McAlister: Surgeons working to solve riddle of dealing with Ebola

Editor’s note: The following editorial, ‘Surgery in patients with Ebola virus disease,’ originally appeared in the Canadian Journal of Surgery (Issue 57, pages 264-5) and is reprinted here with permission of the author and publisher. It has been edited for space. To read the full editorial, click on this story at westernu.ca.

Thirty years ago, surgical trainees like me were asked to undertake diagnostic lymph node excisional biop­sies in patients with AIDS. Our teachers believed the procedures to be futile and risky. We thought we were invincible. We arranged the set-up so we could oper­ate alone in double masks, gowns and gloves. The purpose of the inner layer was to permit safer removal of the outer barrier. Similarly, we double-bagged laundry and waste.

Yet again, we are faced with a fluid-borne virus whose potential to harm is unknown.

MCALISTER

MCALISTER

A large experience is making clear the steps that should be taken to fight Ebola virus disease in West Africa. We have only a tiny experience upon which to base care of patients with Ebola in developed countries, such as Canada. Initial hopes that life-supporting procedures, such as mechanical ventilation and hemodialysis, would permit recovery from the advanced stages of Ebola are now less certain.

Our faith in conventional barrier protocols has been shaken.

In this article, I try to address the role of surgery in the care of patients with Ebola.

Protocols for the initial care of patients with suspected or confirmed Ebola have been developed and practiced by Canadian hospitals with the help of the provinces and the Public Health Agency of Canada.

Surgeons are commonly asked to con­sult on other critically ill patients with similar problems. Therefore, we have to face the dilemma of considering surgery in patients with Ebola. Information in this area is rapidly accumulating, and clinical care teams will make their own valid decisions on a case-by-case basis.

The American College of Surgeons has adapted the Centers for Disease Control and Prevention guidelines for the conduct of surgery in patients with suspected Ebola. Surgeons should consult these guidelines frequently because new information is to be expected. The guidelines are currently silent on who should receive surgery.

When considering any invasive procedure or operation in a patient with Ebola, the caregiving team needs to undertake a documented utility-risk analysis, which includes not only the perspective of the patient, but also the 360-degree environment. Other modalities of care and the possibility of procedure postponement must be considered, for now, preferable options.

The well-accepted preference for methods of rehydration should rigidly favour oral over enteral tube and peripheral over central venous routes of administration. Blood work will have to be minimized and possibly restricted to point-of-care testing. The use of imaging in patients with Ebola will also be considerably restricted in comparison to patients without the disease. It will be very difficult to justify the use of arterial lines. Automated noninvasive blood pressure and oxygen satura­tion monitoring will reduce direct patient contact.

The biggest dilemma for surgeons will be trying to deter­mine futility in a disease with which we have almost no direct experience.

The development of organ failure renders the prognosis bleak for patients in health-care systems with limited resources, such as those in areas where the outbreaks have occurred. In the developed world, the prognosis is grave with the onset of organ failure.

Liver failure and necrosis have been observed with Ebola; failure of supportive measures renders the prog­nosis hopeless, and neither transplantation nor liver assist devices should be considered. Surgery for peritonitis, gastro­intestinal hemorrhage, intestinal perforation or intestinal ischemia is likely to fail. Ebola virus disease may result in anasarca with abdominal compartment syndrome for which mechanical ventilation, complete muscle relaxation and dialysis is preferable to laparotomy. Cardiopulmonary resus­citation is not appropriate for end-stage Ebola.

Unfortu­nately, experience in Africa has shown that pregnant women with Ebola appear to be at an increased risk for spontaneous abortion and pregnancy-associated hemorrhage. Neonates born to mothers with Ebola have not survived.

Conventional barrier protocols are being strengthened to combat the transmission of Ebola virus. Elements of military protocols for chemical, biological, radiological and nuclear defense may be useful. Gowns should include a hood and boot covers in a one-piece suit. Buddy checks and assistance will reduce failures during the donning and doffing of personal protective equipment. Decontamination with wipes before removal of barriers prevents inadvertent spread.

In Africa, reusable gowns with final showers using diluted bleach are preferred by the heroic teams working to contain the outbreak. Sterile surgical gowns and gloves may have to be added to Ebola barrier suits, which are not sterile.

Unlike in the early days of AIDS, trainees and young sur­geons with children should not be asked to operate on patients with Ebola. This is a task for experienced surgeons using the smallest possible team in the room. Surgeons asked to consult on patients with Ebola should not hesitate to seek advice from surgeons in experienced centres.

Fol­lowing the initial fear regarding AIDS, we quickly came to understand and treat HIV. Like many surgeons, I went on to perform the full range of operations, including liver trans­plantation, on patients infected with HIV. There are good reasons to hope that Ebola will likewise be attenuated so that the full range of modern critical care and surgical procedures become possible in patients infected with the virus.

Vivian McAlister is co-editor of the Canadian Journal of Surgery. He is the Angus D. McLachlin Professor of Surgery at Western, and is a regular force member of the Royal Canadian Medical Service, Canadian Armed Forces (rank Lieutenant Colonel).