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Indian Orthopaedic Association’s
Suggestions for
Orthopaedic Practice
during CoViD-19 pandemic
DISCLAIMER
Knowledge and best practice about CoViD-19 is rapidly evolving. As new
research and experiences broaden, the understanding and practices may
become different.
Following are suggestions by Indian Orthopaedic Association, considering
various guidelines and publications by various health authorities/associations
across the globe. Surgeons must rely on their experience and knowledge in
evaluating and using this information for patient care. It is the responsibility of
the surgeon, relying on their experience and knowledge of their patient, to
decide the best treatment for their patients and take all safety precautions.
To the fullest extent of law, neither Indian Orthopaedic Association or the
contributors of these guidelines, assume any liability for any injury and /or
damage to person/s or property as a matter of negligence or otherwise from
any method described in the material herein.
INDIAN ORTHOPAEDIC ASSOCIATION
DR. R .C. MEENA, PRESIDENT, IOA.
DR.ATUL SRIVASTAV, SECRETARY, IOA
DR. B. SHIVASHANKAR, PRESIDENT-ELECT, IOA
DR. RAMESH KR. SEN, VICE PRESIDENT, IOA
DR. MANISH DHAWAN, TREASURER, IOA
CONTRIBUTORS
PROF. SANDEEP KUMAR, Joint Secretary, IOA
DR. RAJESH ARORA, Assistant Professor
Department of Orthopaedics
Hamdard Institute of Medical Sciences & Research, New Delhi.
CONFLICTS OF INTEREST:NONE DECLARED
CoViD-19-THE GLOBAL
PANDEMIC OVER 1 MILLION CASES GLOBALLY.
ORIGINATED FROM WET ANIMAL MARKET, WUHAN, CHINA
ZOONOTIC TRANSMISSION
SYMPTOMS INCLUDE FEVER, COUGH, DYSPNEA, DIARRHEA.
CLINICAL PRESENTATION RANGES FROM ASYMPTOMATIC INFECTIONS TO BILATERAL PNEUMONITIS TO ACUTE RESPIRATORY DISTRESS SYNDROME /SEPTIC SHOCK
CoViD-19-THE GLOBAL PANDEMIC
MORTALITY 1- 10%
SUSCEPTIBLE POPULATION :
ELDERLY> 60 YRS
DIABETICS
SMOKERS
HEALTHCARE WORKERS
IMMUNOCOMPROMISED INDIVIDUALS
PATIENTS OF RESPIRATORY, CARDIOVASCULAR DISEASES
W.H.O. DECLARED IT A GLOBAL PANDEMIC ON 11.03.2020
AGGRESSIVE CONTAINMENT & MITIGATION MEASURES LEAD TO
LOCKDOWN OF MANY COUNTRIES INCLUDING INDIA
Coronavirus (SARS CoV-2)
POSITIVE STRANDED RNA VIRUSES
CROWN LIKE APPEARANCE, DUE TO SPIKE LIKE GLYCOPROTEINS ON
ENVELOPE
DIAMETER OF 0.06-0.14 MICRONS
SENSITIVE TO ETHANOL, ETHER (75%), CHLORINE CONTAINING
DISINFECTANT, PERACETIC ACID AND CHLROFORM, EXCEPT
CHLORHEXIDINE.
SENSITIVE TO UV RAYS AND HEAT
CoViD-19 (SARS CoV-2)
SARS CoV-2 HAS SPECIAL AFFINITY TO HUMAN TRACHEAL EPITHELIAL
CELLS
ATTACHES TO ACE-2 RECEPTORS ON HUMAN AIRWAY EPITHELIAL CELLS
ENTERS AND USES CELL MACHINERY TO REPLICATE AND ULTIMATEY CELL
DEATH.
THE CYTOKINE STORM, LEAD BY IL-6, THE FLORID IMMUNE RESPONSE
LEADS TO ARDS AND SEPTIC SHOCK
MAINLY RESPIRATORY/FOMITE TRANSMISSION
FECO-ORAL ROUTE POSSIBLE
PRESENT IN BLOOD, VERTICALLY TRANSMISSION (+/-)
NO VACCINE/ DEFINITIVE RELIABLE TREATMENT YET.
