearly all of the studies that explored provider experience and procedure impact studied intubation. Few studies provided a priori performance criteria for any evaluation metric, or referenced any external guidelines by which to bench mark performance.

CONCLUSION

With respect to aerosol containment, ACDs should reduce exposure among HCP with the device compared with the absence of the device, and provide ≥90% reduction in respirable aerosols, equivalent in performance to N95 filtering facepiece respirators, if the goal is to reduce reliance on personal protective equipment. The ACD should not increase awkward or uncomfortable postures, or adversely impact biomechanics of the procedure itself as this could have implications for procedure outcomes. A variety of standardized instruments exist to assess the experience of patients and healthcare personnel. Integration of ACDs into routine clinical practice requires rigorous studies of aerosol containment and the user experience.

Control of airborne particles in surgical procedures during the Covid-19 pandemic: scoping review

OBJECTIVE

To map the technical and managerial strategies for the management and reduction of airborne particles production in surgical procedures settings during the Covid-19 pandemic.

METHOD

Scoping review, according to the Joana Briggs Institute methodology, based on documents indexed in MEDLINE, VHL, CINAHL Cochrane, Embase, Scopus, Web of Science, and gray literature, published in Portuguese, English, or Spanish. All studies from indexed scientific journals and recommendations published by international agencies or academic associations from 2019 to January 2022 were considered. Findings were summarized and analyzed using descriptive statistics and narrative synthesis.

RESULTS

Twenty-two studies were selected, 19 of which were published in English, two in Spanish, one in Portuguese, with a predominance of literature reviews. Findings were categorized into recommendations for the environment, the team, and the surgical technique.

CONCLUSION

The review mapped the technical and managerial strategies for the management and reduction of the airborne particles production in surgical procedures settings. They involve from the use of personal protective equipment, training, anesthetic modality, airway manipulation, to the execution of the surgical technique.

COVID-19 and otologic surgery

In this article, we aim to summarize the impacts of COVID-19 on the practice of otologic surgery. Cadaveric studies have indicated COVID-19 viral particles are present in the middle ear mucosa of infected hosts. Otologic procedures can generate significant amounts of droplets due to reliance on high-speed drills. Multiple guidelines have been developed to improve patient and provider safety peri-operatively. Particle dispersion can be mitigated during microscopic mastoidectomy by utilizing barrier drape techniques. The barrier drape may similarly be applied to the surgical exoscope. Endoscopic techniques have theoretical improved safety benefits by minimizing the need for drilling. The discoveries and innovations borne of the COVID-19 pandemic will lay the groundwork for the practice of otology amidst future pandemics.

Controle de partículas aéreas nos procedimentos cirúrgicos durante a pandemia da Covid-19: revisão de escopo

RESUMO Objetivo: Mapear as estratégias técnicas e gerenciais para o manejo e a redução da produção de partículas aéreas em ambientes de procedimentos cirúrgicos durante a pandemia da Covid-19. Método: Revisão de escopo, de acordo com metodologia do Joana Briggs Institute, a partir de documentos indexados nas bases MEDLINE, BVS, CINAHL Cochrane, Embase, Scopus, Web of Science e literatura cinza, publicados em português, inglês ou espanhol. Foram considerados todos os estudos provenientes de periódicos científicos indexados e recomendações publicadas por órgãos internacionais ou associações acadêmicas, de 2019 a janeiro de 2022. Os achados foram sumarizados e analisados por estatística descritiva e síntese narrativa. Resultados: Foram selecionados 22 estudos, sendo 19 publicados em inglês, dois em espanhol, um em português, com predominância de revisões da literatura. Os achados foram categorizados em recomendações para o ambiente, a equipe e a técnica cirúrgica. Conclusão: a revisão mapeou as estratégias técnicas e gerenciais para o manejo e a redução da produção de partículas aéreas nos ambientes de procedimentos cirúrgicos. Envolvem desde o uso de equipamentos de proteção individual, treinamentos, modalidade anestésica, manipulação de vias aéreas, até a execução da técnica cirúrgica.

Awake craniotomy for glioblastoma in COVID-19–positive patients and delivering the standard of care: illustrative case

BACKGROUND

Providing the standard of care to patients with glioblastoma (GBM) during the novel coronavirus of 2019 (COVID-19) pandemic is a challenge, particularly if a patient tests positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Further difficulties occur in eloquent cortex tumors because awake speech mapping can theoretically aerosolize viral particles and expose staff. Moreover, microscopic neurosurgery has become difficult because the use of airborne-level personal protective equipment (PPE) crowds the space between the surgeon and the eyepiece. However, delivering substandard care will inevitably lead to disease progression and poor outcomes.

OBSERVATIONS

A 60-year-old man with a left insular and frontal operculum GBM was found to be COVID-19 positive. Treatment was postponed pending a negative SARS-CoV-2 result, but in the interim, he developed intratumoral hemorrhage with progressive expressive aphasia. Because the tumor was causing dominant hemisphere language symptomatology, an awake craniotomy was the recommended surgical approach. With the use of airborne-level PPE and a surgical drape to protect the surgeon from the direction of potential aerosolization, near-total gross resection was achieved.

LESSONS

Delaying the treatment of patients with GBM who test positive for COVID-19 will lead to further neurological deterioration. Optimal and timely treatment such as awake speech mapping for COVID-19–positive patients with GBM can be provided safely.