A retrospective evaluation of characterization, clinical course and anaesthesia management of emergency trauma surgical patients during first wave of COVID-19 pandemic at a tertiary care center in India

Introduction

As millions of people around the globe got infected from novel coronavirus (COVID-19), World Health Organization(WHO) declared COVID-19 as global pandemic on 11 March, 2020.1

Honourable Prime Minister of India requested Janta Curfew on 22nd March 2020. After which nationwide lockdown declared in India from 24^th March which gradually extended till 31^st May. Following this unlock was planned in phased manner 1^st June to 31^st June was unlock 1 and then 1^st July to 31^st July was unlock 2.2

To conserve the resources and prevent cross infection in patients elective surgeries were deferred globally3 but emergency surgeries could not be postponed including trauma surgery. Emergency trauma surgeries are inherently very challenging as severe trauma is associated with life threatening injuries and during the pandemic these patients may be affected with COVID-19 and its multiorgan effects.4 Various worldwide studies show a drastic decrease in trauma surgery cases during the lockdown period of 2020 when compared with the same period in 2019.5, 6

But literature is very sparse on anaesthetic management of this high risk group of patients who underwent emergency trauma surgeries performed during two periods of lockdown and unlock in the pandemic.

The aim of this study is to compare the effect of lockdown and unlock during first wave of COVID-19 pandemic on the volume of emergency trauma surgical patients operated within 24 hours of admission, their covid status and outcomes at a tertiary care centre of North India.

We also intend to share our experience as anaesthesiologists in the management and planning of these patients differently in the pandemic, especially in terms of decreasing exposure and detect areas for improvement.

Materials and Methods

Emergency department management

All trauma victims were considered covid positive on arrival in the emergency department (ED), and the teams who were involved in the first contact with a trauma victim, donned Level 3 personal protective equipment (PPE) at all times and were responsible for the immediate management of the incoming patient, irrespective of their COVID-19 status.

Primary assessment and management was done as per the Advanced Trauma Life Support (ATLS) protocol. Patients with minor trauma went through covid screening before initial assessment and management, whereas major trauma victims were admitted and stabilized before testing for Covid‐19 infection. Samples from nasopharyngeal swab or lower respiratory tract secretions were sent for laboratory investigation of SARS‐CoV‐2 virus by, RT‐PCR, CB‐NAAT or RAT testing. Test reports were available either during or by the end of the procedure in case of emergency surgeries.

The algorithm for the work flow in trauma ED is shown in Figure 1, it was unidirectional flow and was planned to minimise the risk of exposure among healthcare professionals as well as cross infections among patients.

Figure 1

The algorithm for the work flow in trauma emergency

Other measures taken by the anaesthesia team to decrease exposure while providing general anaesthesia was the use of videolaryngoscope for intubation. Before intubating the patient sufficient neuromuscular relaxant was given to abolish cough reflex; aerosol-producing procedures like suctioning was avoided as far as possible. Propofol and rocuronium were used for rapid sequence induction. Etomidate was avoided as its immunosuppressive effects are a relative contraindication to use in COVID-19. After induction of anaesthesia bag mask ventilation was avoided, but in cases of severe hypoxemia ventilation was done with low tidal volume and high frequency. For patients with suspected or confirrmed COVID-19, appropriate positioning of the endotracheal tube was confirmed by chest movement and end-tidal carbon dioxide (Etco2), waveform instead by auscultation. High efficiency particulate air filters were placed between the mask and the breathing circuit and at the expiratory end of the breathing circuit to decrease viral contamination to the anesthesia machine and conserve heat and moisture within the breathing circuit. Disposable anaesthetic equipment in contact with the respiratory tract, such as video laryngoscope lenses, anaesthesia circuits, filters, reservoir bags, suction tubes, were discarded after single used to prevent cross infection among patients.

Beside this, at the end of each day or immediately after surgery of patients with confirmed or suspected COVID-19 cases, fumigation of the operating room was conducted with 15% solution of Gramicid-11 (11% hydrogen peroxide w/v & silver nitrate 0.01%) and mopping with one percent sodium hypochlorite solution. Routine disinfection of the anesthesia machine and external surface of other medical equipments were done with 70% isopropyl alcohol.

It was routinely inspected by the infection control team for proper reinforcement of disinfection services.

