Mandible Fracture in a Patient with Suspected COVID-19
A 28-year-old man presents to the emergency department after an assault with a closed fist. He has a 2-cm laceration over the left mandible and malocclusion. CT scan confirms a displaced left angle fracture. He is otherwise healthy but reports a dry cough and fever for 2 days. His temperature is 38.2°C, and he has bilateral crackles on lung exam. The hospital is in a region with a high prevalence of COVID-19. The patient is scheduled for ORIF of the mandible in the morning. The anesthesia team is concerned about aerosol-generating procedures. The patient's oxygen saturation is 96% on room air.
1. What preoperative considerations are necessary, and how should the surgical plan be modified?
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Preoperative considerations: The patient has symptoms suggestive of COVID-19 (fever, cough, crackles). He should be tested for SARS-CoV-2 immediately. If positive or pending, he should be treated as a person under investigation (PUI) and managed with appropriate isolation and personal protective equipment (PPE). The anesthesia team's concern about aerosol-generating procedures is valid; intubation and extubation are high-risk. The surgical plan should be modified to minimize aerosol generation: consider performing the procedure under local anesthesia with sedation if feasible, or if general anesthesia is necessary, use a closed circuit and avoid unnecessary suctioning. The OR should be a negative-pressure room if available. Staff should wear N95 masks, eye protection, gowns, and gloves. The timing of surgery: if the patient is COVID-positive, surgery should be delayed if not urgent, but mandible fractures with malocclusion are semi-urgent; however, if the patient is stable, delaying 24-48 hours for test results and optimization may be reasonable. The fracture should be managed with antibiotics and analgesia in the interim. The surgical approach should be planned to minimize time and aerosol exposure.
2. What are the key infection control measures for the surgical team during ORIF of the mandible in a suspected COVID-19 patient?
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Key infection control measures include: 1) Use of appropriate PPE: N95 or higher respirator, eye protection (goggles or face shield), gown, and gloves. Consider powered air-purifying respirator (PAPR) for high-risk aerosol-generating procedures. 2) Perform the procedure in a negative-pressure operating room if available. 3) Limit the number of personnel in the room to essential staff only. 4) Avoid aerosol-generating procedures such as high-speed drilling without suction; use a smoke evacuator. 5) Intubation and extubation should be performed by the most experienced provider to minimize attempts, and consider video laryngoscopy to reduce proximity. 6) Use a closed suction system. 7) After surgery, allow adequate air exchange before cleaning. 8) Staff should be trained in donning and doffing PPE. 9) The patient should wear a mask during transport and when possible. 10) Postoperative care should include monitoring for COVID-19 symptoms among staff.