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Surgery- Prevalent surgical manifestations
Discomfort Any pain should exhibit identical characteristics. This can be encapsulated by the acronym SOCRATES:
Sites - What is the location of the pain? Is it specific to a region or generalized?
Onset- Progressive, swift, or abrupt? Intermittent or continuous?
Character- Acute, penetrating, blunt, throbbing, constricted, painful?
Radiation. Does it disseminate to other regions? Ureteric pain radiates from the loin to the groin; diaphragmatic irritation extends to the shoulder tip; retroperitoneal pain manifests in the back; and myocardial discomfort is referred to the jaw and neck.
Associated symptom-. Nausea, emesis, dysuria, icterus?
Timing-. Does it transpire at a specific time? Factors that exacerbate or alleviate.
Exacerbation of symptoms with respiration, movement, or coughing indicates peritoneal or pleural irritation; alleviation through the application of hot water bottles implies deep inflammatory or infiltrative pain.
Surgical history- Is the pain associated with surgical procedures?
Dyspepsia refers to epigastric discomfort or soreness, typically occurring postprandially. What is the frequency? Is it triggered by eating or does it occur spontaneously? Do milky beverages or foods provide any relief? Is it determined by position?
Dysphagia (impairment in the swallowing process)
Is the symptom recent or chronic? Is it deteriorating rapidly or remaining reasonably stable? Is it more detrimental with solids or fluids? Increased severity with fluids indicates a motility issue rather than a stenosis. Can it be alleviated by any means, such as warm beverages? Can the patient indicate a certain 'level' of obstruction? This frequently corresponds to the degree of an obstructive lesion. Is it linked to 'spluttering' (indicating a tracheoesophageal fistula or aspiration of food/fluid)?
Gastroesophageal reflux
(bitter or acidic fluid in the pharynx or oral cavity). What is the frequency? Which color? Green indicates bile, while white signifies only stomach contents. When does it manifest (exclusively while supine, upon bending, or spontaneously in an upright position)? Is it linked to coughing?
Haematemesis refers to the presence of blood in vomit.
What is the color of blood? (Dark red-brown 'coffee grounds' indicates old or low-volume gastric bleeding; dark red may suggest venous bleeding from the esophagus; brilliant red signifies arterial bleeding, typically from significant gastric or duodenal arteries.) What volume has transpired throughout what duration? Did the blood manifest with the initial episodes of vomiting or only subsequent to a duration of extended vomiting? Indicates a traumatic esophageal etiology.
Abdominal distension
Symmetrical distension indicates one of the '5 Fs' (fluid ascites, flatus from ileus or blockage, fetal presence, adipose tissue, or a substantial mass). Asymmetrical distension indicates a confined bulk. What is the duration of the process? Does it fluctuate? Is it altered by vomiting? Defecation or flatulence?
Alteration in bowel habits
Alterations in frequency or consistency (i.e., increased frequency and looser stools are more likely attributable to a pathogenic etiology). Is it enduring or temporary? Prolonged alteration in bowel habits beyond six weeks necessitates additional examination. Defecation frequency and urgency The recent onset of urgency in feces is typically indicative of a medical condition. What is the level of urgency—how long can the patient postpone treatment? Is there accompanying discomfort? Is the stool normal?
Rectal hemorrhage
What is the color of blood? Pink-red coloration, observed solely on the paper during wiping or splashing in the pan, indicates a potential origin from the anal canal. The presence of bright crimson on the stool's surface indicates a lower rectal origin. Darkened blood with clots or marbled appearance in the stools indicates a colonic origin. Blood thoroughly integrated with the stool or modified indicates a proximal colonic origin.
Tenesmus is the need to defecate accompanied by either an absence of results or a sensation of incomplete evacuation. Indicates rectal pathology.
Jaundice (yellow pigmentation of the skin, sclera, or uvula resulting from hyperbilirubinemia;) What was the rate of jaundice development? Is there accompanying pruritus? Are there any indications of discomfort, fever, or malaise? Indicates infection
Haemoptysis (the presence of blood in sputum). What is the color of blood? Pale pink froth indicates pulmonary edema.) Are there clots or dark blood indicative of infection or an endobronchial lesion? What is the volume of blood? Moderate hemorrhages rapidly jeopardize airways—seek assistance promptly.
Dyspnea (difficulty in or awareness of breathing) When does dyspnea manifest? Assess the magnitude of exertion. Is it determined by position?