DIAGNOSTICS
Real time- Reverse Transcriptase Polymerase Chain Reaction (RT-PCR)-
DIAGNOSTIC
But they have high false negative rates especially if done in early stages.
▪ due to less shedding of virus
▪ improper swab technique
▪ poor swab preservation and transport
▪ technical limitation inherent to test, eg: PCR inhibition)
The sample is obtained either by naso-pharyngeal swab, oropharyngeal swabs taken by lab personnel
or physician following all safety protocols. Alternatively, bronchioalveolar lavages, sputum,
endotracheal tube suctioned fluid can also be used.
Serological kits are although rapid, but only detect CoViD exposure after 7-10
days of exposure, have limited diagnostic capabilities.
RADIOLOGY
Chest radiograph & CT findings are non-specific. (similar to other viral pneumonias)
Chest radiograph may be normal in early disease, less sensitive than CT,
CT scan has proven to be more sensitive even RT-PCR (1) , which may negative in
initial stages. But, CT should not be used as a screening tool for mass population (2).
Typical CT findings include multifocal areas of consolidation and ground glass opacities in
peripheral lung field. Other findings include:
• interlobular septal thickening (which when present with the ground glass opacities lead to
the “crazy paving appearance”)
• Pleural effusion and pneumothorax are rarely seen.
1 Ai T, Yang Z, Hou H, et al. Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases [published
online ahead of print, 2020 Feb 26]. Radiology. 2020;200642. doi:10.1148/radiol.2020200642
2 https://www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Recommendations-for-Chest-Radiography-and-CT-for-Suspected-COVID19-
Infection
WHY MODIFY ORTHOPAEDIC PRACTICE
DURING COVID 19?
CONTRIBUTE IN COUNTRY HEALTH CARE.
ANTICIPATING HIGH PATIENT LOAD & NEED FOR VENTILATOR BEDS, MINIMIZE USAGE OF
HEALTHCARE RESOURCES
FOR SOCIAL DISTANCING AND HENCE PREVENTING SPREAD
TO AVOID CONTAMINATION OF OTHER PATIENTS, HEALTH CARE WORKERS AND SETUP.
OPD PRACTICE TIPS
• MINIMIZE OPD PATIENTS
• USE TELEMEDICINE
• SCHEDULE YOUR APPOINTMENTS, AVOID UNNECESSARY
APPOINTMENTS , TALK TO PATIENT ON PHONE BEFORE CALLING
TO OPD/CLINIC
• KEEP WAITING AREA VACANT
• MAINTAIN HAND HYGEINE.
• CALL MINIMAL NECESSARY STAFF
OPD PRACTICE TIPS
• ONE PATIENT ONE ATTENDANT
• MAINTAIN SOCIAL DISTANCING
• PATIENT AND ATTENDANT SHOULD WEAR MASKS
• HEALTH CARE WORKERS SHOULD WEAR HOSPITAL SCRUBS, MASKS
(SURGICAL AT LEAST), GLOVES AND HOSPITAL SHOES
• SHOULD HAVE SEPARATE ASSESSMENT AND PROCEDURE ROOMS
OPD PRACTICE TIPS
GIVE ONE STOP TREATMENT, MINIMAL FOLLOW UP VISITS
AVOID INTERDEPARTMENTAL REFERRALS, IF POSSIBLE
MINIMUM XRAY/INVESTIGATIONS
FOLLOW UP XRAYS ONLY WHEN YOU EXPECT IT WILL HAVE DRASTIC IMPACT OF PATIENT’S MANAGEMENT
SHIFT C-ARM TO OPD, TO AVOID VISITS TO RADIOLOGY DEPT
USE VIDEOS/ONLINE REHAB TOOLS FOR PATIENT REHAB.
