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Excellent. Now we're back for the second session and to start off the second session, uh we have uh Carlos mcgagh Less uh the presidente of the scientific committee for this meeting who is going to talk to us about the surgeon and surgery during COVID working with change. We will do the same format. We will have all the presentations and have questions at the end. So I will start the next talk. Hello, good afternoon to all of you that is protecting the Hello, good afternoon to all of you. Uh Thanks Jan for giving me the floor. It is a great pleasure for me to be here to be with all our friends from is and with all my friends from a notary surgery that are spread all over the world. It is an honor for me to be present in this meeting and want to congratulate my friends from eyes too. I had the idea to organize this meeting, uh mainly Yan and thanks for all the effort diet to concludes and to make it possible, we know that we are in the difficult times. Uh We were not expecting that we were uh at this moment living this special and difficult situation. When we had the idea to, to organize this meeting, we were expecting that we could be discussing the restart of the surgery and mainly ambulatory surgery after the COVID period. But unfortunately, and it looks like it is the same all over the world. We are facing our second wave and we have to deal with this big problem. So my topic year is to try to speak a little bit about the role of the surgeon and the the surgery during this uh COVID period. Working with the change. First of all, I want to send the Bigelow to the big huge to all my friends from the G A. Uh is uh this was a picture from last year in Porto. We met and we had a meeting in Puerto and the one to say hello to all of them. One year ago, May last year we met, we had a fantastic meeting in Puerto our International Ambulatory Surgery Congress. And we remember and they put just some pictures so that we could have memories uh to speak to think about the military surgeon and about uh is and all the ambulatory surgery family. It was a fantastic meeting, a very good experience and I think all of us will stay in our mind with very good memories from Puerto 2019. I am a general surgeon. I work uh only in ambulatory surgery field. I am from Porto in Portugal and I work in a uh research unit, independent one. And uh all my work in hospital is related with the ambulatory surgery. This is my, my unit. It's called Sica sent into grad surgeon um Vittorio. It is one of the biggest in Portugal. And uh it works from Monday to Saturday from the morning and in the afternoon and we can have overnight staying if, if we want to. Sometimes we use it so so many patient's, but sometimes we can use it some pictures from our unit, the main entrance, see the receptions, the operating rooms, the post operative, this area, this is post operative area, the phase one and the post operative area, phase two. So our main goal of this meeting, this online meeting, uh we organize it uh so that we can, we could discuss something about what was happening all over the world to bring our experience about motorist surgery and about ambulatory pathways in the post COVID era. But we know that probably all of us uh in all our countries, we are facing again the second wave and probably uh we are not discussing what we were expecting, but really we have to face another uh difficult situation. This picture I took it uh three or four days ago. Uh On Tuesday, our unit is dedicated only with uh surgery for, for pediatric age. This was a young by he was expecting for this surgery. And as you can see uh, he was alone. Uh, there was no, uh, no one with him waiting and he was a little afraid, waiting for, for his surgery and having some material related to anesthesia. And uh this picture really upset me about what this boy was, was feeling. And we know that these last days, uh these last weeks we had the, the improvement, the increase of the numbers, the big, big increase all over the world. And we know that every new one other infections, we know that probably 50% of them are in, in countries that are located in Europe. And it is expected that every four days, we have 1 million of infections. This is really a big, big number that has to make us to think about what is coming. This is the situation from uh uh met from all over the world and no one is safe and all of us we are facing the same problems. This is devolution in in Portugal. We had our first case in the beginning of March and sorry. And uh we are increasing of, of numbers. Uh March, April then because of the measures that were taken by our government and we could uh slow down the curve and we we were closed for some weeks, we closed everything. Uh we have to close also uh motorist surgery units because of in different hospitals because of different reasons because sometimes we had to uh sent health professionals to, to other places to use unity. Uh It is if you carry units, nurses. And uh so uh other hospitals, we have to close the operating rooms so that they could, they could uh be used by uh other Celsius. But we, we could, after, when we start returning in the beginning of June, we, we could restart safely. And July and August and beginning of September, we were working not to 100% but probably most of the hospitals and most of the ambulatory surgery centers in Portugal. We were working more than 80% maybe 90%. Not all hospitals. Most, most of us, we were working almost more than 80%. Then in September, beginning of September, we start facing the second wave. And now uh in Portugal, beginning of October, we are facing uh really a big improvement, a big increase of the numbers and we have beating all our records with the number of infected cases and the number of people that are admitted in hospitals uh in beginning of March and April our Portuguese and Motorist Social Association. We start having submitting some online meetings discussing what we could do to to restart our ambulatory surgery field. And we had some meetings, one in April, another one in June with our hospitals, all all our units discussing how could we really use the motorist surgery units to start to restart the beginning of the, the surgeries. And uh we have very interesting meetings and another one in September discussing the three months after restarting. And in May, June 2020 we published our national recommendations for the restart of auditory surgery in the COVID 19 era. And uh we had a big group of working group and we made our national recommendations for the restart uh vomitoria surgery. And our main goal was that lottery surgery units and ambulatory surgery centers would be COVID free places. So we wanted that our units could be places where there, there were no, there were no COVID uh positive patient's so that we could do our surgical proceed mints with all our quality and safety that are one of the main uh mm Keret IX of the ambulatory surgical field. So what I'm going to to talk is about what is my perspective as a surgeon and uh what I really, I had to change in uh my work uh related to this, this uh pandemic situation. So I will speak about what was my experience in these last months? I, as I