• Orthopnea. Assess the difficulty in breathing that arises when supine; quantify it by inquiring about the number of pillows the patient need at night to be asymptomatic.
• Paroxysmal nocturnal dyspnea. Nocturnal intermittent dyspnea. Orthopnoea and paroxysmal nocturnal dyspnoea indicate heart failure.
Claudication (muscle soreness in the calf, thigh, or buttock induced by physical activity and alleviated by rest). At what level of exercise does the pain manifest, considering both flat distances and inclines? What is the rate at which rest alleviates pain?
Rest pain (pain in a limb at rest without substantial exertion). What is the duration of the pain's presence? Is it sporadic? Does it primarily transpire during the nocturnal hours? Is it alleviated by the reliance of the affected limb?
Dysuria (discomfort during urination). At what point does the discomfort manifest (initially, at conclusion, or continuously along the process)? Is the sensation localized to the penis or the suprapubic region? Is it correlated with frequency? Is the pee discolored or does it contain particulate matter?
Hematuria (the presence of blood in urine). Does the hematuria manifest at the onset (indicating a bladder source), during, or at the conclusion (indicating a prostatic or penile source) of the urinary stream? Is there concomitant pain (indicative of infection or nephrolithiasis)?
Discomfort Any pain should exhibit identical characteristics. This can be encapsulated by the acronym SOCRATES:
Sites - What is the location of the pain? Is it specific to a region or generalized?
Onset- Progressive, swift, or abrupt? Intermittent or continuous?
Character- Acute, penetrating, blunt, throbbing, constricted, painful?
Radiation. Does it disseminate to other regions? Ureteric pain radiates from the loin to the groin; diaphragmatic irritation extends to the shoulder tip; retroperitoneal pain manifests in the back; and myocardial discomfort is referred to the jaw and neck.
Associated symptom-. Nausea, emesis, dysuria, icterus?
Timing-. Does it transpire at a specific time? Factors that exacerbate or alleviate.
Exacerbation of symptoms with respiration, movement, or coughing indicates peritoneal or pleural irritation; alleviation through the application of hot water bottles implies deep inflammatory or infiltrative pain.
Surgical history- Is the pain associated with surgical procedures?
Dyspepsia refers to epigastric discomfort or soreness, typically occurring postprandially. What is the frequency? Is it triggered by eating or does it occur spontaneously? Do milky beverages or foods provide any relief? Is it determined by position?
Dysphagia (impairment in the swallowing process)
Is the symptom recent or chronic? Is it deteriorating rapidly or remaining reasonably stable? Is it more detrimental with solids or fluids? Increased severity with fluids indicates a motility issue rather than a stenosis. Can it be alleviated by any means, such as warm beverages? Can the patient indicate a certain 'level' of obstruction? This frequently corresponds to the degree of an obstructive lesion. Is it linked to 'spluttering' (indicating a tracheoesophageal fistula or aspiration of food/fluid)?
Gastroesophageal reflux
(bitter or acidic fluid in the pharynx or oral cavity). What is the frequency? Which color? Green indicates bile, while white signifies only stomach contents. When does it manifest (exclusively while supine, upon bending, or spontaneously in an upright position)? Is it linked to coughing?
Haematemesis refers to the presence of blood in vomit.
What is the color of blood? (Dark red-brown 'coffee grounds' indicates old or low-volume gastric bleeding; dark red may suggest venous bleeding from the esophagus; brilliant red signifies arterial bleeding, typically from significant gastric or duodenal arteries.) What volume has transpired throughout what duration? Did the blood manifest with the initial episodes of vomiting or only subsequent to a duration of extended vomiting? Indicates a traumatic esophageal etiology.
Abdominal distension
Symmetrical distension indicates one of the '5 Fs' (fluid ascites, flatus from ileus or blockage, fetal presence, adipose tissue, or a substantial mass). Asymmetrical distension indicates a confined bulk. What is the duration of the process? Does it fluctuate? Is it altered by vomiting? Defecation or flatulence?
Alteration in bowel habits
Alterations in frequency or consistency (i.e., increased frequency and looser stools are more likely attributable to a pathogenic etiology). Is it enduring or temporary? Prolonged alteration in bowel habits beyond six weeks necessitates additional examination. Defecation frequency and urgency The recent onset of urgency in feces is typically indicative of a medical condition. What is the level of urgency—how long can the patient postpone treatment? Is there accompanying discomfort? Is the stool normal?
