COVID-19 for Pediatric Surgeons
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 informattion, 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 consider visiting the APSA Quality and Safety committee data sharing spreadsheet so you can contribute your institution’s practice.
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
Department of Health and Human Services web page
American College of Surgeons COVID-19 and Surgery web page
Society for Critical Care Critical Care for the Non-ICU Clinician web page
Stanford COVID-19 Adult Quick Clinical Guide
Primer for pediatric surgeons ICU care of the COVID+ patient (submitted by Samir Gadepalli and Meghan Arbold, Mott Children’s Hospital)
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.
- resource allocation and sharing, credentialing (10 minutes)
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
- current status (seven minutes)
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
COVID-19 trauma intubation protocol (submitted by Mark Slidell Comer Children’s Hospital, Chicago)
Intensive care unit restaffing models (submitted by Steven Stylianos, Morgan Stanley Children’s Hospital)
Protocol to decrease transmission risk when arriving home.
From the World Health Organization
Wellness resources from Headspace (free but national provider identifier number and email address required)
From the Harvard Business Review
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.
- 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.)
Articles of Interest
COVID-19 Research in Brief: 28 March to 3 April, 2020, Nature Medicine
Considerations in performing endoscopy during the COVID-19 pandemic .
Overview of guidance for endoscopy during the coronavirus disease 2019 (COVID-19) pandemic .
Clinical and CT features in pediatric patients with COVID-19 infection: Different points from adults .
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 .
Precautions for Operating Room Team Members during the COVID-19 Pandemic .
Care of the critically ill and injured during pandemics and disasters - CHEST consensus statements
Business and continuity of operations .
Engagement and education .
Ethical Considerations .
Legal Preparedness .
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
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
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
- Soetikno R, Teoh AY, Kaltenbach T, et al. Considerations in performing endoscopy during the COVID-19 pandemic. Gastrointest Endosc. 2020. [PMID:32229131]
- Lui RN, Wong SH, Sánchez-Luna SA, et al. Overview of guidance for endoscopy during the coronavirus disease 2019 (COVID-19) pandemic. J Gastroenterol Hepatol. 2020. [PMID:32233034]
- Xia W, Shao J, Guo Y, et al. Clinical and CT features in pediatric patients with COVID-19 infection: Different points from adults. Pediatr Pulmonol. 2020. [PMID:32134205]
- Morris SN, Fader AN, Milad MP, et al. Understanding the "Scope" of the Problem: Why Laparoscopy is Considered Safe During the COVID-19 Pandemic. J Minim Invasive Gynecol. 2020. [PMID:32247882]
- Forrester JD, Nassar AK, Maggio PM, et al. Precautions for Operating Room Team Members during the COVID-19 Pandemic. J Am Coll Surg. 2020. [PMID:32247836]
- Tosh PK, Feldman H, Christian MD, et al. Business and continuity of operations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4 Suppl):e103S-17S. [PMID:25144857]
- Devereaux AV, Tosh PK, Hick JL, et al. Engagement and education: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4 Suppl):e118S-33S. [PMID:25144161]
- Biddison LD, Berkowitz KA, Courtney B, et al. Ethical considerations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4 Suppl):e145S-55S. [PMID:25144262]
- Courtney B, Hodge JG, Toner ES, et al. Legal preparedness: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4 Suppl):e134S-44S. [PMID:25144203]