told you, I am a general surgeon. I work only in a motorist surgery field, my ambulatory surgery unit. And well, I will tell you what was my experience in this last month's uh working in this situation so related to the prayer operative time, the pre operative evaluation during the consultations the first week, the first two months and probably we, we canceled, we didn't not canceled. We, we change all our consultations for from the presidential ones to online. And almost all consultations were done by phone mainly. And after when we restart in June, we start slowly changing the way the consultations were done and we were increasing the number of patients that were coming. And at this moment in my unit, we are, we were almost doing 100% of the consultations with the patient's coming to, to, to, to our, to our unit in some weeks. I don't know what will happen, but probably we'll have to step down again and probably we have to, to start again with some of the consultations, uh nonprofessional. Uh We know that that the surgical surgical consultation that is not done with the present of the patient is not easy, mainly a first consultation. But this is the, the way that we have to try to solve our situation when we were in March and April. And now we have to wait to see what will be the evolution about testing. Um This was a big topic, uh big discussion beginning of, of the pandemic situation. March April and uh our government uh took some time to make a decision to, to make some national recommendations. And for, for a motorist social field, we decided that it was a re recommend recommended that all patient's that were being submitted to a surgery with the presence of uh Nexus ist should be tested. The only situations that were excluded for the obligation of the testing word patient's that were submitted to surgery under local anesthesia. And this situation was of course, uh decided uh the surgeon and the surgical team, I had to make the decision if a patient under local anesthesia should be tested. I know that in most of our uh our surgery centers, most of the patient's under local are not tests. All the other are being test. We are testing uh normally 48 hours before the surgery uh in some places probably three days before and patient's are advised to stay at home until they, they are admitted for the surgery related to the professionals. There was, there was no consensus and most of the professionals in Portugal, mainly in ambulatory surgery units. They are not, they were not tested, they are tested only if they start with symptoms. And this is the situation related with the patient's. So we, we had to, to work a lot and to, to really uh be worried with the situation that was related with the pre operative contact. We were, we were, we have been doing this for a long time. Most of our units, we're already calling our patient's uh one or two days before the surgery. But really the this contact is uh contact two days before. Mainly this is the what is uh the basis to make the contact two days before? Helped us a lot to really, to, to ask the patient's what, what was happening what are, were they feeling uh to give them the right information about what time they should arrive to our Totori surgery center to inform the family at what time that they should come to take them the patient home. So really, really did this uh prayer operative contact was one of the main things that we have to work. We had to improve and that really could help us that we could increase the numbers of surgeries that we were doing in these last weeks or or months uh related to the ambulatory surgery unit and miss admission for surgery. Uh I think in all our centers, we start doing individual uh inquired and surveys related to the health status of the patient's. And sometimes we, if we were talking, for example about the kids, also the inquire that were, was done to the parents if they, they were coming with the kids. And also we have, we started evaluating the corporal temperature for all the people that were admitted to ambulatory surgery center related to the admission in operating room. All our patient's were using uh a mask. This was obligatory. We see in the first picture a patient that is admitted for orthopedics surgery. And in this second, on the right side, uh female patient that was submitted for a surgery under local and uh sedation. And she was of course, wearing, wearing a mask and some pictures about the teams uh in, in my hospital. It was decided that all people that were inside operating room should use uh the the adequate protections and related to the mask. All of us, we had to use uh P two FP to uh mask. So everyone that was working uh surgeons, uh ethicists and uh nurses and uh people that are supporting us, everyone has to wear this type of mask in the beginning. Now, this situation was not being used and, and we know that all our patient's were test and we just admitted for uh about all the surgery, all the patient's that were tested and were negative. We are not admitting in our uh watery surgery centers, positive cases only negative. And then on the beginning because uh probably some of the teams were a little more afraid. They were also using these protective devices that this is a plastic that is protecting the face of the patient's. And in these last weeks, uh I have to tell you that I didn't see this, this type of protection anymore. So the old team has to wear the appropriate protection. And in my hospital, at least old person's old health personal FF to use the FFP two masks and uh general protection glasses, cap surgical gown and gloves. These related to the surgical technique. Of course, uh we have to use the best surgical technique that we, we thought was appropriate for the patient. We didn't have to change so many things related to the surgical technique would our main main, the problem that we have to face or these potential area of saul raising, uh proceed, mint, surgical proceed mints. Mainly those are related to uh to laproscopic approach, video assisted approach and the use of some smoke and uh energy generate, generating equipment and, and devices. And in these situations, we had to consider and we were using of course, uh deficients particulate the residences devices uh for the the recovery of the smoke because we didn't know related with the laparoscopic approach. If the smoke really is uh probably focus of contamination, we don't want, we don't know probably it can be 11, one focus of infection. And what we have been doing is uh was using of this type of devices so that we could be more safe related to this surgical approach. In my my unit, we, we used this device, our nurses uh start using this, you see, this is a five millimeter stronger and we used this device and it was uh adapted to, to the exploration uh device and it was working very well. We we, we are, we are using it for all uh laparoscopic approach and we have, we had no no problems also the use of the filters here in, in the in the device for the dioxide carbon. Uh and you can see a picture of, of the total total uh device. This was like an adaptation. It is a little more not so expensive you see here without using, being used here. And you see this is it, it was a picture