Rectal hemorrhage
What is the color of blood? Pink-red coloration, observed solely on the paper during wiping or splashing in the pan, indicates a potential origin from the anal canal. The presence of bright crimson on the stool's surface indicates a lower rectal origin. Darkened blood with clots or marbled appearance in the stools indicates a colonic origin. Blood thoroughly integrated with the stool or modified indicates a proximal colonic origin.
Tenesmus is the need to defecate accompanied by either an absence of results or a sensation of incomplete evacuation. Indicates rectal pathology.
Jaundice (yellow pigmentation of the skin, sclera, or uvula resulting from hyperbilirubinemia;) What was the rate of jaundice development? Is there accompanying pruritus? Are there any indications of discomfort, fever, or malaise? Indicates infection
Haemoptysis (the presence of blood in sputum). What is the color of blood? Pale pink froth indicates pulmonary edema.) Are there clots or dark blood indicative of infection or an endobronchial lesion? What is the volume of blood? Moderate hemorrhages rapidly jeopardize airways—seek assistance promptly.
Dyspnea (difficulty in or awareness of breathing) When does dyspnea manifest? Assess the magnitude of exertion. Is it determined by position?
• Orthopnea. Assess the difficulty in breathing that arises when supine; quantify it by inquiring about the number of pillows the patient need at night to be asymptomatic.
• Paroxysmal nocturnal dyspnea. Nocturnal intermittent dyspnea. Orthopnoea and paroxysmal nocturnal dyspnoea indicate heart failure.
Claudication (muscle soreness in the calf, thigh, or buttock induced by physical activity and alleviated by rest). At what level of exercise does the pain manifest, considering both flat distances and inclines? What is the rate at which rest alleviates pain?
Rest pain (pain in a limb at rest without substantial exertion). What is the duration of the pain's presence? Is it sporadic? Does it primarily transpire during the nocturnal hours? Is it alleviated by the reliance of the affected limb?
Dysuria (discomfort during urination). At what point does the discomfort manifest (initially, at conclusion, or continuously along the process)? Is the sensation localized to the penis or the suprapubic region? Is it correlated with frequency? Is the pee discolored or does it contain particulate matter?
Hematuria (the presence of blood in urine). Does the hematuria manifest at the onset (indicating a bladder source), during, or at the conclusion (indicating a prostatic or penile source) of the urinary stream? Is there concomitant pain (indicative of infection or nephrolithiasis)?
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Surgery -Analgesia
Effectively managing a patient's pain during the perioperative period is a fundamental obligation of a surgical student. The advantages of managing acute pain encompass: • Wound healing. • Mobility. • Patient contentment. • Premature hospital discharge. • Decrease in the likelihood of thromboembolic occurrences. In instances of acute pain resulting from trauma, surgery, delivery, or a medical condition, it is crucial to ascertain the location, temporal characteristics, and intensity of the pain. Various approaches are available for evaluating the patient's pain
Techniques for Evaluating Acute Pain
Visual analogue scale (VAS)
-Scored between ‘no pain’ and ‘pain as bad as it can be’
Verbal response score (VRS)
Pain scored as a number, e.g. 4 out of 10, or verbally, e.g.
mild, severe, excruciating
Autonomic response
Sweating, tachycardia, hypertension (HTN)
Dynamic pain scores
Pain on movement; ability to take a deep breath; ability
to cough
The objective of postoperative analgesia is to reduce the dosage of analgesic drugs, hence avoiding side effects, while ensuring sufficient and efficient pain relief. The World Health Organization analgesic ladder This was initially devised for the management of persistent pain associated with cancer. The ladder is being employed to address multiple forms of pain. The technique involves the immediate prescription of analgesics upon the onset of pain and the adjustment of the regimen until the patient achieves pain relief, utilizing the ladder system
Postoperatively, patients will necessitate potent and effective analgesia. The oral route is favored whenever feasible. In the acute postoperative phase or in cases of vomiting, intravenous administration may be necessary.
The intramuscular (IM) method is unpleasant and has inconsistent absorption; it should be avoided when feasible. The analgesic regimen can be titrated down utilizing the World Health Organization (WHO) ladder as the patient convalesces in the days subsequent to the procedure. To guarantee that patients receive consistent and extended analgesia, these should be supplied routinely rather than on an as-needed basis. Adjuvant medicines are agents that augment the efficacy of analgesics, such as anticonvulsants like gabapentin utilized for neuropathic pain.
