COVID-19 for Pediatric Surgeons

Introduction

"The most amazing thing that has come out of this is the can do attitude that everyone has among teams who have never worked together. As pediatric surgeons we a have a unique perspective and ability to fill this critical need." Meghan Arnold (Mott Children’s Hospital, Ann Arbor)

This is a rapidly changing environment and we will do our best to keep this page regularly updated. Thanks to Loren Berman, Christopher Newton, the American Pediatric Surgical Association’s Quality and Safety and Professional Development committees for contributing to this page.

Not wanting to be redundant with other information sources and in order to keep up with the latest information, please see the Helpful Resources module below.

If you have resources you think will be helpful to other pediatric surgeons please share them with us at NaT@eapsa.org.

Please visit the latest APSA Quality and Safety committee data sharing spreadsheet so you can contribute and update your institution’s practice. The original spreadsheet id now real only. See the April 20 summary video.

ExPERT subcribers may get continuing medical education credit by taking the COVID-19 for Pediatric Surgeons test.

COVID-19 visual abstract 4-20-20

MIS-C

from the Practicing Surgeons Curriculum (Minna Wieck)

Important Resources

Government informational links

CDC COVID-19 web page

CDC Interim Guidance for Healthcare Facilities: Preparing for Community Transmission of COVID-19 in the United States web page

CDC Strategies for Optimizing PPE

Department of Health and Human Services web page

OSHA Guidance on Preparing Workplaces for COVID-19

Organizational links

American College of Surgeons COVID-19 and Surgery web page

ACS Early Report from New York

Society for Critical Care Critical Care for the Non-ICU Clinician web page

AAP Red Book Online COVID-19 resources

AAP COVID-19 Initial Characterization in Children

SAGES Telehealth Primer in Response to the COVID-19 Pandemic

SAGES Basics of Mechanical Ventilation for Non Critical Care MDs

Institutional links

Johns Hopkins All Children’s Hospital COVID-19 Information for Patients and Families

Stanford COVID-19 Adult Quick Clinical Guide

Primer for pediatric surgeons ICU care of the COVID+ patient (submitted by Samir Gadepalli and Meghan Arnold, Mott Children’s Hospital)

Video conferences

On August 14, 2020 Christopher Newton moderates a discussion about the continuing/second surge. Martha-Conley Ingram (Lurie Children’s Hospital), KuoJen Tsao, Hanmin Lee and Robert Letton discuss the current state, testing and scheduling issues, institutional decision-making and expected permanent changes to their practice.

• view the video (44 minutes)

On April 29, 2020 Christopher Newton (Pediatric Surgical Associates, Oakland) moderates a discussion on prioritizing case scheduling during and after the pandemic surge. updates a report from the Quality committee data sharing spreadsheet and Grace Mak and Mark Slidell (Comer Children’s Hospital) discuss their modification of the pMeNTS (Pediatric Medically-Necessary Time Sensitive) worksheet.

• view the video (45 minutes)

On April 20, 2020 Loren Berman discusses the current state of pediatric surgery based on a real time interpretation of the Quality committee data sharing spreadsheet

which includes data from 41 institutions. Huge thanks to Martha-Conley Ingram (Lurie Children’s Hospital)

• view the video (14 minutes)
• view the PowerPoint APSA COVID response 4-20-20

On April 10, 2020 Loren Berman (Nemours - A.I. DuPont Hospital for Children) moderates a discussion of tips and techniques for pediatric surgeons asked to provide critical care for COVID-19 adults. Huge thanks to Marjorie Arca (Strong Memorial Hospital, Rochester), Megan Arnold (Mott Children’s Hospital, Ann Arbor) and Samir Gadepalli (Mott Children’s Hospital, Ann Arbor) for sharing their experiences and wisdom. Here is the link to the adult critical care for pediatric surgeon primer presentation.

"Wow, these are not kids." Samir Gadepalli (Mott Children’s Hospital, Ann Arbor)

• view the complete video (70 minutes)
  • status update and staffing models (14 minutes)
    • Expanding and opening additional adult intensive care units including in children’s hospitals to offload sixk patients
    • Surgeons involved in both procedures (lines) and management
    • Intubation is a high risk aerosolizing procedure
    • Important team mechanics with adult and pediatric critical care and hospitalists
  • role of extracorporeal life support (seven minutes)
    • Thrombotic complications and anticoagulation even before ECLS
    • Poor prognosis
  • limiting exposure with critical care management (17 minutes)
    • Be thoughtful about going into the room and bundle procedures, limit radiographs
    • Although theoretically aerosolizing, now using more high flow nasal candidate to avoid intubation
    • "PPP" High positive end-expiratory pressure, prone positioning, paralysis
    • Left internal jugular venous access
    • Nasogastric feeding early (but lots of calories from propofol)
    • Avoid benzodiazapines
    • Anticoagulation
    • High rate of acute kidney injury
  • fluid management, vasopressors (10 minutes)
    • minimal parenteral fluid
    • aggressive diuresis if overloaded at presentation
    • norepinephrine as initial vasopressor
    • continuously febrile
    • don’t check central venous pressor
    • family communication is difficult with required isolation
  • inflammatory markers (two minutes)
    • antibiotics and infectious disease
  • when to check your pediatric surgery knowledge at the door and closing suggestions (12 minutes)
    • ventilator strategies unique to each patient
    • vascular access different
    • assistance from adult medicine providers
    • exhausting and stressful for everyone
    • pediatric surgeons are used to unique challenging situations

