ANNEX 22

GUIDELINES ON SURGICAL MANAGEMENT OF SUSPECTED OR CONFIRMED

COVID-19

1. Introduction

Due to the dynamic nature of the pandemic situation, recommendations are refined over
time, based on the latest evidence and guidelines.

2. General Measures

2.1 Screening

Screening shall be done at all entry points (clinic or patient admission centre) using
Mysejahtera app/SJ tracing.

2.2 History taking

● Patient can be categorized as below:

o Confirmed COVID-19
o Suspected COVID-19/ Probable COVID-19/ Person Under
Surveillance (PUS)/Severe Acute Respiratory Infection (SARI) patient

● Management of the patient undergoing surgery, shall be carried out according

to patient’s category and urgency of the surgery.

2.3 COVID-19 Testing

● COVID-19 testing should be carried out on all patients undergoing surgery.

● Patients scheduled for elective surgery cases should do COVID-19 testing
within 24-36 hours of surgery and should limit their movements.
● The testing strategies is divided into the following:
a. Patients requiring general anaesthesia and or AGP: *RTK-Ag professional.
b. Saliva RTK-Ag for patients undergoing surgery under local anaesthesia or
non-AGP surgery).

*RTK-Ag professional is a point-of-care testing conducted by the healthcare

professionals using Nasopharyngeal Swab (NPS) or Oropharyngeal Swab
(OPS).

2.4 COVID-19 Repeat Screening for Hospitalized Patients

● Patients who have been in the ward and are required to undergo surgery are
suggested to repeat RTK-Ag testing after 5 days from admission OR earlier in
the following scenarios:
I. When patient develop new onset of symptoms such as ILI or SARI
II. New evidence of epidemiological link (e.g. household contact COVID-
19 positive)

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 III. Outbreak in the unit in the hospital
IV. Plan of referral/transfer of patient to other hospital for operation
purposes.

2.5 Measures to be taken following admission

2.5.1 Infection Prevention and Control (IPC)

a. The number of staffs managing a suspected or confirmed COVID-19

patient should be kept to a minimum.
b. Suspected or confirmed COVID-19 patients should wear a properly fitted
surgical mask.
c. In cases requiring surgical intervention, a medical officer or a specialist
should be involved, and all staffs must use appropriate PPE based on
the risk exposure as stated in the guidelines.
d. Body fluids, tissues, mask and other consumables in contact with the
patient should be disposed as per current available recommendations
(as for Retroviral Disease patients).
e. The operating theatre should be cleaned as per biohazard based on
current available protocols.
2.5.2 Surgical Team

a. All members providing care to suspected or confirmed COVID-19 patient

shall be optimally trained in using PPE, sample collection and
packaging. (Refer to Annex 8 on Infection Prevention and Control
Measures).
b. The number of staff shall be kept to a minimum.

2.6 Anaesthesia

a. Choice of anaesthesia: Where applicable, regional anaesthesia is preferred.

b. Specific biohazard measures pertaining to SARS-COV-2 shall be adhered to
during and post procedure.
c. Intubation and extubation: Appropriate PPE shall be used.

2.7 Designated Area for Suspected and Confirmed COVID-19 Patients

a. Suspected / Probable / PUS patients should be placed at a dedicated area

with recommended distancing (at least 2 m) to minimize exposure to other
patients.
b. Confirmed COVID-19 cases should be isolated in a dedicated area and
should not be mixed with suspected or probable cases.
c. Where available, ventilated COVID-19 patients should be managed in a
negative pressure room.

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 2.8 Operation Theatre

a. All hospitals should have a dedicated OT and ICU for COVID-19 patients.
b. Where available surgery is to be done in a negative pressure ventilation
system.