WHO Pain Relief Ladder
Mild pain
Non-opioid (e.g. aspirin, paracetamol or NSAID) +/− adjuvant
Mild to moderate pain
Weak opioid (e.g. codeine)
+/− non-opioid
+/− adjuvant
Moderate to severe pain
Strong opioid
(e.g. morphine)
+/− non-opioid
+/− adjuvant
Effectively managing a patient's pain during the perioperative period is a fundamental obligation of a surgical student. The advantages of managing acute pain encompass: • Wound healing. • Mobility. • Patient contentment. • Premature hospital discharge. • Decrease in the likelihood of thromboembolic occurrences. In instances of acute pain resulting from trauma, surgery, delivery, or a medical condition, it is crucial to ascertain the location, temporal characteristics, and intensity of the pain. Various approaches are available for evaluating the patient's pain
Techniques for Evaluating Acute Pain
Visual analogue scale (VAS)
-Scored between ‘no pain’ and ‘pain as bad as it can be’
Verbal response score (VRS)
Pain scored as a number, e.g. 4 out of 10, or verbally, e.g.
mild, severe, excruciating
Autonomic response
Sweating, tachycardia, hypertension (HTN)
Dynamic pain scores
Pain on movement; ability to take a deep breath; ability
to cough
The objective of postoperative analgesia is to reduce the dosage of analgesic drugs, hence avoiding side effects, while ensuring sufficient and efficient pain relief. The World Health Organization analgesic ladder This was initially devised for the management of persistent pain associated with cancer. The ladder is being employed to address multiple forms of pain. The technique involves the immediate prescription of analgesics upon the onset of pain and the adjustment of the regimen until the patient achieves pain relief, utilizing the ladder system
Postoperatively, patients will necessitate potent and effective analgesia. The oral route is favored whenever feasible. In the acute postoperative phase or in cases of vomiting, intravenous administration may be necessary.
The intramuscular (IM) method is unpleasant and has inconsistent absorption; it should be avoided when feasible. The analgesic regimen can be titrated down utilizing the World Health Organization (WHO) ladder as the patient convalesces in the days subsequent to the procedure. To guarantee that patients receive consistent and extended analgesia, these should be supplied routinely rather than on an as-needed basis. Adjuvant medicines are agents that augment the efficacy of analgesics, such as anticonvulsants like gabapentin utilized for neuropathic pain.
WHO Pain Relief Ladder
Mild pain
Non-opioid (e.g. aspirin, paracetamol or NSAID) +/− adjuvant
Mild to moderate pain
Weak opioid (e.g. codeine)
+/− non-opioid
+/− adjuvant
Moderate to severe pain
Strong opioid
(e.g. morphine)
+/− non-opioid
+/− adjuvant
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Surgery - Fundamentals of effective prescribing
Optimal prescribing practices The UK GMC delineates the principles of effective prescribing practice (% Duties of a doctor): Stay informed on current laws and regulations. Operate within the boundaries of your expertise—administer treatment solely when you possess sufficient understanding of the patient's condition.
• Deliver effective treatment grounded in the most reliable evidence available. Ensure that the care or treatment you administer aligns with any other therapies the patient is undergoing. Utilize the resources at your disposal, such as the British National Formulary (BNF) app/book, hospital-wide policies (e.g., antibiotic prescribing policy), the ward pharmacist, and the ward intravenous (IV) drug guide. Collaboration In the hospital, numerous healthcare specialists are often consulted for specialized prescribing guidance. Key domains pertinent to surgery encompass the prescription of:
• Analgesics:
• Acute pain team—beneficial for complex pain management requirements following surgery.
Anaesthetists possess proficiency in patient-controlled analgesia (PCA), epidural treatment, and perioperative symptom management.
• Palliative care team— for terminal symptoms.
• Antiemetics (as already mentioned). Antibiotics: for infection care, adhere to hospital antibiotic guidelines as the primary approach; for complex infections, consult with microbiologists or infectious disease specialists.
• Anticoagulants—consult a haematologist for guidance on patients with bleeding issues and the administration of perioperative anticoagulation; utilize the local anticoagulation service for long-term anticoagulation recommendations.
