Ebola Surgery Guideline Sherry M Wren MD, FACS, FCS (ECSA) Professor of Surgery and Director of Global Surgery CIGH Stanford University Director of Clinical Surgery Palo Alto Veterans Health Care System

Why discuss Ebola and surgery?  There will be suspected or early cases that develop a surgical problem.  West Africa experience shows symptom overlap between early Ebola and other surgical disease.  Surgery is part of basic health care.  Ethically not right to deny potential survivors care.  Other organizations (CDC or WHO) not addressed surgical needs.  Only preparation, training, and information will diffuse EBOLA-Hysteria.

Ebola facts relevant to surgeons  Blood and fluids transmit infectious diseases.  EVD viral load very high in severe cases, boldily fluids teeming with virus.  Severely ill have massive amounts of diarrhea/day, liters/day  No data on amount needed to transmit infection.

Surgery, who and when  NO Elective procedures if suspected/ confirmed EVD.  Emergent/Urgent Procedures: Persons Under Investigation, Probable Cases, and early Confirmed Cases.  Severe EVD patients would not likely survive due to the severity of their disease.  Weigh risks and benefits of proposed intervention and risk of exposure to the OR team  Operative approach (open or MIS) selection should minimize fluid exposure.  Consider non-operative management with antibiotics for certain conditions when appropriate (appendicitis, diverticulitis, sealed perf DU, etc)

OR preparation  Surgeons must take leadership role  Pre-planning to ensure all proper PPE available in OR  Designate experienced OR team members (No trainees)  Practice through simulation Don/Doff PPE  Have cognitive aids/checklist ready for PPE procedures  Designate an OR room for procedures, must have waste management prepared for contaminated trash/waste disposal  Surgical checklist pre-incision to cover EVD status and sharps safety.

Supplies  AAMI 4 gowns, drapes, integrated togas  Leg covers with full plastic film  N95 Masks, integrated air supplied helmet, or Powered Purified Air Purifier (PAPR)  Surgical hood  Long face shield if N95 used without helmet system  Double gloves: Outer layer long length (GYN) style glove

 Barrier level measures resistance to fluid and/or pathogen exposure.  Level 3 gowns/drapes: resist liquid penetration in splash, spray, or direct contact with fluids.  Level 4 resists liquid and viral penetration (under time/pressure tests) using a bacteriophage test system.  Gowns are constructed with “critical zones” having most protection,  Size gowns/togas appropriately

GOALS: 1.NO EXPOSED MUCOUS MEMBRANES OR SKIN 2.AEROSOL PROTECTION

Hood: head + neck cover N95 PAPR Long glove Standard glove Impervious Leg Covers

Long Shield Short Shield Potential skin exposure Integrated Purified Air Helmet and Level 4 Toga Gown

Technical considerations  Minimize sharps  Use instruments, not fingers, to touch needles/ tissue.  Verbal announcement when passing sharps  No hand-to-hand passage of sharps  Agree to use a basin or neutral zone  Use cautery not scalpels for incisions.  No #11 blades  Use MIS surgery when possible.  Desufflate pressure prior to trocar removal  No needles or sharps on the Mayo stand  No recapping of needles  Use blunt tip needles  Don’t rest on Mayo stand

Post procedure  Maintain sharps safety  Doff PPE using trained observer/?buddy system and CDC guidelines.  Have a designated doffing area  Wash hands in alcohol based hand rub (ABHR)  Waste management critical issue: must also prepare with supplies, training, and follow CDC guidelines

Colorado ’08: operation on a patient with Marburg hemorrhagic fever  44 y/o female returns after 2 weeks in Uganda on safari.  Day 3 HA, chills, N/V, diarrhea, self medicated with cipro  Day 4-5 outpatient tx w/ antiemetics and labs  Day 6 diarrhea, abdominal pain, fatigue, weakness  Day 7 Admitted to hospital, critically ill  Eventual OR: cholecystectomy  Subsequent dx of Marburg viral infection  No transmission to OR or hospital team

Keep it in perspective…..  Ebola is a serious challenge but through preparation, training, and knowledge we can successfully treat/support patients.  With modern medical care case fatality rates should be much less than the 70% seen in West Africa.  Surgical decision making will need to be done case by case through risk benefit analysis of the patients medical condition and need for surgical intervention.