that I took at the end of the surgery. And you can see that we had here some blood and some, some material that was retained. Also uh the system for desperation of, of, of the, the smoke when we, we were doing the surgeries and also some, some uh we had to take some care related to the surgical devices that could generate some smoke and the electrical electrical devices related to the recovery phase one. And we had, we had some adaptations. Of course, we have to change some things always the mask for, for the patient's the distance between the patient's and but related to, to surgical field, we have, we have to make some adaptations but not so different related with the recovery with the phase two of the recovery. The same situation, patient's always using the masks. Unfortunately, it was not possible that the family or the caregiver was not present, but we had of course to go on with the same um situation related to the post operative evaluation. The first, we usually, we see we evaluate our patient's after one week, post surgery. This is an example of uh total uh thyroidectomy that we performed some weeks ago and our patient was coming of course, the first week for the evaluation. It is not possible that we can make this evaluation without the patient. So we are, we are insisting that our patient's come to, to visit us so that we can see how they are going for the surgery. So this is our new normal. Uh Probably we were expecting to discuss a little more our normal activity. Uh One question that I make is that for how long will be this new, new normal? And our main conclusion, uh my main conclusion that is that our main challenge is to solve this problem and to to slow down a little more, all this situation is that we have to be focused on our teamwork and quantification on the organization. Only with this, we will really be being the success with the slow down of this pandemic situation and only with this, we will will will have success on the stop of Corona virus. Because as we know, and I think this is also can be a challenge that motorists units can be the places where hospitals that are in more difficult situations without beds for, for patient's, they can go on working with ambulatory surgery in, in safe and with the quality that is associated ambulatory surgery. And I think it can be a good options if the hospitals go on and uh go on with the surgical, proceed mints in ambulatory surgery because we don't know that we, we, we come back again for this situation without patient's in our units and no one working and uh no surgeries. This is what we don't want, we want to, that our units are going on with, with surgeries. So thank you very much or I hope you enjoy this meeting. I'm sure that the experts that we choose can help you with the experience and that we can share with you our main difficulties and what we can do for the solve of these problems and that we can go on with our surgeries with totally safe and also with the same quality as ever. So, thank you very much and I hope to see you all in 2021. I don't know where. Good afternoon, ladies and gentlemen, their colleagues. I am Mark opens, I am anesthesiologist in the University Hospital of Gantz and I'm the Presidente of the Belgian Association Ambulatory Surgery. Today, I will tell you about the implementation of a digital patient platform in our ambulatory surgery unit. The hospitals have a case mix of many minor operations with an increase in more complex surgical procedures. And as you know, the work around time is very limited ambulatory care aims at guaranteeing the continue itty of care post operatively. And therefore we need some kind of follow up of the patient. We wanted to optimize the patient's ambulatory pathway and search for digital tools to assist various caretakers to follow the patient along a continuum from the pre operative period to time of discharge, including the early and late post operative recovery, digital patient platforms may impact clinical outcome and health delivery service through different mechanisms. They aim at improving patient participation and patient empowerment to ultimately contribute to patient satisfaction and better therapy compliance. The primary goal of the study we performed to us to identify barriers and facilitating conditions for successful implementation of a digital patient platform. We used an existing platform called Kazu, which is Dutch for collaborative care platform, whose mission is to be a digital healthcare cooperation platform, connecting patient's and caretakers that allows quick and safe exchange of medical information, multidisciplinary. The first care pathway within a digital patient platform within cause. Oh, was developed in the oncology department. Later, we included care pathways and orthopedics here. No stroke and other medical disciplines. Originally, it was only accessible on computer, but the mobile application was launched in 2018 and it became possible to send push messages. We started with a limited number of clinical care pathways in a step wise approach. First arthroscopic research, we including the anterior cruciate ligament reconstruction and we compared outpatients with impatience we choose for orthopedics as we hoped to reach young healthy people who have access to digital tools and feel confident in the use of computer mobile phone and are willing to explore personal health information on the digital platform. We also included EMT patient's undergoing sinus operations and hospitalized patient's which allowed us to compare causal with commercially available apps like my sinus coach. This is the causal start screen which is obtained after the patient has registered to an electronic ID and pink coat. The screen indicates patient demographics informed consent to share information with different healthcare workers. At right, you can see the different hospitals where the patient has consulted previously and our way to share information. Then at the bottom several options for the patient, he or she can see results of laboratory investigations or radiologic images. He can make online appointments and he can consult specific care pathways including specific surgical care pathways in ambulatory surgery. Secure messaging enables the patient to exchange non urgent health related information with a team member responding to incoming messages. This is an example of a care pathway for knee arthroscopy, providing practical information, preoperatively information on preoperative tests. The possibility of having a preoperative anesthetic consultation. Patient platform includes an informative part with the visualization of the individual individualized care path. Different steps can be choosen for each patient which makes the pathway customized provision of reliable information about the diagnosis and the treatment. Links to relevant websites, contact details of the team and an active part with the possibility to have secure conversations with the treatment team, self registration of complaints and other problems and diaries and other questionnaires and a question prompt list. We used the mixed method approach to get insight and problems related to implementation and use of our digital patient platform with quantitative analysis analysis of log data to know how many how often and what specific items were used by the patient. We held interviews both with patient's and all kinds of healthcare providers. We offered validated questionnaires to patient's to evaluate more specifically patient satisfaction with a digital platform. The goal was to know why or why not a platform was used and recognize you sort of a typical patient and ambulatory surgery. We screened 555 patient's 140 were not included for organizational issues. The or Shuttler didn't have time. Completely forgot to study. 