• Intravenous medications—ward nurses (or intensive care unit nurses). General guidance, such as medication reconciliation and interaction advisories, is provided by the ward pharmacist.
• Additional specialty-specific guidance—senior colleagues, advanced nurse practitioners.
Optimal prescribing practices The UK GMC delineates the principles of effective prescribing practice (% Duties of a doctor): Stay informed on current laws and regulations. Operate within the boundaries of your expertise—administer treatment solely when you possess sufficient understanding of the patient's condition.
• Deliver effective treatment grounded in the most reliable evidence available. Ensure that the care or treatment you administer aligns with any other therapies the patient is undergoing. Utilize the resources at your disposal, such as the British National Formulary (BNF) app/book, hospital-wide policies (e.g., antibiotic prescribing policy), the ward pharmacist, and the ward intravenous (IV) drug guide. Collaboration In the hospital, numerous healthcare specialists are often consulted for specialized prescribing guidance. Key domains pertinent to surgery encompass the prescription of:
• Analgesics:
• Acute pain team—beneficial for complex pain management requirements following surgery.
Anaesthetists possess proficiency in patient-controlled analgesia (PCA), epidural treatment, and perioperative symptom management.
• Palliative care team— for terminal symptoms.
• Antiemetics (as already mentioned). Antibiotics: for infection care, adhere to hospital antibiotic guidelines as the primary approach; for complex infections, consult with microbiologists or infectious disease specialists.
• Anticoagulants—consult a haematologist for guidance on patients with bleeding issues and the administration of perioperative anticoagulation; utilize the local anticoagulation service for long-term anticoagulation recommendations.
• Intravenous medications—ward nurses (or intensive care unit nurses). General guidance, such as medication reconciliation and interaction advisories, is provided by the ward pharmacist.
• Additional specialty-specific guidance—senior colleagues, advanced nurse practitioners.
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Clinical Surgery – Covid 19 Surgical Practice
Insights from the COVID-19 epidemic Coronaviruses are zoonotic pathogens that typically induce respiratory symptoms in humans. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease 2019 (COVID-19) were recognized as a global pandemic following the World Health Organization's (WHO) declaration of a public health emergency on January 20, 2020. This exceeded prior coronavirus epidemics, including SARS-CoV in 2002 and Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012. The majority of COVID-19 patients have moderate symptoms; however, more severe manifestations include pulmonary edema, severe pneumonia, acute respiratory distress syndrome (ARDS), and sepsis. At-risk populations encompass the elderly, immunocompromised individuals, and those with a body mass index (BMI) exceeding 40. The median incubation period is predicted to be 5.1 days, with additional symptomatic infections unlikely after 14 days of exposure without symptoms.
Severe complications and the magnitude of the disease exerted considerable pressure on global health systems, resulting in substantial compromises to surgical services during the initial wave. Certain surgical services indicated suboptimal outcomes in individuals who either presented with or developed COVID-19 during the perioperative period.
The gold standard for COVID-19 screening is a pharyngeal swab reverse transcriptase polymerase chain reaction (RT-PCR), with a sensitivity of 71–98% and generally requiring over 24 hours for results. Four Rapid testing utilizing lateral flow devices offers a more expedient option, generally within 30 minutes, exhibiting great sensitivity and specificity. A multitude of vaccines have been created, with the initial approval for usage in the UK in late 2020 granted to the Pfizer BioNTech mRNA vaccine and the Oxford AstraZeneca chimpanzee adenovirus-vectored vaccine.
Clinical prioritization
Owing to extensive disruption and bed shortages, all elective surgeries were suspended in the National Health Service (NHS). The Federation of Surgical Specialty Associations (FSSA) categorized cases based on new COVID-19 pandemic criteria
This categorization is beneficial for daily surgical practice, particularly amid ongoing strains on healthcare services, and may be advantageous for trainee doctors to consider. The impact of delays on mortality— the significance of targets The COVID-19 pandemic has underscored the detrimental effects of treatment delays in patients typically managed on an urgent approach. Cancer patients in the UK NHS are often anticipated to be seen within two weeks after referral, known as the '2-week wait (2WW) pathway,' with treatment commencing within two months. Other urgent situations, such as critical limb ischemia, have comparable treatment objectives.
