Experiences of practicing surgical neuro oncology during the COVID 19 pandemic
Venue: Journal of Neuro Oncology
Year: 2020

Since the beginning of 2020, the novel coronavirus disease known as COVID 19 emerged to become an unprecedented global pandemic. By April 5, 2020, the confirmed cases have exceeded 1 million and 57, 206 deaths have been reported globally. The latest study from China indicated that cancer patients were at higher risk of COVID 19 infection and had poorer outcomes than the general population  Patients with tumors of the central nervous system face multiple challenges, not just due to their immunocompromised state, which makes them more susceptible to infection, but also due to the need for extreme caution when performing treatments including surgery. We are also faced with significantly altered hospital systems, as well as shortage of medical supplies. Here, we share our current experience in the surgical management of patients with CNS tumors during the COVID 19 pandemic. Our first strategy is triage. Patients with CNS tumor were classified at initial visit according to their diagnoses and clinical status. Patients who required routine follow up were encouraged to take advantage of virtual healthcare options using online medical platforms. For the patients with tumors that are more likely benign or low grade gliomas, and if they are asymptomatic, elective surgery would be postponed until a safer time. Meanwhile, for patients with malignant tumors such as higher grade gliomas or benign tumor with severe symptoms, surgical intervention should be scheduled in a timely manner, since delay in surgery could reduce the chance of treatment success. For emergency cases, such as patients with acute hydrocephalus or cerebral herniation, surgery must be arranged immediately. In these cases, the results of COVID 19 testing may not be available prior to surgery, and thus the surgery should be performed under strict precautions to minimize possible exposure to the novel coronavirus. Hierarchical protection is another important tactic in our current practice. We now adopt three levels of protection to avoid occupational exposure to novel coronavirus during surgery. Based on current Chinese guidelines for aerosol transmissible diseases, precautions for health care professionals are currently categorized into 3 levels, with level 1 being the lowest level of precaution, and level 3 being the highest. Level 1 precautions requires the use of a surgical cap, surgical face mask, protective gown and gloves. Level 3 precaution requires surgical cap, N95 face mask, goggles, face shield, full face piece respirator, protective gown, gloves. All patients admitted for surgery must undergo "COVID19 screening" including contact tracing, symptoms interrogation, novel coronavirus nucleic acid and antibody test, and chest CT scan. Specific precautions will then depend on the results of pre procedural screening. A variety of personal protective equipment (PPE) are advised to choose for each level  To be specific, patients who are confirmed COVID 19 negative could be operated under level 1 precautions as in low risk areas. For patients who are suspected of having COVID 19 but who require emergency surgery, or patients from a high risk area, the tertiary health care facility must be equipped to perform the surgery. Patients who are COVID 19 positive should be transferred to the designated hospitals for accepting COVID 19 positive patients, with the exception of emergency cases, in which case the operation should be carried out under level 3 precautions  Besides appropriate PPE, a negative pressure operating room and corresponding intensive care unit (ICU) support are indispensable in the management of these patients. Zhong ping Chen chenzhp@sysucc.org.cn