415 patient's were asked consent, but 189 of them failed to get access for different reasons. The recruiting nurse didn't have enough time because of a high workload. Patient wasn't physical present when the appointment for surgery was made and so on. So have the patient's lost interest after all. And the most difficult part, they didn't have an EID reader for secure access. 226 patient's achieved to get access, but some of them get overwhelmed, forgot the whole thing lost interest, didn't feel the need for additional information and we're not convinced about it and value so that we had the right target population as ambulatory care is only characterized by a brief contact with the hospital. Only 22% of actually, they're of patient's actually registered on a digital platform. And many of them without making further use of the system, 60% of participants make use of the platform between one and four times. There is a difference in the frequency of use between knee surgery, patient's and ent the patient's used platform 50% less frequent than ent patient's. The platform was used 82 times preoperatively and 70 times post operatively when that patient choose the platform. While most often it was used between 12 days before and 14 days after the procedure, the day before operation was a day with the highest participation rate, reminder email was sent the day before the operation. What can explain the peak coupling of the patient's email was essential and for legal and GDPR reasons, the patient had to do this himself. Patient's that coupled their email address were 111.4 times more likely to use the platform. Not amazing. Of course, analysis of log data confirmed that ent patient's used the platform more often there were no significant differences in the use of causal according to age or gender or between inpatient versus outpatients. When the mobile app became available, it was used in 36% of patient's. We received 321 different questionnaires or diaries. Only nine conversations took place, only half of the patient's filled in their email address. These patient's more frequently used the tool we couldn't find real predictors for not using the digital platform as having a smartphone differences in social status, the amount of worrying postoperative, the need for contacting the surgeon, lack of pain medication or level of experience with technology. This could be caused by the fact that people are schedulers and nurses kept giving the information on paper as well. Although we insisted not to do this, the users after all were quite satisfied with user friendliness, usability, usual conditions with scores between three and four on a scale between one and five. This was an eye opener. A postoperative questionnaire revealed that 23% of patient's were worried about postoperative pain or recovery. 28% contacted the hospital or GP and as many as 20% return to hospital or visited the general practitioner, 11% had insufficient pain relief. We can only hope that these figures are biased by the fact that only patient's which was outcome would have used the platform while those with better outcome didn't seek help or additional information. And for that reason, we're less interested, although of course, we would have liked to hear from a good outcome as well. We held semi structured interviews with different users of the platform are shuttlers surgeons, it specialists and patient's barriers for successful implementation of our digital platform were a lack of user friendliness. At least for the our shuttler who had to start the pathway for a particular patient concerns about liability in case of breached privacy or harmful patient behavior or liability when failing to respond in a timely way to patient inquiries or red flags like high paints, course lack of added value for all involved parties was a barrier, increased workload and disruption of workflow were feared. There was concern among providers that they did not possess the skills and capacities to deal with technical problems and requirements. If patient's experience problems to get into the system, for answering questionnaires, for instance, some providers were reluctant to give autonomy. A consequence of giving patient's control over activities. Traditionally, traditionally arranged by the providers themselves such as booking appointments, user friendliness, follow up possibility and the remote monitoring were perceived as facilitator. The robust authentication process reassured both patient's and providers. The introduction of the mobile app was an advantage for patient's data exchange with electronic health record of the hospital is yet not possible. And a barrier for ease of consultation of preoperative questionnaires. For instance, direct communication from the digital patient platform of postoperative validated score ing systems could result in less time consuming postoperative check up or even reduce the need for postoperative consultations. Our shuttlers played a crucial role in the implementation of the portal but we're especially concerned about the increased workloads. They felt incapable of giving enough information to the patient on the content of the digital platform, the accessibility, the completeness of information and the stability of the system itself. Moreover, as it was a clinical study, they had to inform the patient about both the platform and the study as well. Although the or shuttlers had the continuous support of our study ners, they felt that this was not enough and not sustainable on the long term. And we're convinced that it was the responsibility of an advanced nurse practitioner to assist the patient. Two out of the whole very operative period. It is not clear if this is affordable in a business case, as financial incentives are either an existing or too low. Financial remuneration is actually too low or non existing. More over there are no documented cost savings from using patient portals. Cost savings could be quicker and more efficient postoperative consultation and checkups. Patient's using the tool. Feel more engaged with care, feel more in control of decision making concerning their health, they feel empowered to ask questions. So the overall feeling of safety has increased. These are well motivated patient's technically skilled to access and use the digital tool, nonusers giver prematurely not being able to overcome technical problems. They argue that a digital patient platform should augment and not replace human ducts and prefer personal conversation, real life. Compelling value proposition is needed to convince these patient's. So we must conclude on low participation rate for several reasons cause. Oh