132 Angiologia e Ci u gia Vascula / Publicação O icial SPACV / www.ac jou nal.com
*Au o pa a co espondência.
Co eio ele ónico: An oniomdua [email protected] (A. Dua e).
An ónio Dua e*, Ryan Melo, Alice Lopes, João Ra o, Ma a Rod igues, Mickael Hen iques, Miguel
Gomes, Vanda Pin o, Ka la Ribei o, Emanuel Sil a, Ma iana Mou inho, Ped o Ga ido, Vi iana Manuel,
Augus o Minis o, Gonçalo Sob inho, Luís Sil es e, Ped o Amo im, Ruy Fe nandes, Nuno Mei eles,
Ca los Ma ins e Luís Mendes Ped o
Se iço de Ci u gia Vascula , Depa amen o de Co ação e Vasos, Cen o Hospi ala Uni e si á io Lisboa No e (CHULN),
Lisboa, Po ugal.
Faculdade de Medicina da Uni e sidade de Lisboa, Po ugal
Cen o Académico de Medicina de Lisboa
ADAPTAÇÕES NO SERVIÇO DE CIRURGIA VASCULAR
DO CHULN DURANTE A PANDEMIA DE COVID-19 E
IMPACTO NA ATIVIDADE GLOBAL
EDITORIAL
ADAPTATIONS IN THE VASCULAR SURGERY DEPARTMENT OF THE CHULN DURING THE
COVID-19 PANDEMIC AND IMPACT ON OVERALL ACTIVITY
Pala as-cha e
COVID-19; pandemia; ci u gia ascula ; su o; SARS-CoV-2
Keywo ds
COVID-19; Pandemic; ascula su ge y; ou b eak; SARS-CoV-2
RESUMO
Com o su gi da pandemia a
SARS
-CoV-2 no início de 2020, os se iços de saúde so e am á ias adap ações de o ma a
mi iga e con ola a p og essão do su o a ní el eu opeu e nacional. Es es ajus es epe cu i am-se ine i a elmen e na
dinâmica da maio ia dos se iços hospi ala es, nomeadamen e no nosso se iço de Ci u gia Vascula . Pe an e a p e isí el
chegada de uma segunda aga na Eu opa e em Po ugal, com des echos e epe cussões imp e isí eis nos se iços de
saúde, é undamen al ap ende com as expe iências an e io es e pa ilha es a égias pa a p es a o melho cuidado aos
nossos doen es, apesa das es ições impos as pela pandemia. A a és des e a igo, analisamos as adap ações no Cen o
Hospi ala Uni e si á io Lisboa No e pa a supe a a pandemia e, em pa icula , no se iço de ci u gia ascula . A aliamos
ainda o impac o dessas mudanças na nossa a i idade global, em compa ação com a expe iência i enciada nou os cen os
nacionais e in e nacionais. Pe an e uma segunda aga iminen e, é c ucial i a lições des a pandemia po o ma a e i a
uma po encial c ise na saúde.
ABSTRACT
Wi h he onse o he SARS-CoV-2 pandemic in ea ly 2020, heal h se ices and pe sonnel adap ed hei esou ces o mi iga e
and con ol he ou b eak. These needs ine i ably led o adap a ions in mos medical and su gical depa men s, including in
ou Vascula Su ge y depa men . As we a e acing a second ou b eak o his pandemic, wi h unp edic able ou comes and
epe cussions in heal h se ices, i is c ucial o lea n om p e ious expe iences and sha e s a egies o pe o m he bes
ca e o ou pa ien s, despi e he es ic ions ha ha e been imposed. Th ough his pape , we e iew he adap a ions in
Cen o Hospi ala Uni e si á io Lisboa No e and pa icula ly in ou depa men o o e come he pandemic. We also assess
he impac o hese changes in ou ac i i y and compa e wi h he expe ience o o he ellow su geons. Wi h an upcoming
second ou b eak, i is c ucial o lea n om his and o he depa men s’ expe iences o o e come a po en ial heal h c isis.
Núme o 03 / Volume 16 / Se emb o 2020
local ou b eak and some doc o s had also a basic ICU aining.
