key: cord-322497-hdy3va8e authors: LUBANSU, Alphonse; ASSAMADI, Mouhssine; BARRIT, Sami; DEMBOUR, Victoria; YAO, Gedeon; HADWE, Salim EL.; WITTE, Olivier DE. title: COVID-19 impact on neurosurgical practice: lockdown attitude and experience of a European academic center. date: 2020-09-03 journal: World Neurosurg DOI: 10.1016/j.wneu.2020.08.168 sha: doc_id: 322497 cord_uid: hdy3va8e Introduction The Coronavirus disease 2019 (COVID-19) pandemic is an unprecedented challenge. Different models of reorganization have been described aiming to preserve resources while ensuring optimal medical care. limited clinical neurosurgical experience including COVID-19 patients have been reported. We share organizational experience, attitudes, and preliminary data of patients treated at our institution. Methods Institutional guidelines and patient workflow are described and visualized. A cohort of all neurosurgical patients managed during the lockdown period is presented and analyzed assessing suspected nosocomial infection risk factors. A comparative surgical subcohort from the previous year was used to investigate the impact on surgical activity. Results A total of 176 patients were admitted in 66 days, twenty tested positive for COVID-19. Patients initially admitted to the neurosurgical ward were less likely to be suspected for a COVID-19 infection when compared to patients admitted for critical emergencies, particularly with neurovascular and stroke-related pathologies. The mortality rate of COVID-19 patients was remarkably high (45%), and even higher in patients that underwent surgical intervention (77 %). In addition to the expected drop in surgical activity (-53%), a decrease in traumatic emergencies was noted. Conclusion By applying infection prevention and resource-sparing logistics measures shared by the international medical community, we were able to maintain essential neurosurgical care in a pandemic with controlled nosocomial infection risk. Special consideration should be given to medical management and surgical indications in patients infected with the SARS-CoV-2 virus, as they seem to exhibit a problematic hemostatic profile that might result in an unfavorable clinical and surgical outcome. A total of 176 patients were admitted in 66 days, twenty tested positive for COVID-19. 69 Patients initially admitted to the neurosurgical ward were less likely to be suspected for a 70 COVID-19 infection when compared to patients admitted for critical emergencies, 71 particularly with neurovascular and stroke-related pathologies. The mortality rate of COVID-72 19 patients was remarkably high (45%), and even higher in patients that underwent surgical 73 intervention (77 %). In addition to the expected drop in surgical activity (-53%), a decrease in 74 traumatic emergencies was noted. Despite being a developed country, the country is not able to acquire nor produce enough 100 personal protective equipment (PPE) to ensure the healthcare providers' optimal safety, in 101 addition to the lack of reagents and logistical resources to proceed with mass testing. Accordingly, the health ministry guidelines reserved biochemical tests of nasopharyngeal 103 samples only for suspected COVID-19 patients requiring hospital admission, and no targeted 104 screening strategy was defined for healthcare providers. Since March 12, 2020, all medical 105 activities of our academic hospital have been reorganized. Non-urgent elective surgeries and 106 outpatient activities were suspended. Wards, resources, and teams were redeployed to 107 anticipate any potential congestion according to the latest national and institutional forecasts 2 . To our knowledge, no specific neurosurgical practice recommendations anticipating such 109 situations were available at the onset of the outbreak in our country, and there are still only 110 limited clinical experiences reported to support recently published ones 3,4,5 . We, therefore, share our lockdown experience, attitude, and taken measures from the frontlines, substantiated 112 by preliminary data of treated patients, outlining some features of COVID-19 patients. All descriptive statistics and statistical analyses were performed using "R" version 3.6.1 136 within the RStudio software version 1.2.1335. Chi-square test was used to investigate 137 independence for categorical data; Fisher's exact test was applied when sample size consisted 138 of occurrences less than five, Welch's t-test, was used as a location test when applicable. The 139 pre-defined statistical significance level was assumed when p-value was inferior to 0.05. (Table 2) . The retrospective review resulted in a crisis cohort of 176 inpatients ( Table 3 ). The mean age Moreover, concern about a potentially delayed aftermath due to postponed surgeries and the • Patient transportation on a closed circuit to a small size negative pressure suction room. • Respect airway management protocols for intubation/extubation (minimal personnel in the room, using contained air purifying respirators, out-of-room waiting time). • Limit unnecessary personnel. • Avoid endonasal surgeries. • Decrease speed of bone drilling to reduce spread of bone dust. • Optimize surgical team to shorten duration of surgeries. • Disposable FFP2/N95 mask, water-resistant gown, gloves, goggles, cap, and full-face visor shield. • For COVID-19 positive patients, FFP3 mask and/or Powered Air Purifying Respirators (PAPRs). • Endonasal surgery: manage patient as suspected case -nasal irrigation with povidone-iodine (PVP-I) solution, caution with dural handling, minimize drilling and prefer osteotomes. • Spine surgery: favor prone position, minimally invasive approach, reduce suction and splatter. • Brain surgery: avoid awake strategies and biopsy rather than surgical resection if possible. Intensive care unit • Manage positive COVID-19 patients to a separated COVID ICU unit. • Postoperative care for uncomplicated surgery includes craniotomies cases in a medium care unit rather than ICU. • Emphasize rapid discharge with close telemedicine follow-up. • Follow universal precautions and personal protection equipment (PPE) guidelines. • Social distancing for all group-based activities. • Reduce the number of healthcare staff on clinical duty. • Clinical team-bases rotations to reduce virus exposure. • Social distancing for all group-based activities. • All in-person conferences were canceled and replaced by seminars or webinars through video teleconferences. COVID-19 situation reports Epistat -Covid19 Monitoring COVID-19 outbreak: a single-366 centersingle center experience in neurosurgical and neuroradiological emergency network 367 tailoring. World Neurosurg Response to COVID-19 in Chinese neurosurgery and beyond. 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New Microbes and New Infections Three unsuspected CT diagnoses of COVID-19 Letter: 426 COVID-19 Infection Affects Surgical Outcome of Chronic Subdural Hematoma Fisher's exact test or student's t-test, CHD: coronary heart disease ☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☒The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:J o u r n a l P r e -p r o o f