performs good on share ing information between healthcare workers, hospitals and patient's. The release of a mobile app. The introduction of reminder males positively influenced the frequency of use and overall easy and secure access is necessary. Essential. An adoption of a digital patient platform is to search for the needs of a particular patient group. Patient's seem to be more interested in preoperative information. While doctors are more interested in the postoperative course, a digital patient portal should right directly in the electronic patient record, the management and ideally the government should stimulate and support digitalization. For successful implementation of a digital patient platform. It is important to consult different stakeholders before implementation and greets consensus about the need for the system, a competent, competent it, project leader and team are necessary. The system itself has to be user friendly and intuitive needing little training, the complete management team starting with preoperative anesthesia, consultation, surgeon and the ambulatory care unit personnel should encourage patient's throughout the entire pathway. Ideally, the case manager is assigned for postoperative follow up. These are some reference we used for in the study and in this presentation and I thank you for your attention. Thank you very much for that mark. That was an excellent presentation uh on something that is quite dear to my heart, the use of uh it within uh ambulatory surgery. Uh We now move across to the USA once more and Arnie Arnaldo valid in who is going to talk to us about COVID conversion after elective surgery to worry or not to worry. Good afternoon, everyone again. My name is Arnie Ballad on I am the medical director for outpatient area, part of services as part of Welsh Band Health in Pennsylvania United States. And I'm also representing the Ambulatory Surgery Center Association located in Washington DC. Uh in the United States Presidente Formosa would like to thank the rest of the scientific committee uh members who have put together an excellent conference as well as our Presidente uh Doug mckinney from the UK. Thank you very much again for putting together a, an excellent set of topics uh on a very timely uh pandemic time that I believe will be with us for, for a little while to come. So, thank you again. Then we certainly hope that we can engage in the discussion at the end of all, all of our topics that would be relevant to everyone. Uh, our topic today is gonna be COVID 19 positive conversion after elective surgery to worry or not to worry. Mhm. I have no disclosures financially or otherwise, uh, to declare and what we have in front of us is a dashboard, uh, that has been put together by Johns Hopkins University in, uh, in Maryland is a dashboard that has been used again around the world. One of several, uh, but one that is really comprehensive and this is, again, be a background. We currently have about close to 40 million cases of COVID, uh, around the world, close to 1.1 million deaths. As we can see it from the map. Just about every, uh, country banning a few, uh, in the world have been affected by COVID 19 banning again, maybe Antarctica and some of the outlying, uh, territories in some of our uh, countries around the world have, have been affected. And it is my opinion. Uh, you probably would agree as well that this is with us, uh, for some time to come. So, certainly challenging times now you might ask why, uh why should we worry, uh, what is the clinical significance of converting to a positive status, uh, have an elective surgery? Uh I must start by saying that the data that we have regarding complications rates as well as mortality after surgery, especially when it comes to COVID 19 is limited. It is emerging and it's emerging quickly. Uh Again, we have surgery uh being, being done around the world. Uh with patient that matter might, might not be COVID positive. So to the data is there, it is to be collated and more research is is needed at this point. The data uh is limited. Um also with respect to testing capability. Uh We know that uh around the world, we have variable testing availability as well as tests that are sufficiently sensitive and specific uh for the disease. The issue of testing uh pre operatively also variable as well as potentially testing postoperatively or a very minimum following the status of patient's postoperatively is something that I would like to discuss with you uh during the presentation. Now, we know that uh the evidence that at least the CDC uh in the United States has been able to put together for us with respect to increase risk for severe calling. 19 illness is associated with certain diagnoses. The strongest and most consistent evidence that we currently have is with patient's that have COPD measures that have cancer pages that have type two diabetes, melodies sickle cell disease, solid organ transplantation, as well as some serious heart conditions, not all but heart failure, coronary artery disease and cardiomyopathies. Now, not all data again, is strong as uh inconsistent um as the first group. So we have some mixed evidence for patient's who have hypertension pregnancy, asthma, using cortical steroids, smoking, uh and using immunosuppressive medications. There are limited evidence to date regarding HIV labor disease, pediatrics, thalassemia, and bomber of transportation. So I fully expect that we'll know more uh in the months and years to come regarding this. Now, with respect to uh post operative mortality as well as perioperative complications. What do we, what do we know at present? Well, we do know and again, limited, but we do know that patients undergoing surgery who have COVID 19 confirmed within seven days before or 30 days after surgery have worse morbidity and mortality. And I'd like to share with you some of the data that we have. So we can have a discussion and uh come up with some practical pathways so we can move forward the largest rental turkey study out there and analysis to date uh includes 1128 patient's. This is from 24 hospitals around the world. And, uh, the study took place between January 1st and March 31st 2020. In this group, just about 74% of patient's had emergent surgery. Roughly about 25% had a lack of surgery. And out of the pensions who had surgery, 26.1% had confirmed COVID 19 preoperatively. Out of that group, the 30 day mortality was close to 24% improvement are complications was roughly about 51% out of that group. Specifically, the eternity mortality was even higher. It was about 38%. Again, fairly significant numbers in the adjusted analysis. Uh In that group, what was noted was that carried a mortality was associated with six major conditions, male sex. A SS status 3 to 5, I was supposed to 1 to 2, 8 70 or above a malignant versus benign or obstructive diagnosis, major versus minor surgery as well as emergency versus elective surgery. And I have something to say about that. It's an important note regarding elective surgery, even though the mortality and the pulmonary complications showed higher statistical significant for emergency cases. What the data tells us is that the there is still significant mortality in the elective