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Pain Distraction During Awake Low Anterior Resection and Cuddle Delivery Initiative for Inpatient: Frugal Procedural Options to Support Surgery in the COVID-19 Era

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Pain Distraction During Awake Low Anterior Resection and Cuddle Delivery Initiative for Inpatient: Frugal Procedural Options to Support Surgery in the COVID-19 Era European Review for Medical and Pharmacological Sciences 2021; 25: 3116-3121 Pain distraction during awake low anterior resection and Cuddle Delivery initiative for inpatient: frugal procedural options to support surgery in the COVID-19 era A. ROMANZI1, M. GABAGLIO2, M. MILANESI1, A. PUTORTÌ1, F. ROSSI1, R. SCOLARO1, B. VIGNATI3, A. ZACCARELLI2, M. ZANARDO1, A. VANNELLI1 1Department of General Surgery, Valduce Hospital, Como, Italy 2Department of Anesthesiology and Critical Care, Valduce Hospital, Como, Italy 3Department of Clinical and Biomedical Sciences “Luigi Sacco”, University of Milan, Milano, Italy Abstract. – OBJECTIVE: Since minimally in- Introduction vasive surgery and general anesthesia are both aerosol-generating procedures, their use be- During coronavirus disease 2019 (COVID-19) came controversial during the outbreak of coro- pandemic the demand for critical care beds navirus disease 2019 (COVID-19). Moreover, so- cial distancing resulted in serious psychological among the medical services has rapidly exceed- consequences for inpatients. This case report ed its supply and this put almost all healthcare investigates pain distraction during awake lapa- systems to the test. Elective surgery has been rotomy, as well as new possibilities for emotion- drastically limited. After lockdown, innovative al postoperative support to inpatients. COVID-19 preoperative triage protocols allowed PATIENTS AND METHODS: A 72-year-old to gradually reopen and ramp-up elective surger- man affected by middle rectal adenocarcinoma underwent lower anterior resection plus total ies. Nevertheless, ICUs remained far from being mesorectal excision under combined spinal-epi- COVID-free for a long time and this restricted dural anesthesia. A 3D mobile theatre (3DMT) the surgical strategies. was intraoperatively used for pain distraction. Major abdominal surgeries are generally car- A postoperative “Cuddle delivery” service was ried out with minimally invasive surgery (MIS) instituted: video-messages from relatives and under general anesthesia (GA). Since MIS and close friends were delivered daily to the patient through the 3DMT. Emotional correlations were GA are both aerosol-generating medical proce- investigated through a clinical interview by the dures (AGMP), their use became controversial psychologist of our Hospital. during pandemic1,2. RESULTS: Intraoperative, as well as postop- Besides the risk of contamination inside the erative pain, resulted well-controlled: visual operating theatres, frail patients may be affected analogue scale (VAS) ≤3. Conversion to gener- by GA which can be associated with delayed al anesthesia and postoperative intensive sup- recovery after anesthesia and can lead to the port/monitoring were unnecessary. The “Cud- 3 dle delivery” initiative positively fed our pa- admission of the patient to the ICU . At a time of tient’s mood and attitude, strengthening his scarce resources, this was prohibitive. bond to life. In such a peculiar context, performing open CONCLUSIONS: During pandemic, awake lap- abdominal surgery under loco-regional anesthe- arotomy under loco-regional anesthesia may be sia (LA) helped us to deliver acute care surgery a crucial option in delivering acute care surgery to selected patients when intensive care beds to selected patients in the COVID-19 era. During are unavailable. Our procedure introduces po- LA (spinal, epidural or combined spinal-epidur- tential ways to optimize this approach. al), anesthetic agents are administered by lumbar injection in the spinal and/or epidural space. This Key Words: approach reduces exposure to patients’ respirato- Awake surgery, Pain distraction, Loco-regional an- ry secretions, the risk of perioperative viral trans- aesthesia, Neuraxial anestesia, Surgical oncology, COVID -19. mission and preserves patients’ cardiorespiratory function. On the other hand, analgesia represents 3116 Corresponding Author: Andrea Romanzi, MD; e-mail: [email protected] Pain distraction during awake laparotomy a relevant issue during awake surgery. Of course, The use of a catheter-through-needle set allowed patients are continuously monitored, but anxiety, to insert a polyamide catheter in the epidural fear, discomfort and pain sometimes become space. The catheter was then connected to an intolerable and require sedation or conversion to elastomeric pump filled with a solution of sterile GA. water (192 ml), Ropivacaine (200 mg) and Mor- In the recent past, the use of different electron- phine sulphate (6 mg), on the basis of patient’s ic devices for pain distraction during ambulatory