The COVID-19 health care crisis resulted in the postponement of numerous procedures for urgent, life-threatening disorders. In several instances, private hospitals or designated 'COVID-19-free' zones were utilized to maintain surgical or oncological services. A balance existed between decreasing the risk of morbidity or mortality from COVID-19 and the danger posed by the underlying condition. It was established that elderly patients (>80 years) and individuals in high-risk categories had elevated perioperative risk and adverse outcomes when treated in regions with high COVID-19 transmission rates. COVID-19 was linked to increased in-hospital mortality (25–36%) and a heightened risk of thrombotic events, including end-organ ischemia in surgical patients.
FSSA prioritization system
Level
Priority 1a
Category
Emergency Operation Needed within 24h
Example
Ruptured abdominal aorti aneurysm (AAA), laparotom for peritonitis or trauma.
Ear, nose, and throat (ENT) bleeding or airway compromise
Open fracture with neurovascular compromise
Level
Priority 1b
Category
Urgent— operation needed within 72h
Example
Laparotomy for bowel obstruction
Level
Priority 2
Category
Within 4 weeks
Example
Cancer surgery
Level
Priority 3
Category
Within 3 months
Example
Colectomy— inflammatory bowel
disease (IBD)
Level
Priority 4
Category
Can be delayed for >3 months
Example
Elective total knee/ hip replacements
Conversely, preliminary evidence indicated that treatment delays for younger and medically healthier patients resulted in poorer outcomes. Patients with cancer (breast, colorectal, lung, and oesophageal) are estimated to experience an additional 5-year mortality of 6–15% due to delays in diagnosis and treatment caused by pandemic restrictions.Five For individuals with a big aortic aneurysm over 7.0 cm, a treatment delay of over 3 months correlates with a projected mortality rate of 76%, while for abdominal aortic aneurysms more than 6 cm, the rate is between 1.5% and 2%.6 This underscores the significance of prompt examination and intervention in critical situations. The implementation of designated 'pathways,' such as the 2WW system, facilitates the prioritization of such instances.
Remote consultation
To mitigate transmission risk, the majority of outpatient consultations were performed via telephone or video call, accompanied by remote triage prior to the consultation. This has facilitated the continuation of most outpatient services and the priority of urgent referrals. This novel consultation strategy is expected to persist following the COVID-19 pandemic. Investigations must be conducted over the validity of video assessment examinations; hence, a certain capacity for in-person clinics remains necessary. The Royal College of Surgeons England advises against the usage of virtual consultations. • For individuals with high-risk conditions that may require a physical examination or detailed visual assessment of a specific location. When an interior examination is necessary. When the patient's mental condition is inappropriate for a virtual consultation (e.g., dementia).
• For patients who are unable of utilizing remote technology for communication and lack caregiver support to facilitate its use. • In instances when safeguarding issues arise. In such instances, clinical spaces must be equipped with effective procedures, including personal protective equipment (PPE) and symptom screening, to ensure the safety of both patients and clinicians. Infection control protocols: hand hygiene and personal protective equipment The fundamental principles of infection control have been emphasized during the COVID-19 pandemic, yet they are also pertinent to other nosocomial infections, such as methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile, and resistant enterobacteria, including vancomycin-resistant Enterococcus (VRE) and carbapenem-resistant Enterobacteriaceae (CPE). Handwashing COVID-19 can persist on surfaces for as long as 9 days.
Consequently, proper hygiene and surface disinfectants are crucial in reducing transmission. Concentrations of alcohol ranging from 60% to 95% are considered appropriate for use; however, handwashing is the preferred method when feasible. According to the WHO, efficient handwashing can prevent the transmission of COVID-19 and many infectious illnesses, including MRSA and C. difficile, by up to 50%. Seclusion Patients who test positive for, or are suspected or proven to have, COVID-19 are isolated in side rooms on the ward and during investigations or surgical operations. During surgery, specific precautions are implemented to reduce contamination of surgical equipment and personnel; post-surgery, the theatre necessitates specialized cleaning protocols. This should be considered while compiling a theatre list, with positive patients preferably deferred to the end of the list. Only essential personnel are permitted in the operating theatre for the induction of patients suspected of having COVID-19 and those with an uncertain COVID status.
