Perioperative management of covid 19 positive surgical patients – a modern and ayurvedic aspect .

Epidemics or outbreak is a sudden spread of the disease within a short time to a large number of people in a given population. The World Health Organization (WHO) named this pathogenic virus for 2019nCoV. [1,2] surgical patients are particularly at risk of infection and negative outcome. To guarantee adequate care to these patients, while minimizing the risk for infection, the early postponing of elective surgery, the creation of COVID-free facilities and the identification of COVIDdedicated operating theaters and teams should be proposed. Meanwhile, because the operating room is a busy environment, it further increases the risk of nosocomial infections of the perioperative team. Ayurveda is an ancient system of medicine, clearly mentioned about such diseases causing epidemic under a broad term 'Janapadodhwamsa’. To assess the concepts of epidemiology in Ayurveda and to compare the same with recent COVID-19 pandemic. When COVID-19 pandemic compares with Janapadodhwamsa, it shows similarity in concepts like aetiology, modes of transmission, principles of prevention of outbreaks etc. Also, control measures of COVID-19 can be compared with Hetuviparit and Vyadhi-viparitchikitsa. The concepts described in Ayurveda regarding Janapadodhwamsa are more or like the present modern concept of the pandemic/epidemic. The coronavirus disease 2019 (COVID-19) pandemic has raised several issues regarding the management of surgical patients. The aim of the current study was to clarify the management of surgical patients during the pandemic. Therefore, development of safe medical practices and infection prevention protocols for the perioperative management of patients with COVID-19 is important. AYURLOG National Journal of Research in Ayurved Science (A peer-reviewed open access Indexed e-journal of Ayurved Since 2013) http://www.ayurlog.com Nov2020 | Volume 08th | Issue: 6th ISSN: 2320-7329


ABSTRACT-
Epidemics or outbreak is a sudden spread of the disease within a short time to a large number of people in a given population. The World Health Organization (WHO) named this pathogenic virus for 2019-nCoV. [1,2] surgical patients are particularly at risk of infection and negative outcome. To guarantee adequate care to these patients, while minimizing the risk for infection, the early postponing of elective surgery, the creation of COVID-free facilities and the identification of COVID-dedicated operating theaters and teams should be proposed. Meanwhile, because the operating room is a busy environment, it further increases the risk of nosocomial infections of the perioperative team. Ayurveda is an ancient system of medicine, clearly mentioned about such diseases causing epidemic under a broad term 'Janapadodhwamsa'.
To assess the concepts of epidemiology in Ayurveda and to compare the same with recent COVID-19 pandemic. When COVID-19 pandemic compares with Janapadodhwamsa, it shows similarity in concepts like aetiology, modes of transmission, principles of prevention of outbreaks etc. Also, control measures of COVID-19 can be compared with Hetuviparit and Vyadhi-viparitchikitsa. The concepts described in Ayurveda regarding Janapadodhwamsa are more or like the present modern concept of the pandemic/epidemic. The coronavirus disease 2019 (COVID-19) pandemic has raised several issues regarding the management of surgical patients. The aim of the current study was to clarify the management of surgical patients during the pandemic. Therefore, development of safe medical practices and infection prevention protocols for the perioperative management of patients with COVID-19 is important.

INTRODUCTION-
The Coronavirus disease 2019  pandemic is an infection caused by SARS-CoV-2. The pandemic poses many challenges to the healthcare system particularly in infection control and disease treatment.

Clinical management of surgical patients:
The outbreak of the COVID-19 pandemic has raised several issues in the management of surgical patients. It is widely recognized that the goal of surgical care during any pandemic should be to guarantee essential care and minimizing the risk of spread and conserving valuable resources. These strategies and recommendations cover the entire field of surgical care, from preoperative management of positive and suspected cases, to organization of the operating theaters and postoperative patient care.

Preadmission and admission considerations in COVID-19 pandemic
All patients who are eligible for operative intervention need to be categorized into three groups based on the possibility of having a 2019-nCoV infection (i.e. noninfected people, asymptomatic carriers and symptomatic patients). Preadmission history regarding patient's general condition, presence of active or recent respiratory or gastrointestinal symptoms, anosmia, history of recent travel to an endemic country in the last 14 days or history of contact with a person at risk to have the 2019-nCoV infection should be evaluated properly.
It is recommended that all surgery patients must complete preoperative health screening despite being asymptomatic. [7] Regardless of patient status of infection; it is recommended that all elective surgeries to be postponed knowing the fact that hospitals are rapidly becoming hot zones for treatment and transmission of this disease [8], [9] All suspected patients or symptomatic patients need to be evaluated carefully to confirm the diagnosis of COVID-19 disease. If the diagnosis is confirmed, the patient should be quarantined and reported to the national authorities. On the other hand, patients who are non-suspected or proved to be disease-free should be admitted into single rooms to prevent hospitalized patients from incubating in 2019-nCoV infection or asymptomatic 2019-nCoV infection, and prevent the possibility of cross-infection with people in contact. [8]

Patient Preparation for Emergency Surgeries
In cases of emergent and life-threatening conditions where PCR is not available, all patients should be presumed diseased and approached similarly to infected patients. [10] All preoperative, intraoperative and postoperative measures should be taken into consideration until the diagnosis is confirmed or the patient is discharged.

