Study Design and Participants
This retrospective study included a single-center consecutive cohort of emergency aSAH inpatients from Beijing Tiantan Hospital (Beijing, China) between January 20, 2020 and March 25, 2020. The inclusion criteria were as follows: (1) Patients’ preoperative CTA or digital subtraction angiography (DSA) indicated that the responsible lesion for SAH was cerebral aneurysms. (2) Patients undergoing emergency craniotomy clipping for the responsible aneurysms. (3) The duration between emergency admission and craniotomy was less than 72 hours. Written informed consent for collecting clinical information was obtained from each patient at admission. This study was performed according to the guidelines of the Declaration of Helsinki and was approved by the Institutional Review Board at Beijing Tiantan Hospital.
Finally, a total of 42 aSAH patients were enrolled in this study. In order to assess whether the BTP increased the risk of preoperative hospitalized adverse events and poor postoperative prognosis, we collected the baseline characteristics and prognostic data of emergency aSAH patients during the retrospective period last year (18 cases).
Data Collection and Definition
Epidemiological, demographic, clinical, laboratory, treatment, and outcome data were extracted from electronic medical records using a standardized data collection form. Fever was defined as axillary temperature of at least 37.3°C (5). Positive epidemiological history, laboratory test and imaging findings were defined according to the Chinese management guideline for COVID-19 (version 5.0) (6). Fisher scale, modified Fisher scale, Hunt-Hess scale, World Federation of Neurological Surgeons (WFNS) scale, Glasgow Coma Scale (GCS) was used to evaluate the categories of severity (7-10). DCI was defined as new cerebral infarction identified on CT or magnetic resonance imaging (MRI) or proven at autopsy after excluding procedure-related infarction, or a new focal neurologic deficit and a persistent clinical deterioration after excluding other potential causes (11, 12). The mRS score was obtained when discharge. All data were checked by two physicians (YC and XLC) and a third researcher (LM) adjudicated any difference in interpretation between the two primary reviewers.
Beijing Tiantan Protocol
After the patient came to the emergency department, the emergency physicians prescribed CT/CTA and clinical presentations to confirm the diagnosis of aSAH. Emergency physicians protect themselves according to the second-level protection standards: work clothing, shoe covers, disposable working caps, N95 masks (replace every 4 hours or when it is wet or at any time if there is pollution), goggles, protective clothing or isolation clothes, latex gloves (6, 13). Preliminary screening for COVID-19 in the emergency department included epidemiological history, admission axillary temperature, routine blood test, and lung CT (6). And then, the consultation team of COVID-19 prevention and control experts (consist of directors of emergency department, respiratory department and nosocomial infection department) in our hospital would evaluate the preliminary screening results and divided them into five groups: negative, preliminary undetermined (1), preliminary undetermined (2), suspected, and confirmed (Figure 1).
Since February 28, COVID-19 NAT was added to the screening protocol. The first COVID-19 NAT (pharyngeal swab, result waiting time: 6 hours) and routine preoperative preparation would be performed immediately in the transition ward (the standard of protection is the same as COVID-19 isolation ward: third-level protection standards). If the consultation result was “suspected or confirmed patient”, we do not recommend delaying surgery if the hospital has adequate protective equipment. We have dedicated patients transport channels, dedicated surgical teams and dedicated negative pressure OR. The surgical team should protect themselves according to the third-levels of protection standards: work clothing, protective boot covers, disposable working caps, N95 masks, goggles, medical protective masks (or positive pressure head covers), protective clothing, double-layer latex gloves (6, 13). After the surgery, the patients would be sent to the COVID-19 isolation negative pressure ICU. For the “preliminary undetermined” patients, if any 2 items of epidemiological history and clinical presentation were positive, the management protocol would be similar as the “suspected and confirmed” cases. If any 1 item of epidemiological history and clinical presentation was positive, the treatment protocol would be similar as the screening “negative” cases. For the screening “negative” patient, emergency craniotomy for clipping aneurysms would be arranged in the conventional OR. Both of the screening “negative and preliminary undetermined (1)” patients would be sent to the ordinary ICU after the surgery. The second COVID-19 NAT would be performed 24 hours after the first NAT for all emergency aSAH patients. According to the second COVID-19 NAT, it would be determined whether the patient be transferred to the Ordinary Ward / Ordinary Ward (single bed) / Transition Ward (refer to ordinary ward 14 days later if confirmed negative) / Isolation Ward (refer to designated hospital for COVID-19 when suitable).
Perioperative management of aSAH was the same as that recommended in previous guidelines (3, 14). Besides, the above screening procedures were performed again in patients with postoperative fever of unknown causes and in preoperative undetermined suspected cases. If the COVID-19 NAT was positive, the patients would be transferred to the COVID-19 designated hospital for further treatment after the intracranial condition stabilized. For screening negative, preliminary undetermined (1) and preliminary undetermined (2)/suspected/confirmed patients, paramedic adopts first-level protection standards (first-layer work clothes [eg, scrubs], disposable working caps, surgical masks), second-level protection standards and third-level protection standards after operation, respectively (6, 13). Family members of the patient are not allowed to accompany the patient in the ward during the hospitalization. Visitors need to pass the preliminary screening of epidemiological history and temperature measurement.
Continuous and categorical variables were presented as mean ± standard deviations (SD) and counts (with percentages). Two-tailed t tests were used otherwise for continuous variable with Gaussian distribution. The Mann-Whitney U (Wilcoxon) test was used to compare non-normal distribution continuous variables. For categorical variables, either the Fisher exact test or the Pearson chi-square test was used. Statistical analysis was performed using SPSS (Version 25.0, IBM). The significance threshold was set at a 2-sided P value less than 0.05.