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Case Report - Ahead of Print

http://www.dx.doi.org/10.5935/2177-1235.2020RBCP0045

ABSTRACT

Introdução: A pandemia decorrente da Covid-19 modificou de forma significativa a rotina e o trabalho das especialidades médicas. Relatamos o caso de um paciente tratado pela cirurgia plástica que contraiu o vírus Sars- CoV-2.
Relato de caso: Homem de 66 anos, com ferida complexa em tornozelo, foi tratado com desbridamento cirúrgico e terapia por pressão negativa, sendo posteriormente submetido à cobertura cutânea da ferida com enxerto de pele parcial. No pós-operatório imediato, iniciou quadro de tosse seca, sendo que nesse mesmo dia havia sido confirmado um exame positivo do novo coronavírus em outro paciente que estava no mesmo quarto. Diante disso, solicitamos testagem com PCR que também resultou positiva para presença de Sars-CoV-2. O paciente evoluiu bem, com alta hospitalar no 5º dia de pós-operatório, após a retirada do curativo de Brown, e com retorno após o período de isolamento preconizado (14 dias).
Discussão: O manejo de pacientes que necessitam de procedimentos cirúrgicos em meio a uma pandemia viral deve considerar a adoção de medidas preventivas que reduzam a possibilidade de transmissão do vírus. Como exemplo, citamos a redução do tempo de internação hospitalar, o uso de terapias que aceleram o processo terapêutico, o isolamento do paciente em casos confirmados e o uso de equipamentos de proteção individual.
Conclusão: Apesar da infecção deste paciente pelo Sars-CoV-2, enfatizamos que a equipe de cirurgia plástica deve atuar de maneira precoce durante o processo de tratamento. Tais ações reduzem a possibilidade de disseminação do novo coronavírus para outros pacientes e para equipe de saúde.

Keywords: SARS Virus; Surgery, Plastic; Coronavirus; Wounds and injuries; Debridement.

RESUMO

Introdução: A pandemia decorrente da Covid-19 modificou de forma significativa a rotina e o trabalho das especialidades médicas. Relatamos o caso de um paciente tratado pela cirurgia plástica que contraiu o vírus Sars- CoV-2.
Relato de caso: Homem de 66 anos, com ferida complexa em tornozelo, foi tratado com desbridamento cirúrgico e terapia por pressão negativa, sendo posteriormente submetido à cobertura cutânea da ferida com enxerto de pele parcial. No pós-operatório imediato, iniciou quadro de tosse seca, sendo que nesse mesmo dia havia sido confirmado um exame positivo do novo coronavírus em outro paciente que estava no mesmo quarto. Diante disso, solicitamos testagem com PCR que também resultou positiva para presença de Sars-CoV-2. O paciente evoluiu bem, com alta hospitalar no 5º dia de pós-operatório, após a retirada do curativo de Brown, e com retorno após o período de isolamento preconizado (14 dias).
Discussão: O manejo de pacientes que necessitam de procedimentos cirúrgicos em meio a uma pandemia viral deve considerar a adoção de medidas preventivas que reduzam a possibilidade de transmissão do vírus. Como exemplo, citamos a redução do tempo de internação hospitalar, o uso de terapias que aceleram o processo terapêutico, o isolamento do paciente em casos confirmados e o uso de equipamentos de proteção individual.
Conclusão: Apesar da infecção deste paciente pelo Sars-CoV-2, enfatizamos que a equipe de cirurgia plástica deve atuar de maneira precoce durante o processo de tratamento. Tais ações reduzem a possibilidade de disseminação do novo coronavírus para outros pacientes e para equipe de saúde.

Palavras-chave: Vírus da SARS; Cirurgia plástica; Coronavírus; Ferimentos e lesões; Desbridamento.


INTRODUCTION

The pandemic resulting from the new respiratory syndrome called Covid-19 has significantly changed the routine and work of all medical specialties around the world1-4. Among them, Plastic Surgery was also affected, so that the Brazilian health authorities recommended the postponement of elective surgeries, maintaining the treatment of urgent or emergency cases, such as burns, complex wounds, skin tumors, among others. Even with this restriction, it is clear that all the patients treated are exposed to contracting the new Sars-CoV-2 coronavirus in the health unit, either in the hospital or on an outpatient basis5-8.