Results

Between 31^st March 2020 to 31^st June 2020, total fifty-nine patients operated within twenty-four hours for emergency trauma surgery, twenty-nine during lockdown period and thirty during unlock. During lockdown period 25 (86.21%) were male and 4 (13.79%) of the patients were female, during unlock 29 (96.67%) patients were male and only 1 of the patients (3.3%) was female (p=0.66).

The mean age of the patients was 30.65517± 13.17in the lockdown and 34.8±13.30 in unlock (p=0.23).

Of the total cases only 4(13.8%) in the lockdown period and 11 (36.7%) patients in unlock period tested positive for Covid-19. Although covid positive cases were slightly higher during unlock but it was statistically not significant (p=0.07). The median of ISS in lockdown and unlock period are 11 and 15 respectively, (p= 0.1) which shows there is no significant difference of ISS between both the periods. The median length of hospital stay in days is 15 during lockdown and 12.5 during unlock (p=0.88) indicating there is no significant difference in length of hospital stay between both periods. Out of 29 patients, 25(86.21%) were discharged and 4 (13.79%) died in the lockdown period and during unlock 22(73.33%) patients were discharged and 8 (16.67%) succumbed to death (p= 0.3). (Table 1)

Mechanism of injury is shown in Table 2. The most common modes of injury were road traffic accidents, followed by stabbing, falls at home, self-inflicted injury and shooting in that order. Self inflicted injury which occurred in 5 patients during lockdown and zero during unlock, none of these showed a significant difference (p > 0.06).

GA has been administered equally in both the periods i.e. 24(82.76%) patients in lockdown and 25(83.33%) patients in unlock period. Combined spinal epidural (CSE) and GA+ caudal has been administered only in lock down period for 3 (5.08%) and 1 cases (3.45%) respectively. A total of 5 patients (8.47%) have been given subarachnoid block (SAB) which consists of 1 in the lockdown period and 4 in the unlock period. Monitored anaesthesia care (MAC) was provided to only 1 patient (3.33%) in the unlock period (Table 3).

Patient vitals on arrival like heart rate and room air saturation (SpO2), glasgow coma scale, number of blood transfusions, use of inotropic support are depicted in Table 4.

Discussion

At the end of January, 2020 first case of COVID-19 was spotted in India.7 By 25^th March 2020, the total numbers cases increased above 600 in Indian subcontinent. At that point government of India ordered a sequential country-wide lockdowns that lasted for 68 days (March 25—June 1, 2020).8

Over the 2 periods, lockdown and unlock we did not see any statistical difference in the numbers, age, or sex distribution of the patients presenting for emergency trauma surgery.

Reason for no significant difference in number of patients between these two periods may be because of strict lockdown which controlled the spread of the fast spreading pandemic and was then relaxed in multiple phases.9

It was planned as phase one and two of unlock with only few people involved in certain important activities were allowed to come out and rest of the population was either doing work from home or were allowed to go out only for a limited time of the day.

Number of covid positive patients were slightly higher during unlock but it was statistically insignificant (p=0.07) and the number of patients died during unlock was also higher during unlock as compared to lockdown but statistically insignificant(p=0.3).

Stringent preventive measures were implemented by the government across the country, such as wearing masks, using hand sanitizer, maintaining social distancing, and controlling mass gatherings, which slowed infections significantly during unlock phase.

Although it is a single centre study it suggests that phased unlock with appropriate preventive measures did not lead to rise in number of emergency trauma patients, covid positivity rates and deaths in these group of patients. The other reason may be the low infection fatality rate of 0.46% during first wave in India in comparison to other Western countries.10

Workflow designing at our centre may also have played an important role in preventing cross infection to other trauma patients.

A systematic review by Antonini et al in 35 studies involving 36,987 patients observed that number of major trauma admissions overall decreased during the first wave of COVID-19 due to movement restriction policies but the severity and mortality did not change in this period as compared to previous years.11

Surek A et al studied retrospectively the patients who underwent emergency surgery at Level I trauma center in Germany from March 14^th to May 15^th 2020 during pandemic and within the same period from the year 2019. They observed number of emergency surgeries conducted due to trauma, gastrointestinal system bleeding, perforation and mesenteric ischemia were not altered by the pandemic. The demographic profile of these patients was also similar in the two groups.12

In our study the mean age of the patients was 30.65 in the lockdown and 34.8 in unlock (p=0.23), it can be justified as our study was entirely on trauma patients in a country with 65% population under 35 years of age.