MINIMIZE ADMISSIONS FOR INPATIENT CARE
PATIENT TRIAGING FOR SURGERIES
MINIMIZE ADMISSIONS FOR INPATIENT CARE
AVOID ROUTINE SURGERIES
USE HEALTHCARE RESOURCES WISELY
TRIAGE PATIENTS WITH HIGHER TENDENCY FOR NON OPERATIVE MANAGEMENT
AVOID SURGERIES IN GERIATRIC PATIENTS (SUSCEPTIBLE POPULATION FOR COVID,
CHANCES OF NEED OF VENTILATOR CARE HIGHER IN POST OP PHASE)
PATIENT TRIAGING FOR SURGERIES
DO INCISION AND DRAINAGE FOR LOCAL ABSCESSES /
SUTURE LACERATED WOUNDS IN ER ONLY
SUGGESTED PATIENT TRIAGING GUIDES* (IN FOLLOWING SLIDES)
NOT COMPREHENSIVE, SURGEONS SHOULD WEIGH THE RISK
TO BENEFIT RATIO AND AVAILABILITY OF RESOURCES IN
SETUP.
COVID-19 Guidelines for Triage of Orthopaedic Patients. American College of Surgeons. Online March 24, 2020. https://www.facs.org/covid-19/clinical-guidance/elective-case/orthopaedics
BOAST - Management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic. British Orthopaedic Association. https://www.boa.ac.uk/uploads/assets/ee39d8a8-9457-4533-9774e973c835246d/COVID-19-BOASTs-Combined-v1FINAL.pdf
ORTHOPAEDIC
SUBSPECIALITY OPERATIVE MANAGEMENT
NON-OPERATIVE
MANAGEMENT
ABSOLUTE
INDICATIONSRELATIVE INDICATIONS INDICATIONS
TRAUMA & GEN ORTHOPAEDICS • OPEN FRACTURES
• POLYTRAUMA
• TRAUMA WITH
NEUROVASCULAR INJURIES
• IRREDUCIBLE FRACTURE
DISLOCATIONS
• COMPARTMENT SYNDROME
• CRUSH INJURIES
• SEPTIC ARTHRITIS
• ACUTE OSTEOMYELITIS
• AMPUTATIONS FOR
GANGRENE
• FEMUR FRACTURES
(SHAFT/NECK/DISTAL FEMUR)
• UNSTABLE PELVIC/
ACETABULAR FRACTURES
• INTRAARTICULAR/
FOREARM FRACTURES
• UNSTABLE TIBIAL SHAFT
FRACTURES
• COMMUNITED/COMPLEX
FRACTURES
• UNSTABLE UPPER LIMB
FRACTURES
• DIABETIC FOOT
• STABLE TIBIAL SHAFT
FRACTURES
• CLAVICLE FRACTURES
• STABLE UPPER LIMB
FRACTURES
• NON UNIONS
• MALUNIONS
• INFECTED NON UNIONS
• CHRONIC OSTEOMYELITIS
HAND • CRUSH HAND
• REPLANTATION SURGERIES
• INFECTIONS
• TENDON INJURIES
• COMMUNITED/ UNSTABLE
FRACTURES
• FRACTURE -DISLOCATION
• IRREDUCIBLE DISLOCATIONS
• COMPRESSIVE
NEUROPATHIES
• TENDINITIS
• STABLE FRACTURES
ORTHOPAEDIC
SUBSPECIALITY OPERATIVE MANAGEMENT
NON-OPERATIVE
MANAGEMENT
ABSOLUTE INDICATIONS RELATIVE INDICATIONS INDICATIONS
SPINE • CAUDA EQUINA
SYNDROME
• EPIDURAL ABSCESS
• DISCITIS PYOGENIC
• SPINE FRACTURE
UNSTABLE WITH
PARAPLEGIA
• ACUTE/PROGRESSIVE
COMPRESSIVE
MYELOPATHY
• UNSTABLE SPINE
FRACTURE WITH
NEURAL DEFICIT
• SCOLIOSIS WITH