Perioperative measures in COVID-19 patients Preoperative considerations
All medical staff should be performing their clinical tasks wearing gloves, hats, and disposable surgical masks correctly. Whenever a suspected patient or a COVID-19 diseased patient is encountered, extra precautions should be taken to keep protection at a high level. If this the case, all providers should utilize personal protective equipment (PPE) including fit-tested disposable N95 respirator, goggles, face shield, gowns, double-layered gloves, and protective footwear to achieve maximum droplet/contact isolation precautions. [ As Medical staff has extensive contact with patients and their families as well as other health care providers, they are very likely to cause cross-infection. Because of that, the daily assessment of personnel health status and recording body temperature should be implemented. Any medical staff with an increase in his body temperature should be isolated and investigated for the possibility of acquiring the disease. [8] Properly protected anesthetists need to oxygenate patients with 100% O2 for 3-5 min then to perform rapid sequence induction and intubation to avoid manual ventilation and decrease the possibility of aerosolization of virus from airways. 30 Once PPE is removed proper handwashing before touching the surrounding environment. It is recommended to use a high-quality HMEF (Heat and Moisture Exchange Filter) between the facemask and breathing circuit. It is estimated that HMEF can remove 99.97% of airborne particles equal to or greater than 0.3 microns. [12], [13] Anesthetic equipment must be used by one person only as well as the anesthesia machine is strictly disinfected according to requirements after use. [13]

Intraoperative considerations
If a patient is having COVID-19 disease or even highly suspected, the operation should be performed in a designated negative pressure environment [9] ; it is essential to keep pressure difference between the operating room below -4.7 Pa. [4] Medical staff should be reduced as much as possible as well as their temperature needs to be measured before starting the surgery.
Surgeons and adjunct medical staff should be aware of blood and body secretions at the time of surgery, all equipment should be kept clean of these secretions. [7] AGPs include and not limited to intubation, extubation, chest tube insertion, bronchoscopy, bag masking, gastrointestinal endoscopy, laparoscopy and the use of energy devices (e.g. electrocautery). When using electrocautery or other energy devices in surgery, adjust to the lowest effective power possible to reduce the amount of surgical smoke, and use a smoking evacuator. [8],[7] The choice between laparoscopy and laparotomy as a surgical approach needs to be cautious. As the use of laparoscopy was proved to have advantages, patients with good cardiopulmonary function and general condition can be considered for laparoscopic surgery.
Careful attention during pneumoperitoneum creation and strict aerosol management must be made even during the operation. [7], [8] In response to artificial pneumoperitoneum, there will be a reduction in lung volume, increased airway pressure, increase CO2 retention, and decreased lung compliance. Therefore, the risk of perioperative infection 2019-nCoV is considered high. To minimize the impact of pneumoperitoneum on lung function, circulation and susceptibility for pathogen infection, both intraoperative pneumoperitoneum pressure, and CO2 ventilation should be at the lowest possible. Surgical smoke and pneumoperitoneum should be evacuated only using a direct suction connected to a vacuum suction unit. [7] Postoperative considerations Postoperatively, specimens should be labeled as 2019-nCoV and handled as infectious specimens for treatment with the pathology department. Disease-free patients can be transferred to the regular surgical ward for their postoperative management. Daily assessment of body temperature as well as respiratory symptoms is mandatory. [8] Any patient with new-onset fever or cough should be isolated and investigated thoroughly to rule out 2019-nCoV infection. [14] Suspected or confirmed patients should be isolated in a single room with a negative pressure, sufficient oxygen supply and nebulization should be considered.
Postoperative rounds, medications and wound management should be performed under personal protection to avoid contact with secretions. In case of suspected COVID-19, all medical staff should be isolated and quarantined for observation until the patient is cleared.
If the diagnosis of COVID-19 is confirmed or was previously identified, the medical staff involved in the surgery need to be isolated for 14 days after the surgery. [8]

Endoscopy: General recommendations
Endoscopy is generally considered a highrisk procedure because of the potential contact with pulmonary and gastric secretions. Therefore, its use during the COVID-19 pandemic should be limited to the management of endoscopic emergencies (ie, gastrointestinal bleeding, acute cholangitis, biliary pancreatitis, foreign body retrieval), as well as some suspected or confirmed cancer cases after accurate caseby-case evaluation. The same principles that have been adopted for surgical interventions should be applied when performing highrisk endoscopic procedures, including bronchoscopy, upper gastrointestinal procedures and any procedure performed in suspected or confirmed patients.
In such cases, an adequate space with specific areas for donning and doffing of PPE should be identified, and adequate personal protections should be used (including N95 respirators or equivalent and water-resistant gowns). Adequate sedation should also be carried out to minimize patient retching and aerosolizing of nasopharyngeal secretions.