surgery group in this cohort close to 19%. Again, these are thousandfold mortality rates that we're used to seeing for elective surgeries. So even though in comparison is lower, it's only plenty uh significant. Also, we know from that group that a higher percentage of mortality was observed. And those who had a post operative diagnosis are supposed to pre operative diagnosis, pulmonary complications, again, follow the same pattern as mortality. And there was also observations of from body complications uh in those patient. So again, in summary, certainly mortality way higher than we used to pulmonary complications as well as thrombotic complications. So the original question that we had was uh do we worry about this called with Positive Convention or do we not worry? And the answer is we do need to worry about it, unfortunately. So what do we do? One of the questions that comes up, of course, is why are we observing the storms? And there are several theories out there. We don't know 100%. Uh what yet, but we do know that patients that are undergoing surgery have a pro inflammatory response uh under the saddle kind pathway as well as immunosuppressive responses to surgery and they cannot an election that is well known. So it is theorized that surgical patient's um, that have COVID 19 would be again at a higher risk of potentially having these complications and potentially explaining the increased morbidity and mortality uh that we're observing now Chroma Norco to the practical side. What do we do if we have an unresolved tid patient on the day of surgery? I am sure this is something that we're faced with many of us on a daily basis. I can tell you that what is about to follow our guidelines and um clinical judgment uh should supersede um any kind of guideline wherever we are. So, um, again, very important, who should we not proceed with? Again, these are my observations as well as the opinions of others. But, uh, again, guideline is not standard. When do should we not proceed with surgery when we have on resulted pages? Knowing what we know now about post operate complications. We'll certainly, uh if the patient's are having elective or semi elective surgery that can wait, we should probably not proceed with that. Number two pensions that have uncontrolled morbidities, particularly being listed on the groups that we just caused above for which we have strong evidence, potentially limited or mixed evidence and are in any of the categories that we just saw in the study. Again, male sex age over 78 S A physical status. 3 to 5, a malignant diagnosis for medical surgery. It would probably be a good idea to hold off and I have a quick comment. Thank her doctor Antonio's for uh, having this discussion with me. Uh And that has to do with uh Belinda diagnosis. What does that mean? But that means typically that question has cancer. So you might argue why should we wait to proceed with surgery when somebody has cancer? We all know that cancer comes in many different forms. Uh There's a lot of clinical judgment that comes with this clearly. Uh, this is a slower growing cancer and the testing would be done in a day or two, potentially three days. It is reasonable if this is something that if the diagnosis are fairly malignant, uh, and a few days will make a difference. Certainly we should not proceed, uh, with certainly. Uh, up note again, again, patient's with a benign or obstructive diagnosis, having elective surgery or minor surgery have lower complication rates and mortality when compared to malignant diagnosis, emergent surgery, but certainly not zero as I shared with you before. So when should we proceed? You might ask. Well, certainly patient's with a life threatening injury coming in for emergent interventions. Patient's with no comorbidities and undergoing a low or intimated risk procedure or patient's with controlled comorbidities and undergoing a low or intimate of his procedure. And not in any of the categories. This is categories that I mentioned previously. Five I should ask um, in the previous slide. So again, a lot of clinical judgment goes with this. These are the references that we have in front of us. I can tell you, uh the papers number two, number three and number four that they're at least they're here for you. But very enlightening want to come to this topic. So I very much look forward to uh discussion. Um, and I thank you. Thank you for that. Ah, Runny. And I, uh now becomes an exciting moment for, for me because it's our first live presenter So Xavier, are you there? Can you turn your microphone on? Yes, excellent. I'm going to start your slide and I'm, I'm hoping that you can see the screen. Can I see the next? Okay. I hand over to you then. Thank you, Ian. So uh I'm sorry for you from the Netherlands with a French passport and presidente of the Dutch Association for ambulatory care and short stay. So uh we have a use problem and I was speaking from a hotel room where we had a crisis uh meeting all day and I stayed there because easier. So we have now to avoid aerial sir generating procedures in ambulance, ambulatory surgery and in all surgery when possible and perhaps his local regional anesthesia, the best solution. So Xavier your microphone seems to have gone on. It's okay. Hello? Yes, you're good. Okay, good again. Okay. The who stays asked that we have to protect everybody working at hospital. It's not only a PB, but it's all the principles of infection prevention and control and unless physiologists and all the personal involved at the ot as to be protected. Uh when I had uh our friend Carlos Magnus, speaking about what they are doing in Portugal. When I compare to the Netherlands, the Netherlands, we don't test mostly all patient's. We just have an health uh question. Ery. And if it's negative, we go on very normally. Uh patient just have to wear a mask going to the Okot and going back from the ot but not at the operating theater. So, uh we perhaps we will compare uh how many infections we got in our hospitals and uh hospitals taking a lot of measures. So we know the procedures which generate other soul, the manual ventilation, the intubation, the cough after excavation. It's a big problem. And then we will speak perhaps about the noninvasive ventilation and giving oxygen to patient after uh sedation of during sedation or after G A tracheostomy for sure. And cardiopulmonary resuscitation and bronchoscopy. So, back to our avoiding generating procedures and resort generating procedures is avoiding giving general anesthesia. So as giving reach local general anesthesia, so we have several solutions for the low lymph spinal and blocks, low abdominal surgery. Spinal, we have all the different tablets and the local infiltration and for the upper length, the peripheral blocks. So spinal anesthesia is very interesting in ambulatory surgery is safe, reliable for short procedures, but there are limitation factors. It can delay. The ambulation. Urinary retention is a well known problem and the pain after block regulation is an issue. And I can tell you, I don't know your experience, but spinal anesthesia, the ward is sometimes the nurse nightmare because they don't like it in the afternoon because the patient is going to stay too long. So