In this article, we report the case of a patient treated by the Plastic Surgery team at Hospital das Clínicas, Ribeirão Preto Medical School, University of São Paulo (HCFMRP-USP), who contracted the Sars-CoV-2 virus during hospitalization, discussing the outcome and consequences of this new experience.

CASE REPORT

It was a 66-year-old man from Orlândia-SP, admitted by the Vascular Surgery team at HCFMRP-USP on 03/25/2020 due to a complex wound in the left posterior ankle, of arterial etiology, with three months of evolution (Figure 1A). As comorbidities, he had type 2 diabetes mellitus and smoking (40 pack-years). On physical examination, he had a femoral pulse present and distal pulses absent on the left, despite good perfusion. During arteriography, obstruction of the left tibiofibular trunk was diagnosed, and treatment with posterior femorotibial bypass was indicated and performed on 03/30/2020. The next day, the Plastic Surgery team was called in to help with wound management. Right after discussing the case, on the same day, we performed surgical debridement (Figure 1B) followed by negative pressure therapy (NPT) to speed up the preparation of the wound bed (Figure 1C).

Figure 1 - A: Wound on the posterior left ankle. B: Wound bed after surgical debridement. C: Preparation of the wound bed with negative pressure therapy. D: 5 days postoperative skin grafting to cover the wound with satisfactory graft integration and epidermolysis areas.

The patient progressed well, requiring only one TPN exchange. On 04/06/2020, the skin was covered with a partial skin graft, with a donor area of ​​the left thigh, and a Brown dressing. Due to the absence of confirmed cases of Sars-Cov2 in the vascular surgery ward, until then, the care of the health team was restricted to face mask and procedure gloves. In the immediate postoperative period, the patient started a dry cough. On the same day, it was confirmed the diagnosis of Sars-CoV-2 virus in another patient who was in the same room as the patient in question. Therefore, we carry out the notification of a suspected case, proceed with the isolation of the patient in a specific bed, and the adoption of individual protection measures, with the use of “face shield,” surgical gown, use of goggles, in addition to the face mask. At the same time, we requested a chest X-ray, Sars-CoV-2 testing, and a complete blood count.

On 4/8/2020, the RT-PCR test was positive for the presence of Sars-CoV-2, the chest radiograph showed bilateral veiling in the base, and the blood count showed no changes. The patient evolved well, without fever and other respiratory complaints. On the 5th postoperative day, we removed the Brown dressing and verified functional integration of the skin graft, despite the presence of areas of epidermolysis (Figure 1D). The patient was discharged from the hospital on the same day with instructions for daily home dressing at home by the patient’s family members (after guidance by our team regarding the use of protection) and return after the recommended isolation period (14 days).

DISCUSSION

The management of patients who need surgical procedures during a viral pandemic must consider the adoption of preventive measures that reduce the possibility of transmission of the virus7-8. As an example, we quote:

    minimize the length of hospital stay;

    use of therapies that accelerate the therapeutic process;

    isolation of the patient on confirmed cases;

    use of personal protective equipment (patient and health team).

In this report, we highlight that the Plastic Surgery team sought to act early in all phases of the process, reducing the patient’s exposure due to the hospitalization itself, and reducing the possibility of transmission after the diagnosis. As soon as it was requested, we performed the service on the same day and started treatment with surgical debridement and TPN. We opted for the use of TPN to speed up the preparation of the wound bed until the definitive surgery (skin grafting)9-10. Furthermore, it was possible to discharge the patient on the same day as the dressing was removed, and the skin graft integration was verified.

Due to the possibility of infection with the new coronavirus in the hospital environment, we should follow the guidelines of the authorities and only perform urgent or emergency surgeries during the Covid-19 pandemic.