Janopadodhwansa-
Ayurveda is an ancient system of medicine, clearly mentioned about such diseases causing epidemic under a broad term 'Janapadodhwamsa'. The principles were described in piecemeal when compiled, analysed and interpreted the same as a modern theory of Epidemiology. Many of today's medical sciences coincide with some of the basic principles of Ayurveda. The ancient Ayurvedic treatise Charaka Samhita explained these epidemic/Pandemic diseases as Janapadodhwamsa. [15] The main etiological factors responsible for any epidemic or pandemic diseases are the contamination of Jala (water), Vayu (air), Desha (land) and Kala (season) giving rise to infectious diseases which kills mass of people.
According to Sushruta, one of the causative factors for fever is Agantu Karana or Para Hetu (Jivanu). Dalhana explains this Para Hetu as Bhutabhishanga. Jivanu [16] (Micro organisms) which develop in the atmosphere due to Adharma [17] (improper behaviour of people of the world) as well as Mitya Ahara-Vihara with special reference to Sleshmaja Krimi. [18] As per Ayurveda Prajnaparadha is also one of the causes of all miseries as it leads to malfunctioning of Buddhi and aggravates Tridoshas. [19] Sushruta has described the mode of spread of infectious disease as Oupasargika or Sankramika Roga (Communicable disease). The Agantu Hetu / Para Hetu vitiates all the three Doshas and thereby severely affects Pranavaha Srotas and Rasavaha Srotas leading to the depletion of Ojas resulting in the death of the patient. [20] Nidhana-Samprapti: Aetio-Pathogenisis Sankramika or Oupasargika Roga Susrutha has described the mode of spread of infectious disease as Oupasargika or Sankramika Roga. [21] Most of the infections are spread from one person to other by

Adharma-
Ahita/Virudha Ahara/Prajnaparadha Prajnaparadha is loss of restraining oneself from Dhee (true knowledge), Dhruti (controlling power which restrains one from harmful activities), Smruti (ability to recognise basic nature of substances/ recollect matters). [22] All the Tridosas are aggravated by the affliction of evil spirits or germs. This disease is born from all the three Doshas with Kapha and Vata being the predominant ones. It can be specially classified as Abhishangaja Jwara and more particularly as Bhutabhishangaja due to the microscopic germs caused due to contact with certain toxins. [23] Jwara is accompanied with symptoms of great increase of Sleshma, sometimes appearing as epidemic. [24] Jivanu is carried through the air, spreads quickly throughout the community from person to person through respiration and enters into the respiratory track and produces fever, sometimes the entry may be through the mouth also.

Lakshana
Shlesmaka Jwara-Main symptoms are running nose, headache, malaise, pain in chest, cough, great loss of strength, dyspnoea. If alimentary tract is invaded there will be vomiting, diarrhoea or both. [25] Pratisyaya is flow of more watery fluid from the nose in some persons only and not in all. Great loss of body strength within five or six days these two are special symptoms; weakness happens in all the muscles including the heart muscle. Because of weakness of the heart sometimes even death also takes place.
In Pranavaha srotas the organs involved are mainly Swasapatha (trachea) and two Phuppusa (Lungs). Abnormalities in these organs are Vranasotha, Kaphapurnata and rarely Raktasthivana. Kapha-Vaata Jwara-Main Symptoms are fever dyspnoea, cough, choking type of throat afflictions, sore throat and pain in the cardiac region and sides of the chest. [26] The Superhuman Causes of Disease Sometimes even without any derangement in the seasons, the population gets extinct by Adharma. Further, in the places where Vayu (air) is contaminated, people suffer from cough, dyspnoea, common cold, head ache and fever. [27]