NEURAL DEFICIT
• ACUTE RADICULOPATHY
• LOW BACK PAIN
• NECK PAIN
• FLAT BACK SYNDROME
• SCOLIOSIS WITHOUT
NEURAL DEFICIT
• SPINE FRACTURE
STABLE
ARTHROPLASTY • PROSTHETIC JOINT
INFECTIONS
• PROSTHETIC JOINT
DISLOCATIONS
• PERIPROSTHETIC
FRACTURES
• CHRONIC HIP/KNEE
PAINS
ORTHOPAEDIC
SUBSPECIALITY OPERATIVE MANAGEMENT
NON-OPERATIVE
MANAGEMENT
ABSOLUTE INDICATIONS RELATIVE INDICATIONS INDICATIONS
ORTHOPAEDIC
ONCOLOGY
• INFECTION INCLUDING
INFECTED JOINTS
• SARCOMA/MALIGNANCY
IN CHEMO/RADIATION
WINDOW
• BENIGN AGGRESSIVE
TUMOURS LIKE GCT
• IMPENDING
PATHOLOGICAL FRACTURES
• BENIGN SOFT TISSUE
TUMORS
• BENIGN BONE
TUMOURS
SPORTS • MULTILIGAMENTOUS
INJURIES WITH
NEUROVASCULAR
DEFICIT
• MULTILIGAMENTOUS
INJURY
• ROTATOR CUFF REPAIRS
(YOUNG)
• MAJOR MUSCLE TEAR
• CHRONIC KNEE, ELBOW,
SHOULDER, WRIST, HIP
PAINS
• RECURRENT SPRAINS/
DISLOCATIONS
• ACL/PCL TEAR
PREOPERATIVE WORK UP
ROUTINE PREOPERATIVE WORK UP
RULE OUT HISTORY OF SYMPTOMS/ CONTACT/TRAVEL HISTORY TO HOT-SPOTS
CONSIDERING ASYMPTOMATIC INFECTED PATIENTS CAN SPREAD DISEASE AND THE POTENTIAL RISK OF CONTAMINATION OF HEALTHCARE SETUP & WORKERS, EVERY PATIENT PLANNED FOR INVASIVE/SURGICAL PROCEDURE SHOULD IDEALLY BE TESTED FOR CoViD-19.
IF REGIONAL/INSTITUTIONAL POLICIES, DON’T PERMIT CoViD, ONE SHOULD GET CT CHEST.
IF NONE, TREAT ALL PATIENTS AS COVID POSITIVE WITH FULL PRECAUTIONS
PREOPERATIVE WORK UP
American College of Radiology doesn’t recommend use of CT as a
primary screening tool or diagnosis of COVID-19.
But, due to its high sensitivity, immediate reporting, equivalent
costs and ease of access, one can use CT scan to screen the
patients, WHICH ARE PLANNED FOR SURGERY, for any possible
features of incipient pneumonitis, as contamination of precious
health care setup and workers is at stake.
• Ai T, Yang Z, Hou H, et al. Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in
China: A Report of 1014 Cases [published online ahead of print, 2020 Feb 26]. Radiology. 2020;200642.
doi:10.1148/radiol.2020200642
• https://www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Recommendations-for-Chest-Radiography-and-CT-for-Suspected-COVID19-Infection
PREOPERATIVE WORK UP
If CT findings are positive, one should go for formal RT-PCR
even if asymptomatic; and if CT/PCR findings are negative with
negative history, one can proceed as with normal OT
precautions.