On April 3, 2020 Loren Berman (Nemours - A.I. DuPont Hospital for Children) moderates a follow-up discussion. Huge thanks to Marilyn Butler (Oregon Health and Sciences University), David Mooney (Children’s Hospital of Boston), Mauricio Escobar (Mary Bridge Children’s Hospital), Art Cooper (Columbia University Harlem Hospital Center) and Dan Ostlie (Phoenix Children’s Hospital) for sharing their experiences and wisdom.

• view the complete video (30 minutes)
  • current status (seven minutes)
    • Minimal pediatric COVID-19 case burden except for Harlem
    • Resource preservation is key
    • Pediatric units and surgeons used for adult care
  • flexing resources for the adult surge (16 minutes)
    • Systems and regions collaborating but different policies and procedures
  • institution specific policies and testing (seven minutes)
    • Access to tests is still an issue with reagent issues and long turn around times
    • Most treating emergencies as positive without test result
    • PAPRs are difficult to operate with
    • Aerosolizing procedures (intubation, endoscopy) have special risks

On March 26, 2020 Christopher Newton (Pediatric Surgical Associates, Oakland) moderates a discussion of the COVID-19 effect on pediatric surgeons. Huge thanks to Steven Stylianos (Morgan Stanley Children’s Hospital, New York), Adam Goldin (Seattle Children’s Hospital), Michael Dingeldein (Rainbow Babies and Children’s Hospital, Cleveland) and Samir Gadepalli (Mott Children’s Hospital, Ann Arbor) for sharing their experiences and wisdom.

• view the complete video (44 minutes)
  • resource allocation and sharing, credentialing (10 minutes)
    • Resource sharing and available volunteer provider databases are great.
    • Hassles with credentialing are not.
    • Hospitals are transferring pediatric nonCOVID patients to the children’s hospital to make bed space for sick adults.
    • Children’s hospitals are raising age limits.
    • Personal protective equipment continues to be a huge issue.
  • changes to resident training (five minutes)
    • All education has gone virtual.
    • Rounding teams are much smaller and many faculty and trainees are asked to stay home unless absolutely needed.
    • Research residents are being pulled into clinical roles.
    • Medical students are not performing clinical duties.
  • changes to clinical practice (12 minutes)
    • Decreasing exposure is the key.
    • Elective cases and clinic visits are cancelled.
    • Appendicitis management is controversial depending on the scarcity of inpatient beds (outpatient surgery) versus PPE (nonoperative management).
    • Intubation protocols limit exposure.
    • As time allows all preoperative patients are getting COVID-19 testing.
    • Laparoscopy (filters should be used) and endoscopy include additional risk.
    • Limiting extracorporeal life support to those with single organ system failure.
  • personal wellness (six minutes)
    • Stressful environment but this is our job.
    • Family is important but precautions need to be taken to avoid exposure at home.
    • Sharing experiences with peers is therapeutic.

COVID-19 Toolkit

The following policies, procedures and protocols are currently being used in their local institutions. They may not be appropriate for all environments and resource deprived situations.

PPE triage protocol

Appendicitis treatment (nonoperative management) in persons under investigation for COVID-19 explanation memo; nonoperative management protocol (submitted by Children’s Hospital of Colorado)

COVID-19 trauma intubation protocol (submitted by Mark Slidell Comer Children’s Hospital, Chicago)

COVID-19 screening for operating room patients and operating room personal protective equipment strategies (submitted by Adam Goldin, Seattle Children’s Hospital)

Care of COVID-19 patients in and around the operating room procedures (submitted by Derek Wakeman University of Rochester Medical Center)

COVID-19 Guidelines for ECMO cannulation and personnel positioning diagram (submitted by Steven Stylianos, Morgan Stanley Children’s Hospital)

COVID-19 patient laparoscopy presentation and endoscopy manuscript (submitted by Steven Stylianos, Morgan Stanley Children’s Hospital)

Intensive care unit restaffing models (submitted by Steven Stylianos, Morgan Stanley Children’s Hospital)

Restructuring attending physician schedule (submitted by Adam Goldin, Seattle Children’s Hospital)

Protocol to decrease transmission risk when arriving home.