Ou medical s a was di ided in wo sepa a e eams. Each
eam pe o med p esen ial wo k e e y wo weeks unde
all sa e y p ecau ions in o de o educe i us ansmission
ac oss ou pe sonnel. In addi ion o his eo ganiza ion, one
esiden was ealloca ed o a
COVID
-19 speci ic wa d and
one senio assis an s ayed a home, acco ding o a decision
om he Head o he Vascula Depa men . Fu he mo e, 6
membe s o ou nu se pe sonnel we e ealloca ed o o he
uni s, including
COVID
-speci ic wa ds. All 6 membe s se ed
as leade s in hei espec i e eams. Addi ionally, ou wa ds
we e con e ed in o COVID-speci ic ICU uni s and ou pa ien s
we e admi ed in he Ca diology and Ca dio ho acic Depa -
men s, leading o a dec ease in ou o al capaci y.
We also c ea ed a e e al guide o ascula eme gencies
du ing nigh shi s (
able 1
). All medical and nu se membe s
ul illed all sa e y and p o ec ion ecommenda ions. So a ,
we epo ed no posi i e
SARS
-CoV-2 case in ou depa men .
THE VASCULAR SURGERY ACTIVITY DURING
THE PANDEMIC FIRST OUTBREAK.
Acco ding o he Po uguese Medical Associa ion ecom-
menda ions o he COVID-19 pandemic, all non-eme gen
su gical ac i i y was supp essed o educed.
All he eme gen su gical ac i i y was main ained in he
cen al eme gency hea e. Howe e , as he a ailabili y
o he elec i e OR o non-eme gen cases was ma kedly
educed, we ocused on u gen cases, namely symp oma ic
ca o id s enosis, abdominal ao ic aneu ysms wi h diame e
highe han 5,5cm and ch onic limb- h ea ening ischemia
pa ien s wi h a high isk o ampu a ion.
(2)
Mo eo e , we
pe o med mo e endo ascula su ge ies wi h he collabo a-
ion o he Radiology depa men and used mo e equen ly
pe cu aneous accesses and local o loco egional anes hesia.
This s a egy was ound o be bene icial because o a lesse
isk o ae osol-gene a ing p ocedu es and c oss-in ec ion,
as well as he possibili y o mo e blood p ese a ion.(3)
This p io i iza ion s a egy was also adop ed by depa men s
in o he coun ies highly a ec ed by he pandemic and
epo ed in he li e a u e. In I aly, Pini and colleagues ocused
on eme gency and acu e su gical cases while main aining
he same s anda d o ca e and sa e y o hei pa ien s.(4)
In Tu key, Ünal and colleagues de ined a g oup o 4 le els
o p io i y o dis inguish eme gen and u gen cases om
de e able su ge ies, hence imp o ing he decision-making
p ocess in hei clinical p ac ice.(3)
In ou depa men , simila ly o o he g oups, all pa ien s,
whe he elec i e o u gen , we e es ed o SARS-CoV-2.
Pa ien s deemed o g ea e eme gency we e assumed o be
INTRODUCTION
A no el espi a o y i us ou b eak sp ead om he p o ince
o Wuhan, China in ea ly 2020.(1)
Wi h he onse o he SARS-CoV-2 pandemic, heal h se ices
and pe sonnel ocused hei e o s and esou ces on mi i-
ga ing he ou b eak and con olling he sp ead o cases. These
needs ine i ably led o adap a ions in mos medical and su gical
depa men s, including in ou Se ice o Vascula Su ge y.(2)
As we a e acing a second ou b eak o his pandemic, wi h
unp edic able ou comes and epe cussions in heal h
sys ems, i is c ucial o lea n om p e ious expe iences and
sha e s a egies o pe o m he bes ca e o ou pa ien s,
despi e he es ic ions ha ha e been imposed.
The aim o his pape is o epo he impac o he COVID-19
pandemic in he su gical se up and ac i i y o ou Vascula
Su ge y depa men .
HOW DID THE CENTRO HOSPITALAR
UNIVERSITÁRIO LISBOA NORTE (CHULN)
REACT TO THE COVID-19 PANDEMIC?