Road traffic accidents were most common during both the periods, this may be because of the empty roads which might have led to high speeds, self-inflicted injury was higher in lockdown but it was zero during unlock this may be because of increase in depression and anxiety in the population during lockdown.

The ICON Trauma study in United Kingdom observed during the lockdown period in 2020 falls (both those greater or less than 2 m) increase in the proportion of presentations as compared to the year 2019. Elderly population those aged 65 years suffered from it mostly, may be due to decreased care and social support provided by family members not living in the same house were the attributable factors contributing towards this.¹³

Increase in suicidal tendency was observed in various parts of the world during pandemic and the reason may be social isolation and loss of employment.13 Kreis et al observed a decrease in the total number of surgeries during the shutdown period at a Level I trauma centre of Germany, but an increase in emergency surgeries, severe open fractures, house hold related injuries and injuries related to psyschological disorders.14

Chiba et al in a retrospective study from California compared epidemiological and clinical characteristics and outcomes of trauma admissions during the lock- down period (March 20, 2020, to June 30, 2020) to a similar period in the previous year (March 20, 2019, to June 30, 2019) they observed increased trend of suicides by 38.5 percent.15

We observed higher ISS during unlock as compared to lockdown (p=0.1), Fojut R. from Italy also observed reduced major trauma admissions during first lockdown but more severe injury presentation measured by ISS.16

Nia et al in a retrospective study from a level I trauma center, identified patients admitted between 15 March 2020 and 30 April 2020 (lockdown) and compared them to those between 15 March 2019 and 30 April 2019 (baseline). It was observed that total number of trauma patients decreased during lockdown but injury severity score in major trauma patients was significantly high during lockdown.17

In our study general anaesthesia was the most common anaesthesia technique used in both the periods. Regional anaesthesia was provided in both the periods in the form of CSE, SAB, GA combined with caudal. MAC was also used in one patient during unlock.

Wade et al reviewed anaesthesia charts of patients who underwent emergency surgery at London, United Kingdom from March 23, 2020 to May 10, 2020 and compared it with same period of year 2019, it was observed that regional anaesthesia (RA) was increasingly used as the sole mode of anesthesia for patients during the COVID-19 pandemic. This was especially distinct in the surgical specialties of gynecology, urology and general surgery where RA was not primary anesthetic of choice before the COVID-19 pandemic.18

Sugand K et al in a longitudinal, multicenter, retrospective, observational, cohort study conducted in United Kingdom during the peak 6 weeks of the first wave from 17 March 2020 compared with the same period in 2019 observed, that for the patients undergoing surgery for acute orthopaedic trauma during COVID-19, there was an increase in odds 
of aerosolising-generating anaesthesia by three-quarters.19

In summary, it is obvious that the emergency trauma surgeries will continue even during pandemics in periods of general lockdown as well as unlock. Anaesthesia teams working in centres with trauma care must consider this while developing strategies and reallocating resources during such health emergencies, epidemics or pandemics. This study highlighted that in India phased unlock helped in preventing rise of infection rate in general population which reflected in trauma cases and to improve patient outcomes during different phases of pandemic the work flow designing is crucial for minimizing the risk of cross infections among patients. This study also observed that unlike other western countries in India road traffic accident was the most common trauma with high injury severity score and general anaesthesia was used in most of the patients, so in future prepartions adequate logistics for general anaesthesia and resuscitation must be provided for these group of patients.

Conclusion

In the first wave of COVID-19 pandemic there was no significant difference in number of emergency trauma surgical patients between lockdown and unlock in our tertiary care centre of north India. Although the number of covid positive patients and deaths were higher during unlock but it was statistically insignificant. As the volume appeared same during both these periods we surmise that the general public was also adopting covid appropriate behavior independent of government orders. During unlock incidence of self-inflicted injury was zero which suggests improved psychological status of general public through unlock. General anaesthesia was the most commonly used anaesthesia technique which guides future preparedness for the drugs, equipments, infrastructure and planning of anaesthesia during emergency trauma surgery.

Limitation

Single centre retrospective study only analysed emergency trauma surgical patients operated within twenty-four hours of admission. There is also a need for assessing the data from other level one trauma centres in India to see the effect of the lockdown and unlock during pandemic on the emergency trauma facilities all encompassing the trauma care system.

Source of Funding

None.

Conflict of Interest

None.