3. Pre-Operative Management

3.1 Acute Emergency and Emergency Operation

a. Attending Surgeon/Physician shall conduct case assessment.

b. For Confirmed / Suspected / Probable COVID-19 or PUS / SARI patients,
operation shall proceed with appropriate IPC measures and all staff involved
should use appropriate PPE as indicated, at dedicated COVID-19 operation
theatre.
c. Suspected / Probable COVID-19 or PUS / SARI patients requiring general
anaesthesia or AGP are required to undergo COVID-19 RTK-Ag professional.
Only life-threatening emergency shall proceed without waiting for the COVID-
19 test result and all staff involved should use appropriate PPE as indicated.
Other emergency cases should have RTK Ag results before OT.
d. For patients undergoing procedure under local anaesthesia and not requiring
AGP, Saliva RTK-Ag test can be used and proceed with the procedure based
on the test result.

3.2 Urgent and Semi-urgent Operation

a. Attending Surgeon/Physician shall conduct case assessment.

b. Patients requiring general anaesthesia or AGP are required to undergo COVID-
19 RTK-Ag professional.
c. Patients undergoing procedure under local anaesthesia and not requiring AGP,
Saliva RTK-Ag can be used for testing.
d. Proceed with the procedure once test result is available. For life threatening
cases, proceed with surgery without waiting for result of test
e. For confirmed COVID-19 patient, operation shall proceed with appropriate IPC
measures and all staff involved should use appropriate PPE as indicated.

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 Flow Chart for the Surgical Management of Acute Emergency/ Emergency/
Urgent/ Semi Urgent Operation in Suspected or Confirmed COVID-19 Patients

Case Assessment by Attending

Surgeon/Physician

Confirmed Clinically assessed as: Clinically assessed as

COVID-19 Suspected COVID-19 NON COVID-19
Probable COVID-19
PUS
SARI

Requiring
Perform
Perform Yes COVID-19 test
General No
COVID-19 test ( Saliva RTK-Ag /
Anaesthesia
(RTK-Ag # RTK-Ag
or other
Professional) Professional)
AGP?

COVID-19
test result?

Positive Negative

*Inform Anaesthetist Routine OT attire

Proceed for operation

with appropriate IPC
measures and PPE

Refer Appendix 1 for # RTK AG-Professional is an alternative test used in patient who has
Post-operative difficulty or unable to produce saliva.
management * for life-threatening emergencies, to follow pathway for COVID-19
positive patients while waiting for confirmed COVID-19 status

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 3.3 Elective Surgery

a. For Confirmed COVID-19 patient, operation shall be postponed and referred

for COVID-19 management and rescheduled after patient’s recovery.
b. For Suspected COVID-19 / Probable COVID-19 / PUS / SARI patients,
operation shall be postponed and rescheduled.
c. For patients requiring AGP, they are required to undergo RTK-Ag test if the
test has not been performed. It is recommended to be performed within 24-
36 hours prior to the surgery or on the spot, upon admission. If the test result
is negative, operation shall proceed in the usual manner and personnel shall
use the routine OT attire.

Flow Chart for the Surgical Management of Elective Operation in Suspected or

Confirmed COVID-19 Patient

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4. Personal Protective Equipment

a. All personnel involved during the procedure / surgery should don the
appropriate PPE. Personnel performing operation on Confirmed COVID-
19/Suspected/Probable/PUS/SARI should always don appropriate PPE as
the following:

Recommended Personal Protective Equipment

1. PAPR or Fit-tested N95 respirator

2. Coverall or Isolation gown (fluid repellent long-sleeved gown)
3. Eye Protection (face shield/ goggle)
4. Sterile surgical gloves
5. OT cap (when wearing isolation gown)
6. Followed by sterile OT gown

b. All personnel should strictly adhere to proper procedure of donning and

doffing according to Policies and Procedures on Infection Prevention and
Control.

5. Post–Operative Management

5.1 Confirmed COVID-19 Patient

a. Patients shall be extubated and monitored in Operation Theatre

before transferred to the ward.
b. If patient is transferred to ICU, they shall be placed in a dedicated
critical care area.