what should be the ideal anesthetic we could give in spinal anesthesia. We want an either local anesthetic with minimal effect on hemodynamic parameters, rapid onset and offset deep surgical block, minimal effect on urinary retention and sure the minimal risk of tension, neurological symptoms, the TNS. So we had the lidocaine. We many years we use a lot of lidocaine. Uh first the lidocaine 5% and then the 2%. But still with the 2% we have too much TNS and it's not recommended anymore to use lidocaine spinal. The bupivacaine is used low dose hyperbaric. But once again off, we get an insufficient block off. We have so many problems that we avoid goopy decade. Then we have the pre location. It's often presented that the either local anesthetic for spinal in ambulance resetting. Uh Yeah, it could be but we are not so enthusiastic uh about it. We, it works but we can't say that we don't have as much as written urinary retention compared to bupivacaine. Uh So we have the global procaine certainly the best choice. It's a very short acting uh sincerity block is good and the regulation is as good as to procaine. It's good for very, very short procedures. And then we have the Arctic ain't the Arctic cane is off label. It's our choice to use it on note, but it works wonderfully good. And the effect is a little bit between the light or the credo cane and the chloroprocaine. And then we have all the blocks is my patient. I love original anesthesia. So for the lower limits, not very easy because we have the cited the probably each other femoral, the adjective and other ankle blocks. It's anatomically complex. It can be challenging. It needs experience anesthesiologist and it can delay the mobilization. And you know in ambulatory surgery will like early mobilization. So we can combine it. We try to do it is combining a short acting spinal with peripheral blocks and doing this. You don't need to give high concentration, you can give analgetic blocks. I will give you some examples on what we are doing, what I am doing in uh the ambulatory uh ot for instances for an anterior cruciate ligament reconstruction. I will give an eye doctor Kinnel block worth 20 ML ropivacaine two mg per milliliter. I will add the exam it zone and quantity do the same with public share block and the saphenous block. And very interesting for early mobilization for food surgery is depending on the surgery to give three ml on the different nerves. You need to block once again uh block at the anchor or not easy and need some training low a dominant surgery. We do a lot of hernia repair in ambulatory surgery, short acting spinal and or an eye in Grenell block of that block or local infiltration by the surgeon. But it has to be very don't very consensi asleep. It means layer after layer and not only uh ropivacaine of bupivacaine super tennis, which doesn't work. And then we have a very interesting herb, er, arm. Uh, we perform a lot of shoulder surgery in ambulatory, a lot of hand hand surgery and we have a very large banner of blocks and anesthetic mixtures. We can use the patient. What do they want the patient? They want a good block, short acting for the motoring and long acting for the sensitive and that's not so easy. So recommendations could be that you try to choose the best block depending on the surgical indication. I use adjuvants and we all use adjuvants in my hospital. We like it because it gives a very long sensitive block. Uh and it could also prevent hyper JC post hyperalgesia, post block. So mostly all the adjuvants are off label, but they are safe to be used because we have enough literature about it. The DEXAmet ear's own, the cloNIDine, the decks, maternity, deon and magnesium or can be used without any problem. And using adjuvants, you can lower the concentration of local anesthetic. And surprisingly, uh when using enjoyments, you can work with bupivacaine 0.25 0.1 25 or ropey 0.3 75 or 0.2. And you will see you will get a good block uh hand surgery. It's sometimes very, very painful at the after after surgery when the patient is going back home. So what we try to do is to give a central block plexus block with a short acting local anaesthetic as maybe the cane or light. Okay. In. And then uh we give a super of a super particular block, which is a good option for uh to cover the tourniquet pine. And we associated with depending on the surgery or, or radio median or earner nerve of the three blocks. Uh My own nature is basically repeat that can point to with the examiner zone and cloNIDine. And I give three mili litre nerve and patient's are very happy. We found our patient's back the 1st and 2nd day and they are mostly very happy because they don't have pain. Uh the blocks with the theater over interesting surgeon suddenly in ambulatory surgery, uh it's very efficient, it works very good. But in this pandemic time, I would say perhaps it's not the best thing to do because when you have a problem and address even to complication, a problem with the patient, it's not very easy to concert rapidly. You can go to the emergency. There is uh no one. So I will requirement recommending this time, perhaps not to do it. And then the liposomal bupivacaine could be a good option and the sedation because a lot of patient, they would like they want a sedation during a local regional anesthesia. Is it safe? So, uh in this COVID time, we try to avoid a little sore generating procedure and perhaps giving oxygen is not good. So uh this very recent April 2020 presentation shows us that perhaps the wealth has thing to do is giving opposition uh through a nasal cannula at one matter. And when giving a decision through uh oral nasal mask, four liters minutes, it's only 40 centimeter inventory mask three and 33 centimeter and a non rebreathe thing mask 12 later, less than 10 centimeters. So perhaps it could be safe to give oxygen during sedation if the patient want sedation and not using an oxygen, nasal cannula but a mask. So in this difficult COVID time, locoregional aesthesia is certainly the best to avoid aerosol transmission of the COVID using all the banner in different choices we have and all the different combinations of techniques and local anesthetic, we can give wonderful anesthesia, giving sedation is possible. What oxygen administration through a mask and not uh nasal cannula. So thank you, take care and stay safe. Okay. Thank you very much Xavier. That was excellent. Uh Thank you for managing to do that live. Um So we've come to the end of this session. So we're ready for hopefully for some questions as we have Xavier on stage, dug. Do you have a question for Xavier before we ask the others? Yeah, Zevi, this this whole business of giving routine oxygen um that evidence is just coming through. So you're suggesting a nasal cannula rather than face mask, you just go over that again. I was quite interested in that. Yeah. Okay. Uh What, what we try to do first is take the patient. You don't get sedation. That's it. And then we, the nice sedation, we try not to give oxygen and when we need to give oxygen, we, now we use a mask because we know that it's suddenly safer. Mm. Okay. But try now to say to the patient you don't get any sedation. That's it. It's an interest because we don't get