In Ma ch 2020, Po uguese heal h au ho i ies issued a se ies
o ecommenda ions o pe sonnel and esou ces’ eo ga-
niza ion. These adap a ions we e mi o ed by he CHULN
adminis a i e boa d. Fi s , all pe sonnel we e alloca ed o
con ingency g oups, should he e be a need o mo e p o es-
sionals in he on line. Fu he mo e, esiden s in aining
p og ams in o he depa men s we e called back o hei
na i e se ices. Howe e , esiden s wo king in
COVID
-19 uni s
and
ICU
acili ies con inued hei in e nships o espond o he
ou b eak. COVID-19 and COVID-19 ee ci cui s we e c ea ed o
cope wi h inpa ien admissions and he Gynecology ope a ing
oom was con e ed o su gical p ocedu es o SARS-CoV-2
posi i e pa ien s o u gen pa ien s awai ing esul . Pa ien s
we e admi ed o he sho es pe iod necessa y and immedi-
a ely discha ged i no u he ea men was needed. Visi s o
inpa ien s we e supp essed o a oid c oss-in ec ion om he
isi o s. All pa ien s solely awai ing complemen a y exams
we e also discha ged. Las ly, p esen ial ou pa ien isi s we e
educed, wi h p io i y o u gen cases and s ic ly necessa y
ac s. Physicians we e encou aged o pe o m non-p esen ial
isi s o mos pa ien s.
HOW DID OUR VASCULAR SURGERY
DEPARTMENT REACT TO THE COVID-19
PANDEMIC?
In ou depa men , he medical s a ecei ed aining in
pe sonal p o ec ion equipmen wea ing in he e en o a
A. Dua e e al.
134 Angiologia e Ci u gia Vascula / Publicação O icial SPACV / www.ac jou nal.com
Adap ações no se iço de Ci u gia Vascula do CHULN du an e a pandemia de COVID-19 e impac o na a i idade global
hospi al and con ac ing a SARS-CoV-2 in ec ion. Indeed,
Rausei and colleagues epo ed a 45% dec ease in he
numbe o eme gency su gical admissions in one o he mos
a ec ed zones by he pandemic in I aly. The au ho s ela e
hese ou comes o a ea o each he ER o a oid in ec ion,
as well as a esul o he con inemen measu es.
(5,6)
A simila
conclusion ega ding eme gency admissions was d awn in a
publica ion om a majo hospi al in Opo o.(7) Ne e heless,
con a y o hei expe ience, we did no obse e a highe
dec ease in elec i e a e ial su ge y.
Rega ding ou pa ien clinics, we pe o med less han 50% o
he a e age numbe o episodes be ween Feb ua y and June
2018 and 2019. Addi ionally, we s a ed pe o ming non-p e-
sen ial ac s. We pe o med signi ican ly mo e consul s ia
phone calls, p edominan ly o ollow-up appoin men s. This
adap a ion was a di ec consequence o he con inemen
pe iod and he ise o elemedicine clinical ac s. Simila s a -
egies we e adop ed in o he Eu opean coun ies, such as
I eland.
(8)
A case epo om an Ame ican heal h sys em
epo ed a sha p ise in elemedicine isi s close o 700%.(9)
Con a y o he au ho s’ expe ience, who pe o med ele-
medicine isi s bo h o eme gency and elec i e cases, we
main ained p esen ial isi s o u gen and p io i y cases.
Ano he g oup in Washing on also epo ed mo e han 50%
o all consul s we e pe o med wi h elemedicine ools, wi h
he gene al accep ance om hei pa ien s.(10)
F om Feb ua y o June 2020, ou wa d o al capaci y
dec eased om 32 o a minimum o 7 hospi al beds in Ap il,
o 18 in June 2020. Despi e he sho age in ou wa d capaci y,
he a e age du a ion o hospi al leng h o s ay was sho e
du ing he COVID-19 pandemic. In a le e o he edi o ,
Fa oha obse ed a simila dec ease in he leng h o s ay
o pa ien s in a bu n cen e .(11) In ou depa men , we belie e
his may be explained by a highe a e o less in asi e, endo-
ascula p ocedu es and mo e egula use o pe cu aneous
access, as well as a sho e ime om admission o su ge y.