Surgeon Wellness

Toolkit for Emotional Coping for Healthcare Staff from the International Society for Traumatic Stress Studies

From the World Health Organization

Mental health and COVID-19

Coping with stress during COVID-19

Helping children cope with stress during COVID-19

Meditation apps

Wellness resources from Headspace (free but national provider identifier number and email address required)

Calm

Aura

From the Harvard Business Review

That Discomfort You’re Feeling is Grief

Coping with Fatigue, Fear, and Panic During a Crisis

The Contagion We Can Control

Anxiety is Contagious. Here’s How to Contain It

Coronavirus: Leading and working through a pandemic

Case Scheduling Guidelines

APSA supports the guidance distributed by the American College of Surgeons regarding the scheduling of emergent, urgent and elective cases.

Specifically related to pediatric surgery the following case guidelines were included as examples.

Guiding principles

• There is no substitute for sound surgical judgement.
• The goal is to provide timely surgical care to children with emergent and urgent pediatric surgical issues while optimizing patient care resources (e.g. hospital and intensive care unit beds, personal protective equipment, ventilators) and preserving the health of caregivers.
• Surgery should be performed only if delaying the procedure is likely to prolong hospital stay, increase the likelihood of later hospital admission or cause harm to the patient.
• Children who have failed attempts at medical management of a surgical condition should be considered for surgery to decrease the future use of resources (e.g. recurrent infections in a branchial cleft cyst following course of antibiotics).
• Multidisciplinary shared decisions regarding surgical scheduling should be made in the context of available institutional resources that will be variable and rapidly evolving.
• Telemedicine and teleconsult services should be used for patient and physician interaction when available.

Case list examples (The list contains examples and is not meant to be comprehensive.)

Pediatric Modification of the Medically Necessary, Time-Sensitive Scoring System for Operating Room Procedure Prioritization During the COVID-19 Pandemic [1].

Articles of Interest

Fetal Diagnosis and Therapy during the COVID-19 Pandemic: Guidance on Behalf of the International Fetal Medicine and Surgery Society [2].

COVID-19 Research in Brief: 4 April to 10 April, 2020, Nature Medicine

Considerations in performing endoscopy during the COVID-19 pandemic [3].

Overview of guidance for endoscopy during the coronavirus disease 2019 (COVID-19) pandemic [4].

Clinical and CT features in pediatric patients with COVID-19 infection: Different points from adults [5].

Features, Evaluation and Treatment Coronavirus (COVID-19). Cascella et al. StatPearls 2020

Understanding the "Scope" of the Problem: Why Laparoscopy is Considered Safe During the COVID-19 Pandemic [6].

Precautions for Operating Room Team Members during the COVID-19 Pandemic [7].

Medically-Necessary, Time-Sensitive Procedures: A Scoring System to Ethically and Efficiently Manage Resource Scarcity and Provider Risk During the COVID-19 Pandemic [8].

Care of the critically ill and injured during pandemics and disasters - CHEST consensus statements

Business and continuity of operations [9].

Engagement and education [10].

Ethical Considerations [11].

Legal Preparedness [12].

The COVID-19 crisis and its implications for pediatric surgeons [13].

Initial ELSO Guidance Document: ECMO for COVID-19 Patients with Severe Cardiopulmonary Failure [14].

Characterization of initial North American pediatric surgical response to the COVID-19 pandemic [15].

Development of pediatric surgical decision-making guidelines for COVID-19 in a New York City children’s hospital [16].

SARS-CoV-2 Clinical Syndromes and Predictors of Disease Severity in Hospitalized Children and Youth [17].

Helpful Links

COVID-19 resources from GICS (the Global Initiative for Children’s Surgery)

N95 mask substitute video (submitted by Boston Children’s Hospital Surgical Innovation program)

CDC PAPR donning video

Michigan Critical Care Coordination Network web page

Frontline Physician COVID-19 Guide

COVID-19 for Providers app

Society of Surgical Oncology statement on cancer surgery

Western Regional Alliance for Pediatric Emergency Management COVID-19 web page

Hendren Project resources for pediatric surgeins and urologists

Hendren Project podcast with Italian pediatric surgeons

Behind the Knife podcast COVID-19 Essentials for Surgeons

For those sheltering at home with children, the AAP offers a Parenting and COVID-19 video

CovidSurg global surgical research platform

Providence Anesthesiology Associates COVID-19 Resources

Filtering of gas during laparoscopy

Using one ventilator for multiple patients video

VPS COVID-19 PICU statistics

Marriott Community Caregiver rate for first responders and medical staff

Letter or script to families regarding postponing procedures a and clinic appointments. This is script being used when contacting families by phone and the letter being sent to families that we cannot reach by phone. In general, the surgeons are calling families to postpone/reschedule elective operations, while our assistants and APP’s are calling to reschedule clinic visits. (submitted by Derek Wakeman University of Rochester Medical Center)

University of Minnesota Wellness with COVID-19 web page

References

Media

ICU staffing models

PPE triage