age, height and constitution. Infusion speed was surgery or minimally invasive procedures has set on 4 ml/hour. been described4-7. We then wondered if pain dis- Low anterior resection (LAR) plus total me- traction through the use of a 3D mobile theatre sorectal excision (TME), followed by colorectal (3DMT) may have the same role also during ma- transanal end-to-end anastomosis, without tem- jor abdominal surgeries. porary diverting ileostomy, were performed. Op- Lastly, since containment measures and social erating time was of 140 minutes. distancing have been imposed, these resulted Vital signs, intraoperative pain intensity, er- in serious consequences for our inpatients: the gonomic comfort/discomfort level, sense of pres- impossibility to be visited by their loved ones ence and distress were continuously monitored. (sometimes for more than one week), visibly Only light sedation was performed (Midazolam increased the sense of solitude, discouragement, 5 mg). No other drugs were administered to the depression of almost all our inpatients, especially patient during surgery. Intraoperative pain, as- the elderly. This negatively influenced postoper- sessed through visual analogue scale (VAS), re- ative course. We hypothesized that instituting a sulted well-controlled (VAS ≤ 3) and conversion “Cuddle Delivery” service through which rela- to GA was unnecessary. tives and friends could send video-messages to Postoperative pain was daily assessed through the inpatients would have contributed to fill the VAS resulting always well-controlled (VAS ≤ 3). emotional gap related to the strict containment Postoperative intensive monitoring/support was measures inside the Hospital. unnecessary. A distinct COVID-free ward had The aim of this study is to investigate pain dis- been set up for postoperative recovery to keep traction as a potential option to enrich the awake COVID-negative patients separated from all oth- approach for major abdominal surgeries, and to er patients. Epidural elastomeric pump was re- report a functional countermeasure to social dis- moved on postoperative day (POD) 3. The patient tancing in support of inpatients. was discharged free of complications on POD 4. Histological staging was ypT3N1c (Tumor Re- Case Report gression Score after radiotherapy: 3)8. A 72-year-old man affected by middle rectal adenocarcinoma, waiting for post-neoadjuvant 3D Mobile Theatre abdominal surgery, was admitted to our Depart- During surgery patients wore Royole’s Moon ment in October 2020. (RM) (Royole®, Shenzhen, China). RM is an Both surgical procedure and anaesthesiologic all-in-one 3DMT headset. It uses two AMOLED approach were explained to the patient one week displays that deliver 3D or 2D content in Full in advance, on the day of pre-admission tests. On HD 1080p resolution. The displays deliver 3000 that occasion, the patient underwent nasopharyn- pixels per inch (PPI) and a blistering fast image geal swab for COVID-19 diagnosis (resulted neg- response rate of 0.01 ms. The display angle is 10° ative) and the 3DMT was illustrated to the patient below horizontal. Optics are independent so that who became familiar with the device, wore it and they can be adjusted from -7.0 D to +2.0 D. An expressed his approval for its use during surgery immersion mask is mounted on the device for under full informed consent. enclosed eye fitting. Active noise cancellation is incorporated. The right ear pad incorporates Awake Laparotomy flexible sensor technology to navigate the menu Surgery was performed under combined spi- and to adjust volume by swiping or tapping a nal-epidural (CSE) anaesthesia. The site of lum- finger on it. bar puncture was the L2-L3 interspace. A bolus The internal flash storage allowed storing sev- of Hyperbaric Bupivacaine 5 mg/ml (12 mg) and eral 4K ultra-HD videos. Some videos offered Morphine Sulfate 10 mg/ml (150 mcg) solution an aerial ambient nature experience (Fiji Islands, has been injected into the subarachnoid space. Hawaii, Havasupai Falls trail, Redwood National 3117 A. Romanzi, M. Gabaglio, M. Milanesi, A. Putortì, F. Rossi, et al. Park), other videos simulated a walk through good evaluation, or presence of the sensation in a specific scenario (Manhattan, Rome, Vatican question). Marks were interpreted oppositely on Museums). The length of each video was one the basis of the nature of the aspect in question: hour. marks from 1 to 4 were considered indicators of After positioning on the operating table, the a negative impression if related to positive as- patient’s right arm was left free so that the patient pects (on the opposite, they represented a positive was able to self-adjust the device in case of dis- impression in case of negative aspects). Marks placement. The patient wore the 3DMT two times from 5 to 6 were considered indicators of neutral during surgery. The first time started before sur- impression. Marks from 7 to 10 were considered gical incision, for 57 minutes.
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