BUT
N95 MASK/TAPE SEALED SURGICAL MASK WITH FACE SHIELD &
WATERPROOF GOWNS/WATERPROOF APRONS MUST IN ALL
AEROSOL GENERATING PROCEDURES, IRRESPECTIVE OF COVID
STATUS DURING PANDEMIC
*AGP’S : AEROSOL GENERATING PROCEDURES
#WALANT: WIDE AWAKE ANAESTHESIA WITH LIGNOCAINE ADRENALINE AND NO TOURNIQUET
Drug prophylaxis for health care workers
ICMR -National Taskforce for COVID-19 recommends the use of hydroxy-
chloroquine for prophylaxis of SARS-CoV-2 infection for
Asymptomatic healthcare workers involved in the care of suspected or confirmed
cases of COVID-19
DOSE: 400 mg twice a day on Day 1, followed by 400 mg once weekly for next 7 weeks; to
be taken with meals
CONTRAINDICATIONS:
children under 15 years of age.
Persons with known case of retinopathy,
known hypersensitivity to hydroxychloroquine, 4-aminoquinoline compounds
CAUTION: INTAKE OF ABOVE MEDICINE SHOULD NOT INSTILL SENSE
OF FALSE SECUIRITY
https://icmr.nic.in/sites/default/files/upload_documents/HCQ_Recommendation_22March_final_MM_V2.pdf
PSYCHOLOGICAL SUPPORT
• LOT OF STRESS , FEAR, ANXIETY.
• POTENTIAL FOR HYSTERIA, SUICIDE
• SOCIAL SUPPORT FROM FAMILY and HEALTH
CARE WORKERS MANDATORY
• COUNSELLING BEFORE TESTING SHOULD BE
DONE ALONGWITH ATTENDANTS IF POSSIBLE
• DOCTORS SHOULD GET BREAKS.
PLAN OT LISTAVOID BLOOD TRANSFUSIONS
CHECK RESOURCES ( PPE KITS ,STAFF AVAILABILITY, VENTILATOR AVAILABILITY)
DISCUSS WITH OTHER SURGICAL DEPARTMENTS AND ANAESTHESIA DEPARTMENT
AND PARAMEDICAL DEPARTMENTS
AVOID OPERATING PATIENTS AT NIGHT HOURS
AVOID BLOOD TRANSFUSIONS, AS BLOOD SAFETY IS DOUBTFUL
CHECK DONOR’S HISTORY, BEFORE ACCEPTING BLOOD IN BLOOD BANKS
CONSENT
EXPLAIN PATIENT OF EXTRA EXPENDITURE.
(DUE TO PPE KITS AND EXTRA PRECAUTIONS)
RISK OF COVID EXPOSURE (IF PATIENT IN NOT SUSPECTED/COVID
PATIENT).
HIGHER CHANCES OF MORTALITY/MORBIDITY(MORTALITY 20.5%), IF
PATIENT IS LATER FOUND TO BE COVID -19 POSITIVE LATER.
S. Lei et al., Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection, EClinicalMedicine (2020), https://doi.org/10.1016/j.eclinm.2020.100331
PPE BASICS : RESPIRATORY
• ORTHOPAEDIC PROCEDURES INVOLVE AEROSOL GENERATION.
• BIO-AEROSOLS GENERATED CAN POTENTIALLY CONTAMINATE
EVERYONE.
• NEED ADEQUATE RESPIRATORY PROTECTION.
• HENCE, THE OT PERSONNEL SHOULD INHALE CLEAN AIR WITHOUT
CONTAMINATING SURGICAL FIELD.
• OPTIONS AVAILABLE:
➢ SURGICAL MASKS
➢RESPIRATORS, MOST COMMON N95 MASKS
➢POWERED AIR PURIFYING RESPIRATORS
SURGICAL MASK
LOOSE FITTING DEVICES
MAINLY TO PREVENT CONTAMINATION FROM ONE WHO WEARS IT
POOR SEAL AROUND FACE, HENCE HIGH LEAKAGE
POOR FILTRATION CAPACITY
NOT TO BE SHARED/REUSED
DISCARD IF WET OR AFTER 6-8 HOURS
NOT ADEQUATE FOR AEROSOL GENERATING PROCEDURES
MAY BE USED IN OPD OR OT WHILE OPERATING NON COVID PATIENTS,
PREFERABLY TAPE SEALED.
N95 MASKS/RESPIRATORS
NEAR COMPLETE SEAL DUE TO CONTOURED FIT, MINIMAL LEAKAGE.