Personal protective equipment (PPE) The transmission of COVID-19 via respiratory aerosols has necessitated the stringent implementation of personal protective equipment (PPE) in all clinical settings. Specialized personal protective equipment is recommended during aerosol-generating procedures, including airway intubation, laparoscopy, and specific orthopedic interventions.Training and simulation in surgery While hands-on training in theatre is irreplaceable, adjustments and redeployment during the epidemic have underscored essential complementary facets of surgical practice, such as intensive treatment unit (ITU) administration and communication with patients and their families. Furthermore, there has been an emphasis on simulation training and online education, which has demonstrated significant value in enhancing surgical training and is expected to expand in the future.
PPE types and their indications
Gloves and apron- Contact with blood or body fluids in any setting
Eye protection,mask and goggles or face shield -Risk of splashes or sprays (generally within 1m of patient)
Standard face mask Respirator mask (FFP- 3, N95) -Any clinical area dealing with respiratory fomites (e.g. COVID- 19, tuberculosis),Any surgical procedure,High- risk area or aerosol- generating procedures, e.g. operating theatre, intensive therapy unit) for respiratory formites
Full- length gown and surgical hat (-Any invasive procedure- High- risk area for respiratory fomites
Insights from the COVID-19 epidemic Coronaviruses are zoonotic pathogens that typically induce respiratory symptoms in humans. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease 2019 (COVID-19) were recognized as a global pandemic following the World Health Organization's (WHO) declaration of a public health emergency on January 20, 2020. This exceeded prior coronavirus epidemics, including SARS-CoV in 2002 and Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012. The majority of COVID-19 patients have moderate symptoms; however, more severe manifestations include pulmonary edema, severe pneumonia, acute respiratory distress syndrome (ARDS), and sepsis. At-risk populations encompass the elderly, immunocompromised individuals, and those with a body mass index (BMI) exceeding 40. The median incubation period is predicted to be 5.1 days, with additional symptomatic infections unlikely after 14 days of exposure without symptoms.
Severe complications and the magnitude of the disease exerted considerable pressure on global health systems, resulting in substantial compromises to surgical services during the initial wave. Certain surgical services indicated suboptimal outcomes in individuals who either presented with or developed COVID-19 during the perioperative period.
The gold standard for COVID-19 screening is a pharyngeal swab reverse transcriptase polymerase chain reaction (RT-PCR), with a sensitivity of 71–98% and generally requiring over 24 hours for results. Four Rapid testing utilizing lateral flow devices offers a more expedient option, generally within 30 minutes, exhibiting great sensitivity and specificity. A multitude of vaccines have been created, with the initial approval for usage in the UK in late 2020 granted to the Pfizer BioNTech mRNA vaccine and the Oxford AstraZeneca chimpanzee adenovirus-vectored vaccine.
Clinical prioritization
Owing to extensive disruption and bed shortages, all elective surgeries were suspended in the National Health Service (NHS). The Federation of Surgical Specialty Associations (FSSA) categorized cases based on new COVID-19 pandemic criteria
This categorization is beneficial for daily surgical practice, particularly amid ongoing strains on healthcare services, and may be advantageous for trainee doctors to consider. The impact of delays on mortality— the significance of targets The COVID-19 pandemic has underscored the detrimental effects of treatment delays in patients typically managed on an urgent approach. Cancer patients in the UK NHS are often anticipated to be seen within two weeks after referral, known as the '2-week wait (2WW) pathway,' with treatment commencing within two months. Other urgent situations, such as critical limb ischemia, have comparable treatment objectives.
The COVID-19 health care crisis resulted in the postponement of numerous procedures for urgent, life-threatening disorders. In several instances, private hospitals or designated 'COVID-19-free' zones were utilized to maintain surgical or oncological services. A balance existed between decreasing the risk of morbidity or mortality from COVID-19 and the danger posed by the underlying condition. It was established that elderly patients (>80 years) and individuals in high-risk categories had elevated perioperative risk and adverse outcomes when treated in regions with high COVID-19 transmission rates. COVID-19 was linked to increased in-hospital mortality (25–36%) and a heightened risk of thrombotic events, including end-organ ischemia in surgical patients.
FSSA prioritization system
Level
Priority 1a
Category
Emergency Operation Needed within 24h
Example
Ruptured abdominal aorti aneurysm (AAA), laparotom for peritonitis or trauma.