5.2 Suspected/ Probable/ PUS/ SARI

a. After the completion of surgery, patient shall be extubated in the

same operation room or dedicated airborne infection isolation room
(AIIR) / negative pressure room. Patient shall be transferred to the
dedicated ward and COVID-19 result shall be traced. If the result is
positive, patient shall be transferred to dedicated COVID-19 ward for
further management. For Suspected COVID-19 / Probable COVID-

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 19 / PUS/SARI patient, the requirement for isolation shall be as per
national protocol.
b. If the patient requires ICU admission, extubation shall be done in ICU
based on patient’s condition. Patient shall be isolated and COVID-19
result shall be traced. If the result is positive, patient shall be
transferred to dedicated COVID-19 ICU for further management. For
Suspected COVID-19 / Probable COVID-19 / PUS/SARI patient,
isolation shall be as per hospital protocol.

6. Management of Surgical in Obstetric Patients

6.1 Elective caesarean sections

a. The indication of performing an elective caesarean section should

be as per routine obstetric indications while COVID-19 infection
per se is not an indication for a caesarean section.

b. As per the updated MOH guidelines, all patients undergoing an

elective caesarean should have an RTK-antigen professional
performed 24-36 hours before the procedure as described above
(page 1, annex 22).

c. Although it is best to delay an elective delivery and surgery for

COVID-19 positive mothers, the management and optimal timing of
delivery of COVID-19 positive patients, suspected, probable, PUS
and SARI should be individualized after discussion with a senior
obstetrician.

d. Elective caesarean section should ideally be delayed between 7-

10 days if feasible while regional anesthesia is preferred unless
contraindicated. Seek an anaesthetic review and assessment before
the caesarean section.

e. Adhere to IPC measures and PPE recommendations if the elective

surgery is obstetrically indicated within 7-10 days of confirmation
while repeated COVID-19 RTK-Ag testing is not recommended.

f. The need for a COVID-19 PCR prior to an elective caesarean

section should be individualized based on the clinical suspicion
and to consult a specialist if unsure.

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6.2 Emergency caesarean sections

a. As per the MOH guidelines, an RTK-antigen professional is

recommended for patients undergoing emergency caesarean
sections, especially for *CS category 3 and 4.

b. However, for *CS category 1 where there is immediate threat to the

life of the mother of the fetus and *CS category 2 caesarean sections
where there is maternal or fetal compromise, the caesarean section
should be performed without undue delay associated with the
turn over time of RTK-Ag results. Adhere to IPC measures and PPE
recommendations since the RTK-Ag results are unavailable and
consult a senior obstetrician as well as discuss with an anaesthetist
if unsure.

c. Regional anaesthesia is recommended unless contraindicated.

d. During an emergency caesarean section, manage suspected,

probable, PUS or SARI patients as per COVID-19 patients with strict
adherence to IPC measures with PPE recommendations without
undue delay while the RTK-Ag professional results are obtained.

6.2 Patients in labour

a. All obstetric patients admitted to the ward or in labour have a risk of

having an emergency caesarean section and hence should have an
RTK-Ag professional performed during admission.

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 Flow Chart for the Management in Obstetric

*CS Category based on Classification for urgency for Caesarean Birth (NICE)

Classification for urgency for Caesarean Birth (NICE)

Category 1: Immediate threat to the life of the woman or fetus (for example, suspected
uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or
persistent fetal bradycardia).
Category 2: Maternal or fetal compromise which is not immediately life-threatening.
Category 3: No maternal or fetal compromise but needs early birth.
Category 4: Birth timed to suit woman or healthcare provider. [2004, amended 2021]

*Notes: Word CS is added in front of the word Category (CS Category) to avoid confusion with Category
used to describe severity of COVID-19 infection.

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 APPENDIX 1

Post-Operative Management for Confirmed COVID-19/Suspected/Probable/PUS/SARI

Note:
* If patient extubated in OT, the patient shall remain in OT during the recovery period. Patient shall not be
transferred to Recovery Bay. OT cleaning should be based on Policies and Procedures on Infection
Prevention and Control, Ministry of Health Malaysia, Chapter 12: Environmental.
** If patient extubated in negative pressure room, patient shall remain in the room during the recovery period
before the patient is transferred back to the ward.
*** To limit potential COVID-19 exposure, hospitals (regardless of status i.e. Full COVID-19, Hybrid COVID
or Non-COVID) shall have dedicated area or ward to cohort the patients.

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