any, if, if, if, if it to our mask at the ot only for COVID positive patient. So, uh, we are at risk. So, uh, we try first to avoid giving, uh, sedation to our patient's. Thank you. Hopefully. Yep. I think we now have our knee. Yes, sir. I am back on. I got kicked off but I'm back on here. Arnie. Can you hear me? Yes, sir. Ok. Now, listen, I, I enjoyed that. I think that was a very thoughtful presentation and made us think a lot about patient selection and what should be doing. And, uh, we've all thought very carefully in judgment should be operating this patient or shouldn't we? But these are quite staggering statistics telling us that we should not be doing non essential surgery. Isn't that right? Indeed. Indeed. And again, this is a, there's a lot of data out there now emerging, um, as to how to best proceed and, uh, completely agree with you. If things can wait, let's just have them weight. Um, and I can tell you, at least in our system, we're really seeing that we're not we're not near pre COVID numbers for uh elective procedures such as colonoscopies or endoscopy is of any kind which is in itself where is, um because that's how you catch disease, right? But so it is a conundrum. Um uh I'm not sure that we, that we know how we should 100% best proceed. But something that is clear right now is that if we do proceed, then what happens after surgery is not just those 24 to 48 hours post operatively, which again, when I saw those numbers were staggering our system, I can tell you we are now switching to following patient's for 30 days postoperatively. And the reason is because at two weeks, three weeks out, we have seen some patient's coming back with complications at higher rates than they really should be number one. And also we're having COVID deaths because of it. So it's going to be an ongoing trend is going to be a massive wave of patient's. Uh I don't know that it will, but it is certainly happening. It is certainly worth attention. Um And think in the back of our, of our minds how to, how to best um deal with. I think that going back to what Ian was saying previously, is it reasonable to ask a patient to self isolate for a month after surgery? Probably not. We also know that even if we ask that probably will not do it anyway. Um But again, it's, it's food for thought um as to uh we whether we should be looking and I think we should uh or not. Well, it sounds like we're certainly gonna have to change your threshold's for intervention so well done. Thank you for that Claire Carlos. Yes. Yes. Excellent. Carlos. The, you give us a very realistic overview of what's happening in Portugal, but mainly in Porto obviously and we talked about face to face consultations. Now it strikes me that everybody is suggesting we only have to do remote consultations. We don't have to worry, but a surgeons, I think we do have to worry. And my worry is that major postoperative problems will be missed because people just do a quick remote call. Have you got any evidence of MS diagnosis or misdiagnosis if you like due to remote consultations? Uh Thanks doc, I totally agree with you. I think uh followers, the surgeons. Uh I think we can do some of our surgical practice uh by online, by phone. But I think the measure number of consultations, we have to do it uh with the patient first consultations and follow up after surgery and uh follow up because sometimes if we have to mainly ambulatory surgery field, if we have a patient on follow up, it's because it has any problem or any anything we have to, to rechecked. So for sure, I totally agree with you that we should go on with our patient's visiting us with the present of the patient's, I don't have any data related directly to what you asked me. But there are a lot of colleagues complaining that uh most serious patient's uh mainly oncological patient's are missing the important follow up that they should have. And this is really, uh we have to be worried with it. Yes. I mean, it's, uh, it's all very well diagnosing a hernia at two m but uh seeing everybody else and is always a problem. So I do think that maybe we've gone too far. I mean, might have to reconsider. Yes, I agree with you. But thank you very much for your contribution. That was great. Right then Doug I think we're coming to the end of our allocated time. And uh so I think uh both you and Carlos, it's a suitable time for perhaps Carlos first to wind up from the meeting and then you dug. Thank you. Yeah, just to, to say hello again to everyone. I think I, I couldn't wait on the beginning. It was not working uh to congratulate, congratulate you and that for this big effort to make possible this meeting, I think we have to meet more often. We are, we are long distance. And uh I think it is really, really important that we share our experiences, your experience in England is different. What we are doing in, in Portugal facing the same problems all over the world. I think it is really important that we can share experiencing solutions and and uh some concerns. So just to think to all of you to send a big a lot to allow our friends all over the world, remember that we have next week, the best presentations, I think you can speak a little more about that and to invite all of you to participate because we have very good, excellent papers that will be presented in one week. So thank you very much and see you whenever it is possible. Thanks, Carlos and I will be brief. I just need to thank Marianne lovely presentation Beverly as ever. And Xavier who, who thankfully found a hotel room. So congratulations for that. Uh Carlos and Nourish and Mark and Arnie says, thank you all for your presentations and most of all thank you all for two ning in and being tolerant with us. And finally, I want to thank Webmaster Ian, are given the last word. Uh It's been a difficult time. I'm sure we'll learn from this. We're going to have to make it work for the future. Uh So thank you, Ian and I will let you wind up and then enjoy a small whiskey. Thank you. Thank you. I think it will be, I think it will be a um Right. Well, I, I would like to echo what Doug has just said. I would like to thank all the presenters who put in such a huge effort to get those talks to me before the day and so that they could be online and uh and be ready for, for us to present to you today. I'd like to thank everyone who has joined us at such odd times around the world. I would like to remind you that the the talks are safe for posterity. And so your link to something that's called ever webinar will allow you back in to watch the the presentations again. And finally, as Carlos has said next Saturday at 1 p.m. we have an exciting free paper session. Uh We currently have eight papers being presented. There were nine but due to the huge COVID workload, one of the speakers has had too polite and cannot complete the video for us. But we will have 8, 10 minute presentations at 1 p.m. next Saturday. It will be exciting. There will be a jury judging those and the best one gets a free pass into our next International Congress. So it's hopefully it will be uh exciting afternoon. So once again, I like to thank everyone and say uh good bye. All right, next time in presence. Thanks Jan. And thank you thinking, thinking.