BETTER FILTERING CAPACITY.
MOST COMMON USED VARIANT IS N95: FILTERS 95% OF FINE PARTICULATE
MATTER (<0.3 MICRONS)
NOT TO BE SHARED
DIFFICULT TO USE FOR THOSE WITH BREATHING DIFFICULTY/FACIAL HAIRS/KIDS.
EFFECTIVE FOR AEROSOL GENERATING PROCEDURES WITH FACE/EYE
PROTECTION.
N-95 REUSE??
Nathan N. Waste Not, Want Not: The Re-Usability of N95 Masks [published online ahead of print, 2020 Mar 31]. AnesthAnalg. 2020;10.1213/ANE.0000000000004843. doi:10.1213/ANE.0000000000004843
• Ideally not be shared/ reused• Considering limited /substandard
supply during pandemic➢ Keeping mask in a dry environment for
3-4 days or ➢ Heating at 70 degrees centigrade for
30 min.Needs more validation by studies*
POWERED AIR PURIFYING RESPIRATORS
(PAPR ) BATTERY POWERED BLOWERS
BEST PROTECTION
VERY BULKY, COSTLY, NOISY, CONSUMES ENERGY
TOUGH TO OBTAIN
DOUBTFUL ROLE ??
SURGICAL HELMETS SHOULD NOT BE CONFUSED WITH PAPR’S
Wong, J., Goh, Q.Y., Tan, Z. et al. Preparing for a COVID-19 pandemic: a review of operating room
outbreak response measures in a large tertiary hospital in Singapore. Can J Anesth/J Can Anesth
(2020). https://doi.org/10.1007/s12630-020-01620-9
EYE/FACE PROTECTION
FACE SHIELD GOGGLES BALACLAVA FOR HEAD COVER
IMPERMEABLE GOWNS (WATERPROOF)
& SHOE PLUS LEG COVERS & DOUBLE GLOVES
PPE GUIDLINES
SURGEONS/SCRUB
NURSE/
ANAESTHETIST
(GA)/ANAESTHETIST
ASSISTANT(GA)
FLOOR NURSE/
ANAESTHETIST (NON-
GA)/ HOUSEKEEPING
STAFF*
WARD NURSING STAFF/
SHIFTING NURSING
STAFF
• N95 respirator/PAPR
(ideal)
• IMPERMEABLE/WATE
RPROOF GOWNS
• SHOE COVERS
• LEG COVERS
• DOUBLE GLOVES
• GOGGLES/VISOR/EYE
SHIELD
• BALACLAVA
• N95
• NORMAL SURGICAL
GOWNS/FABRIC
• SHOE COVERS
• SINGLE GLOVES
• GOGGLES
• HEAVY DUTY GLOVES*
• SURGICAL MASK
• HOSPITAL
SCRUBS/NORMAL
SURGICAL GOWNS
• SHOE
COVERS/HOSPITAL
FOOTWEAR
• GLOVE
PPE ADVISE
CONSIDERING HIGH CHANCES OF OPERATING ASYMPTOMATIC
INFECTED PATIENT, WHICH MAY BE COVID NEGATIVE ON
INVESTIGATIONS
ATLEAST N95 MASKS/TAPE SEALED SURGICAL MASKS
WITH FACE SHIELD/EYE PROTECTION
&
WATERPROOF GOWNS/PLASTIC APRON BENEATH NORMAL
LINEN GOWNS
SHOULD BE USED IN ALL SURGERIES
PPE DONNING
https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf
• SHOULD HAVE SEPARATE DONNING AREA,
WHERE ALL GEAR IS AVAILABLE.
• FOLLOW INSTITUTIONAL/ CDC
GUIDELINES.
PATIENT SHIFTING
ASK SECURITY TO CLEAR PASSAGE , TO AVOID CONTAMINATION
TO OTHER PATIENTS, WORKERS.