Fu he mo e, ea ly discha ges we e mo e equen du ing
his pe iod and pa ien s needing mo e complex wound ca e
we e ans e ed o ano he acili y wi hin ou uni e si y
cen e (Hospi al Pulido Valen e). Consequen ly, we ine i-
ably admi ed mo e pa ien s wi h less se e e condi ions o
p ocedu es, and less pa ien s wi h mo e complex p ocedu es,
wi h longe leng hs o s ay. This la e popula ion emains
one o ou main challenges and conce ns o a likely second
ou b eak o his pandemic.
Despi e he dec ease in hospi al beds and in he numbe
o admissions, ou mo ali y a e did no inc ease when
compa ing wi h p e ious yea s. This may be in e p e ed as
a esul o he changes in p ac ice and he abili y o main ain
he bes ca e o ou pa ien s wi h he coope a ion o he
SARS-CoV-2 posi i e and submi ed o su ge y in a COVID-spe-
ci ic ope a ing oom.(2)
O e all, du ing he i s pandemic ou b eak, we epo ed a
ela i e inc ease in he numbe o elec i e admissions while
he numbe o eme gency episodes signi ican ly dec eased.
This educ ion may be explained by a ea o going o he
Table 1 Re e al c i e ia o Vascula Su ge y e alua ion
in he ER in Cen o Hospi ala Uni e si á io Lisboa No e
Re e al c i e ia o immedia e e alua ion by
Vascula Su ge y
Rup u ed o symp oma ic ao ic aneu ysm
Complica ed ype B ao ic dissec ion
Acu e limb ischemia
Acu e-on-ch onic limb ischemia
Vascula auma
Hemo hage ollowing ascula in asi e p ocedu es
Acu e mesen e ic ischemia
Renal ischemia
Lowe limb compa men synd ome
Phlegmasia alba/phlegmasia ce ulea dolens
Hemodyalisis AVF- ela ed complica ions (ongoing
hemo hage, sep ic shock wi h AVF in ec ion)
Re e al c i e ia o de e ed e alua ion by
Vascula Su ge y
Ch onic limb ischemia (c i ical limb ischemia only; e e
o Vascula Su ge y ou pa ien clinics Le iche-Fon aine
class II)
Foo in ec ion
Non-complica ed deep ein h ombosis
Supe icial h ombophlebi is
Supe icial h ombophlebi is
AVF: a e io enous is ula; de e ed e alua ion: du ing he 8h-20h
eme gency shi . Da a a ailable in e e al di ec i es “C i é ios pa a
e e enciação de doen es pa a obse ação di e ida na u gência cen al
do CHLN no âmbi o da especialidade de Angiologia e Ci u gia Vascula ”;
“C i é ios pa a e e enciação de doen es pa a obse ação imedia a na
u gência cen al do CHLN no âmbi o da especialidade de Angiologia e
Ci u gia Vascula ”
Núme o 03 / Volume 16 / Se emb o 2020
A. Dua e e al.
o he Se ices o he Depa men (Ca diology and Ca dio-
ho acic Su ge y). Ne e heless, we canno exclude an
inc ease in ou -o -hospi al mo ali y du ing he pandemic.
Th ough he analysis o Po uguese da a se s be ween
Ma ch and Ap il 2020, Noguei a and colleagues es ima ed
an excess mo ali y o 2400 o 4000 dea hs.(12) Acco ding o
he au ho s, his inc ease canno be ully accoun ed o he
inc ease in COVID-19 ela ed dea hs and may be ela ed o a
dec ease in heal hca e access and an inc ease in he se e i y
o non-COVID 19 condi ions. We a e deeply wo ied ha an
unknown numbe o ou pa ien s migh be unable o ge
adequa e access o he heal h sys em, ei he h ough hei
own ea o coming o he hospi al o di icul y in he p ima y
ca e access and p ope imely e e al.