Ear, nose, and throat (ENT) bleeding or airway compromise
Open fracture with neurovascular compromise
Level
Priority 1b
Category
Urgent— operation needed within 72h
Example
Laparotomy for bowel obstruction
Level
Priority 2
Category
Within 4 weeks
Example
Cancer surgery
Level
Priority 3
Category
Within 3 months
Example
Colectomy— inflammatory bowel
disease (IBD)
Level
Priority 4
Category
Can be delayed for >3 months
Example
Elective total knee/ hip replacements
Conversely, preliminary evidence indicated that treatment delays for younger and medically healthier patients resulted in poorer outcomes. Patients with cancer (breast, colorectal, lung, and oesophageal) are estimated to experience an additional 5-year mortality of 6–15% due to delays in diagnosis and treatment caused by pandemic restrictions.Five For individuals with a big aortic aneurysm over 7.0 cm, a treatment delay of over 3 months correlates with a projected mortality rate of 76%, while for abdominal aortic aneurysms more than 6 cm, the rate is between 1.5% and 2%.6 This underscores the significance of prompt examination and intervention in critical situations. The implementation of designated 'pathways,' such as the 2WW system, facilitates the prioritization of such instances.
Remote consultation
To mitigate transmission risk, the majority of outpatient consultations were performed via telephone or video call, accompanied by remote triage prior to the consultation. This has facilitated the continuation of most outpatient services and the priority of urgent referrals. This novel consultation strategy is expected to persist following the COVID-19 pandemic. Investigations must be conducted over the validity of video assessment examinations; hence, a certain capacity for in-person clinics remains necessary. The Royal College of Surgeons England advises against the usage of virtual consultations. • For individuals with high-risk conditions that may require a physical examination or detailed visual assessment of a specific location. When an interior examination is necessary. When the patient's mental condition is inappropriate for a virtual consultation (e.g., dementia).
• For patients who are unable of utilizing remote technology for communication and lack caregiver support to facilitate its use. • In instances when safeguarding issues arise. In such instances, clinical spaces must be equipped with effective procedures, including personal protective equipment (PPE) and symptom screening, to ensure the safety of both patients and clinicians. Infection control protocols: hand hygiene and personal protective equipment The fundamental principles of infection control have been emphasized during the COVID-19 pandemic, yet they are also pertinent to other nosocomial infections, such as methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile, and resistant enterobacteria, including vancomycin-resistant Enterococcus (VRE) and carbapenem-resistant Enterobacteriaceae (CPE). Handwashing COVID-19 can persist on surfaces for as long as 9 days.
Consequently, proper hygiene and surface disinfectants are crucial in reducing transmission. Concentrations of alcohol ranging from 60% to 95% are considered appropriate for use; however, handwashing is the preferred method when feasible. According to the WHO, efficient handwashing can prevent the transmission of COVID-19 and many infectious illnesses, including MRSA and C. difficile, by up to 50%. Seclusion Patients who test positive for, or are suspected or proven to have, COVID-19 are isolated in side rooms on the ward and during investigations or surgical operations. During surgery, specific precautions are implemented to reduce contamination of surgical equipment and personnel; post-surgery, the theatre necessitates specialized cleaning protocols. This should be considered while compiling a theatre list, with positive patients preferably deferred to the end of the list. Only essential personnel are permitted in the operating theatre for the induction of patients suspected of having COVID-19 and those with an uncertain COVID status.
Personal protective equipment (PPE) The transmission of COVID-19 via respiratory aerosols has necessitated the stringent implementation of personal protective equipment (PPE) in all clinical settings. Specialized personal protective equipment is recommended during aerosol-generating procedures, including airway intubation, laparoscopy, and specific orthopedic interventions.Training and simulation in surgery While hands-on training in theatre is irreplaceable, adjustments and redeployment during the epidemic have underscored essential complementary facets of surgical practice, such as intensive treatment unit (ITU) administration and communication with patients and their families. Furthermore, there has been an emphasis on simulation training and online education, which has demonstrated significant value in enhancing surgical training and is expected to expand in the future.
PPE types and their indications
Gloves and apron- Contact with blood or body fluids in any setting
Eye protection,mask and goggles or face shield -Risk of splashes or sprays (generally within 1m of patient)
Standard face mask Respirator mask (FFP- 3, N95) -Any clinical area dealing with respiratory fomites (e.g. COVID- 19, tuberculosis),Any surgical procedure,High- risk area or aerosol- generating procedures, e.g. operating theatre, intensive therapy unit) for respiratory formites
Full- length gown and surgical hat (-Any invasive procedure- High- risk area for respiratory fomites