SEPARATE TROLLEY FOR COVID-19/SUSPECTED PATIENTS
USE PPE
PATIENTS SHOULD BE SHIFTED IN OT, NO STAY IN PREOPERATIVE
ROOMS
PATIENT SHOULD WEAR MASK ALL THE TIME.
ANAESTHESIA CONSIDERATIONS
AVOID GENERAL ANAESTHESIA: INTUBATIONS/MECHANICAL
VENTILATIONS- AEROSOL GENERATING PROCEDURES
PREFER REGIONAL ANAESTHESIA (SPINAL/EPIDURAL/BLOCKS/ WIDE
AWAKE ANAESTHESIA)
IF NEEDS GA, PREFERABLY IN SEPARATE INTUBATION/EXTUBATION
ROOM.
ANAESTHESTIST AND TECHNICIAN FULL PPE WHEN INTUBATING
OT CONSIDERATIONS
DEDICATED OT FOR COVID PATIENTS/SUSPECTED PATIENTS
NO LAMINAR FLOW OT
NEGATIVE PRESSURE OT
DOORS CLOSED DURING PROCEDURES
MINIMUM ESSENTIAL OT PERSONNEL
NO ENTRY/EXITS IN BETWEEN PROCEDURE.
INTRAOPERATIVE CONSIDERATIONS
MINIMIZE BLEEDING: USE TOURNIQUET/ TRANEXAMIC ACID/ GOOD
HEMOSTASIS
MORE BLOODY FIELD, HIGHER AEROSOL GENERATION
USE CAUTERY MINIMALLY/ LOW SETTINGS/ USE SMOKE EVACUATORS
AVOID PULSE LAVAGES/HIGH PRESSURE LAVAGES; DO GENTLE LAVAGES
INTRAOPERATIVE CONSIDERATIONS
AVOID HIGH POWER INSTRUMENT : DRILLS/
REAMERS/BURR. PREFER OSTEOTOMES,
NIBBLERS, MANUAL REAMERS/DO UNREAMED
NAILINGS
AVOID STAGED SURGERIES
USE ABSORBABLE SUTURES
INTRAOPERATIVE CONSIDERATIONS
AVOID BULKY DRESSINGS WHEREVER POSSIBLE, USE
MINIMAL VISIBLE DRESSINGS LIKE OPSITE, TEGADERM ETC.
ALLOWS WOUND INSPECTION FROM SAFE DISTANCE.
USE REMOVABLE SPLINTS/ SLABS INSTEAD OF CASTS
CAST REMOVAL INVOLVES HIGHER CHANCES OF PATIENT CONTACT, EASIER HOME
BASED MANAGEMENT
POST-OPERATIVE CONSIDERATIONS
ALL PPE SHOULD BE REMOVED INSIDE OT,
EXCEPT MASKS.
FOLLOW INSTITUTIONAL/CDC GUIDELINES.
SEQUENCE: GLOVES, EYEWEAR/FACE SHIELD,
/GOWN, THEN WASH/HAND RUB
REMOVE RESPIRATOR/MASK OUTSIDE
DISCARD PROPERLY
POST-OPERATIVE CONSIDERATIONS
ALL PPE SHOULD BE REMOVED INSIDE OT,
EXCEPT MASKS.
FOLLOW INSTITUTIONAL/CDC GUIDELINES.
SEQUENCE: GLOVES, EYEWEAR/FACE SHIELD,
/GOWN, THEN WASH/HAND RUB
REMOVE RESPIRATOR/MASK OUTSIDE
DISCARD PROPERLY
POST-OPERATIVE CONSIDERATIONS
SHIFT PATIENT TO RECOVERY ROOM/PATIENT’S ROOM USINGSHIFTING PRECAUTIONS
MINIMISE POST OP STAY
TRY FOR DAY CARE SURGERIES.
REHAB PROGRAM USING VIDEOS AND TELEMEDICINES
MINIMAL FOLLOW UP VISITS, GIVE SOS NUMBERS TO PATIENT TOALLAY ISSUES OVER PHONE
OT CLEANING
Clean instruments used separately from other instruments
Normal sterilizing methods enough.