Nature / Clinical features of Epidemics
As said earlier that etiological factors are common to the population under a particular community, the disease produced due to these factors also has a similar set of symptoms.These factors are different according to habitat, seasons, type of sinful acts etc. therefore, the particular disease is not mentioned in Ayurveda as a Janapadodhwamsavyadhi. According to Acharya Sushruta, all these modes of transmission causes genesis of certain infectious diseases which show the presentation of skin diseases (Kushta), Fever (Jwara), Pulmonary Tuberculosis (Shosha), Conjunctivitis (Netrabhishyanda) etc. Common clinical symptoms include fever (not all), cough, sore throat, headache, exhaustion, anxiety, myalgia, and breathlessness. Conjunctivitis has also been described. Thus, the clinical feature of COVID-19 can be compared with Jwara, Shosha & netrabhishyanda. [28] Also, as per Sushrut Samhita, -expired air or inhalation of a droplet from an infected person (Nishvasat), -eating in the same plate with others (sahabhojanat), -sharing beds (Sahashayyasanat), using clothes, -garlands & utensils used by an infected person (vastramalyanulepanat) can be considered as the mode of transmission of COVID-19 pandemics. [29] In contrast, the control & treatment for the recent COVID-19 pandemic can be found as hetuviparitchikitsa & Vyadhiviparitchikitsa in the ancient Ayurveda. [30,[31]]

Control & treatment of Epidemics
The treatment of epidemic aims at both preventive & curative measures. Preventive measures help to minimise the occurrence of emerging disease &limit the hazardous effects of causative factors while corrective actions help to treat the condition properly.
For the management of epidemics, specific preventive measures are described in Ayurveda are as follows 1. Collection of potent medicinal drugs before the outbreak of an epidemic.

3.
Rejuvenation therapy (RasayanaChikitsa) to enhance the immunity and strength of the body. 4. Truthfulness, compassion for living being, charity, generosity, worshipping god, tranquillity, Codes of conduct, protection of the self by mantras & auspicious rituals help to prevent the disease. 5. Search for the things which are suitable for the person, residence in auspicious localities, discussion of religious scriptures.
6. Avoid pollution of air, water, food or environment.
Ayurveda also described control of epidemics by using treatment opposite of etiological factors (HetuviparitChikitsa) and treatment opposite of disease (Vyadhiviparita Chikitsa).

Purification of Air (Vayu)
Purification of air is done by fumigation (Dhoopan). Fumigation is used to disinfect the clothes, bedsheets, surrounding atmosphere etc. It acts as a disinfectant and helps to prevent infectious diseases.

Purification of Water (Jala)
Use of water contaminated with urine, stool, insects, leaves, decomposed material, ova/eggs, etc., having bad taste & smell is strictly prohibited in Ayurveda. Before using such water, it gets purified first. Highly contaminated water is used after boiling. If it is slightly contaminated then, it is purified by quenching hot iron rod or by exposure to sun rays.

Rasayan (Rejuvenation) and Shodhan (detoxification) treatment
Rasayana Chikitsa (Rejuvenation therapy) according to Ayurveda nourishes, develops &corrects the vitiated body elements. It is used to improve immunity & build the strength of the body.
While detoxificationof the body is done by Panchakarma treatment. It helps to remove toxic and infectious substances from the body without causing any side effects.

CONCLUSIONS
In the era of COVID-19 pandemic, all health care providers must implement standardized essential perioperative measures including the use of PPEs to control disease transmission, and avoid unwanted complications. In life saving procedures, all patients need to be managed as COVID-19 patients until results are confirmed. Elective procedures are recommended to be postponed and to consider only urgent, lifesaving procedures and oncologic surgeries that are associated with worse outcome if delayed. The use of laparoscopy is still considered valid option talking in consideration extra precaution during creation of pneumoperitoneum, cardiopulmonary physiology and gas deflation.
The concepts described in Ayurveda and contemporary era are more likely corresponding to each other, and we cannot neglect their significance. Modes of transmission of infectious disease-causing epidemic described by Acharya Sushruta are very much relevant to as described in modern science. When compared with the recent pandemic of COVID-19, we found that vitiated air (Vayu),habitat (Desha) and seasons (Kala), affliction by attacks of germs (rakshsas) are considered as etiological factors for COVID -19 pandemics. Also, as per Sushrut Samhita, expired air or inhalation of a droplet from an infected person (Nishvasat), eating in the same plate with others (sahabhojanat), sharing beds (Sahashayyasanat), using clothes, garlands & utensils used by an infected person (vastramalyanulepanat) can be considered as the mode of transmission of COVID-19 pandemics.
In contrast, the control & treatment for the recent COVID-19 pandemic can be found as hetuviparitchikitsa & Vyadhiviparitchikitsa in the ancient Ayurveda. Thus, we can conclude that indepth analysis of the concepts of Ayurveda can provide light over aetiology, mode of transmission, control, preventive & treatment of many pandemics, epidemic & outbreak modern medical sciences in the present era. Also, scholars from ancient Ayurveda medicine had medicinal knowledge far ahead of their time which is still comparable with many relevant concepts of modern medicinal sciences.