CONCLUSION

Despite the infection of this patient by Sars-CoV-2, we emphasize that the Plastic Surgery team must act early during the treatment process. We opted to use technology to speed up the preparation of the wound bed (TPN), isolate the patient after diagnostic confirmation, perform individual protection care, and shorten the hospital stay with the use of TPN, grafting, and early discharge. As a consequence, we believe that such actions have reduced the possibility of spreading the new coronavirus to other patients and the health team.

COLLABORATIONS

HOCG

Analysis and/or data interpretation, Conception and design study, Data Curation, Final manuscript approval, Writing - Original Draft Preparation, Writing - Review & Editing

PSC

Analysis and/or data interpretation, Conceptualization, Final manuscript approval, Supervision, Writing - Original Draft Preparation, Writing - Review & Editing

VGS

Analysis and/or data interpretation, Data Curation, Final manuscript approval

DHH

Analysis and/or data interpretation, Data Curation, Final manuscript approval

GMAS

Analysis and/or data interpretation, Data Curation, Final manuscript approval

JAFJ

Analysis and/or data interpretation, Conception and design study, Final manuscript approval, Project Administration, Supervision, Writing - Review & Editing

REFERENCES

1. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020 Feb;323(11):1061-9. DOI: https://doi.org/10.1001/jama.2020.1585

2. Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan: big data analytics, new technology, and proactive testing. JAMA. 2020 Mar;323(14):1341-2. DOI: https://doi.org/10.1001/jama.2020.3151

3. Jones DS. History in a crisis - lessons for Covid-19. N Engl J Med. 2020 Mar 12; [Epub ahead of print]. DOI: https://doi.org/10.1056/NEJMp2004361

4. Rosenbaum L. Facing Covid-19 in Italy - ethics, logistics, and therapeutics on the epidemic’s front line. N Engl J Med. 2020 Mar 18; [Epub ahead of print]. DOI: https://doi.org/10.1056/NEJMp2005492

5. Dexter F, Parra MC, Brown JR, Loftus RW. Perioperative COVID-19 defense: an evidence-based approach for optimization of infection control and operating room management. Anesth Analg. 2020 Mar 26; [Epub ahead of print]. DOI: https://doi.org/10.1213/ANE.0000000000004829

6. Rogers LC, Lavery LA, Joseph WS, Armstrong DG. All feet on deck-the role of podiatry during the COVID-19 pandemic: preventing hospitalizations in an overburdened healthcare system, reducing amputation and death in people with diabetes. J Am Podiatr Med Assoc. 2020 Mar 25; [Epub ahead of print]. DOI: https://doi.org/10.7547/20-051

7. Yeo D, Yeo C, Kaushal S, Tan G. COVID-19 & the General Surgical Department - measures to reduce spread of SARS-COV-2 among surgeons. Ann Surg. 2020 Apr 13; [Epub ahead of print]. DOI: https://doi.org/10.1097/SLA.0000000000003957

8. COVIDSurg Collaborative. Global guidance for surgical care during the COVID-19 pandemic. Br J Surg. 2020 Apr 15; [Epub ahead of print]. DOI: https://doi.org/10.1002/bjs.11646

9. Coltro PS, Ferreira MC, Batista BP, Nakamoto HA, Milcheski DA, Tuma Júnior P. Role of plastic surgery on the treatment complex wounds. Rev Col Bras Cir. 2011 Nov/Dec;38(6):381-6.

10. Lima RVKS, Coltro PS, Farina Júnior JA. Negative pressure therapy for the treatment of complex wounds. Rev Col Bras Cir. 2017 Jan/Feb;44(1):81-93. DOI: https://doi.org/10.1590/0100-69912017001001











1. Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brazil.

Institution: Divisão de Cirurgia Plástica - Faculdade de Medicina de Ribeirão Preto da USP, Ribeirão Preto, SP, Brazil.

Corresponding author: Pedro Soler Coltro, Av. Bandeirantes 3900, Câmpus Universitário, Monte Alegre, Ribeirão Preto, SP, Brazil. Zip Code: 14048-900. E-mail: psc@usp.br

Article received: April 21, 2020.
Article accepted: June 04, 2020.

Conflicts of interest: none.

 

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