All non dedicated/ non disposable equipment should be cleaned
including C-arm
Follow manufacturer’s and institutional policies
70% Ethyl alcohol to disinfect reusable dedicated equipment between uses
Sodium hypochlorite at 1% (equivalent 5000ppm) for disinfection of
frequently touched surfaces.
LINEN CLEANING
Soiled linen, if present, should be segregated in labelled
container.
Wash and disinfect them in warm water(60-90 degrees) and
detergent.
OR
If hot water not available, soak linen in 0.05% chlorine solution
for 30 mins.
Rinse with clean water and dry fully in sunlight.
BIOMEDICAL WASTE MANAGEMENT
FOLLOW BIOMEDICAL RULES
DOUBLE LAYERED BAGS, TO AVOID LEAK
WELL LABELLED SEPARATE BINS FOR COVID-19/SUSPECTED
PTS. (“COVID-19 WASTE”)
HANDED CAREFULLY TO BIOMEDICAL WASTE PERSONNEL USING
ALL PREACUTIONS AND PPE (HEAVY DUTY GLOVES)
MESSAGE
TAKE ALL
PRECAUTIONS
ISOLATE & STOP ATTENDING PATIENTS/CLINIC, IF EXPOSED.
QUARANTINE AND GET TESTED.
USE RESOURCES JUDICIOUSLY.
REFERENCES➢ WHO CoViD-19 Dashboard. World Health Organisation.
https://who.sprinklr.com
➢ Fauci AS, Lane HC, Redfield RR. Covid-19 - Navigating the Uncharted. N EnglJ Med. 2020;382(13):1268–1269. doi:10.1056/NEJMe2002387.
➢ Perlman S. Another Decade, Another Coronavirus. N Engl J Med. 2020;382(8):760–762. doi:10.1056/NEJMe2001126.
➢ Cascella M, Rajnik M, Cuomo A, et al. Features, Evaluation and Treatment Coronavirus (COVID-19) [Updated 2020 Mar 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554776/
➢ Zhu N, Zhang D, Wang W, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med. 2020;382(8):727–733. doi:10.1056/NEJMoa2001017
➢ Zhang W, Du RH, Li B, et al. Molecular and serological investigation of 2019-nCoV infected patients: implication of multiple shedding routes. Emerg Microbes Infect. 2020;9(1):386–389. Published 2020 Feb 17. doi:10.1080/22221751.2020.1729071
➢ Chen H, Guo J, Wang C, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records [published correction appears in Lancet. 2020 Mar 28;395(10229):1038] Lancet. 2020;395(10226):809–815. doi:10.1016/S0140-6736(20)30360-3.
➢ Guan WJ, Ni ZY, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China [published online ahead of print, 2020 Feb 28]. N Engl J Med. 2020;NEJMoa2002032. doi:10.1056/NEJMoa2002032
➢ BOAST - Management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic. British Orthopaedic Association. https://www.boa.ac.uk/uploads/assets/ee39d8a8-9457-4533-9774e973c835246d/COVID-19-BOASTs-Combined-v1FINAL.pdf
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ACKNOWLEDGEMENTS
Prof. Shishir Rastogi, Head & Professor, Department of Orthopaedics
Hamdard Institute of Medical Sciences & Research, New Delhi.
Dr. Surabhi Vyas, Additional Professor, Department of Radiodiagnosis
All India Institute of Medical Sciences (AIIMS), New Delhi.
Dr. Shilpee Kumar,Associate Professor, Department of Microbiology,
Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi.
Dr. Arvind Kumar, Assistant Professor, Department of Orthopaedics
Hamdard Institute of Medical Sciences & Research, New Delhi.
Dr. Priyanka Arora, Ex-Assistant Professor, Department of Obstetrics & Gynaecology,
ESIC Medical College, Faridabad, Haryana
INDIAN ORTHOPAEDIC ASSOCIATION
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Email : [email protected], [email protected]
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