CONCLUSIONS
The COVID-19 pandemic led o signi ican changes in
hospi al ca e, including in ou Vascula Su ge y depa -
men . Following pe sonnel ealloca ions and a dec ease in
hospi al beds o espond o he ou b eak, we dec eased ou
numbe o admissions and ou pa ien isi s. Despi e hese
es ic ions, we in oduced non-p esen ial clinical ac s and
ocused on eme gency and p io i y cases. This allowed us
o main ain he bes s anda d o ca e wi hou an inc ease
in ou pa ien s’ in-hospi al mo ali y a e. Wi h an upcoming
second ou b eak, i is c ucial o lea n om his and o he
depa men s’ expe iences o o e come a po en ial heal h
c isis. Fu he s udies need o assess he ue long- e m
impac o he pandemic on ch onic condi ions, namely ch onic
limb- h ea ening ischemia o ao ic aneu ysmal disease.
REFERENCES
1.
Wu D, Wu T, Liu Q, Yang Z. The SARS-CoV-2 ou b eak: Wha we
know. In e na ional Jou nal o In ec ious Diseases. 2020;94:44-
48. doi:10.1016/j.ijid.2020.03.004
2.
Gou eia e Melo R, Ped o LM. Vascula su ge y depa men adjus -
men s in he e a o he COVID-19 pandemic. Jou nal o Vascula
Su ge y. 2020;72(1):375-376. doi:10.1016/j.j s.2020.04.017
3.
Ünal EU, Ma ioğlu HL, İscan HZ. Vascula su ge y in he COVID-19
pandemic. Jou nal o Vascula Su ge y. 2020;72(2):752-754.
doi:10.1016/j.j s.2020.04.480
4. Pini R, Faggioli G, Vaci ca A, e al. Is i Possible o Sa ely Main ain a
Regula Vascula P ac ice Du ing he COVID-19 Pandemic? Eu opean
Jou nal o Vascula and Endo ascula Su ge y. Published online May
2020:S1078588420304469. doi:10.1016/j.ej s.2020.05.024
5.
Rausei S, Fe a a F, Zu leni T, e al. D ama ic dec ease o su gical
eme gencies du ing COVID-19 ou b eak. Jou nal o T auma and
Acu e Ca e Su ge y. 2020;Publish Ahead o P in . doi:10.1097/
TA.0000000000002923
6.
Man ica G, Ricca di N, Te one C, G a a ola A. Non-COVID-19 isi s o
eme gency depa men s du ing he pandemic: he impac o ea .
Public Heal h. 2020;183:40-41. doi:10.1016/j.puhe.2020.04.046
7.
Pe ei a-Ne es A, Rocha-Ne es J, Ce quei a A, Teixei a J. Manage-
men and ou comes o a ascula su ge y depa men wi h sudden
medical s a ou b eak o COVID-19. Jou nal o Vascula Su ge y.
2020;72(3):1151. doi:10.1016/j.j s.2020.05.055
8.
Connolly MJ, Ahmed Z, Aly S, e al. The impac o COVID-19 on an I ish
ascula uni ’s se ice. Jou nal o Vascula Su ge y. Published online
Augus 2020:S0741521420317699. doi:10.1016/j.j s.2020.07.082
9. Mann DM, Chen J, Chuna a R, Tes a PA, No O. COVID-19 ans o ms
heal h ca e h ough elemedicine: E idence om he ield. Jou nal
o he Ame ican Medical In o ma ics Associa ion. 2020;27(7):1132-
1135. doi:10.1093/jamia/ocaa072
10. Hemingway JF, Singh N, S a nes BW. Eme ging p ac ice pa e ns in
ascula su ge y du ing he COVID-19 pandemic. Jou nal o Vascula
Su ge y. 2020;72(2):396-402. doi:10.1016/j.j s.2020.04.492
11.
Fa oha A. Reduc ion in leng h o s ay o pa ien s admi ed o
a egional bu n cen e du ing COVID-19 pandemic. Bu ns. Publi-
shed online June 2020:S0305417920304137. doi:10.1016/j.
bu ns.2020.05.028
12. Noguei a PJ, De A aújo Nob e M, Nicola PJ, Fu ado C, Vaz Ca nei o
A. Excess Mo ali y Es ima ion Du ing he COVID-19 Pandemic:
P elimina y Da a om Po ugal. Ac a Med Po . 2020;33(6):376.
doi:10.20344/amp.13928