How to Keep Pediatric Organ Transplant Patients Safe in the COVID-19 Era

The novel coronavirus is challenging pediatric hospitals to rethink how we deliver all kinds of health care and this is especially true of care for organ transplant patients. At Children’s Health℠, Children’s Medical Center Dallas we have continued performing transplants during the pandemic, and we quickly modified key practices and protocols to minimize risk of COVID-19 exposure among patients and staff. From devising new precautions around anesthesia to deciding whether to modify patients’ immunosuppressant dosage, our team has implemented several new practices that are keeping patients safe and could be informative to other centers.

“We’ve completed five transplants and continued care for dozens of post-transplant patients since COVID-19 struck,” says Dev M. Desai, M.D., PhD, Pediatric Transplant Surgeon at Children’s Health and Professor at UT Southwestern. “Thanks to our team’s rapid response and commitment to safety, none of our patients or staff have gotten the virus and the quality of our care remains as high as ever.” 

Pivoting to Address COVID-19

The transplant team implemented changes in early March, when there was little data about whether immunosuppressed patients were more vulnerable to COVID-19, about the risk for children or about whether they can be asymptomatic carriers.

“There was just a broad notion that children had lower infection rates and might be more protected than adults,” Dr. Desai says.

Still, Dr. Desai and his colleagues sprung into action and made the best decisions they could based on guidance from the Centers for Disease Control and other key agencies. Within five days, they pulled together a comprehensive plan to keep patients and staff safe.

Protecting Post-Transplant Patients from COVID-19

The team’s first order of business was to find ways to avoid in-person appointments that weren’t essential. They did this by sorting patients who have undergone transplant into three groups.

The first group consists of patients with no health concerns who were due for a regular checkup. The team delayed these appointments until June — rightly anticipating that it would take months to resume many face-to-face encounters.

The team identified a second set of patients who had medical issues that could need a physician’s input, but didn’t necessarily need to be seen in person. Dr. Desai and his colleagues started seeing these appointments via telehealth. 

Finally, patients who needed to be seen in clinic fell into a third category, for which the team established new protocols: After signing in, patients go directly to an exam room, where they stay for the entire appointment. All activities, from weighing the patient to taking blood draws, happen in that room, and all staff come to the patient. 

“That way, the only people that patients interact with are wearing the correct personal protective equipment (PPE), and the only space they spend time in is sanitized between each use,” Dr. Desai explains.

Another key question was whether to alter dosage of the immunosuppressants that stop the body from rejecting a transplanted organ, but also make patients more susceptible to viruses. Even in non-pandemic times, doctors will sometimes reduce immunosuppressant drugs to help ward off sickness. But Dr. Desai’s team decided this wasn’t necessary against COVID-19.

“As long as our patients shelter at home, their risk of infection is low,” he says, “so the best thing for them is to stay the course and make sure their risk of rejection remains low.” 

Deciding Which Solid Organ Transplants to Postpone

Some transplant surgeries are urgent, but others are less time-sensitive. So, the team made key decisions about which transplants to postpone.

All transplants from living donors were postponed. Transplants from deceased donors were allowed to continue, but the team contacted all patients to ask whether they wanted to postpone or keep their spot on the transplant list.

“Kids awaiting kidneys can cope well with dialysis, so many of them deferred. But when you need a new heart or liver, it’s potentially much more urgent,” Dr. Desai says.

Modifying How Anesthesia is Delivered

Since implementing its new protocols, the team has completed three liver transplants and two kidney transplants. Children’s Health tests all transplant recipients for the coronavirus, regardless of symptoms, and no patient has tested positive prior to surgery. Still, the team took extra precautions, including modifying how anesthesia is delivered in the operating room.

Intubating a patient aerosolizes a large number of particles from the patient’s lungs and esophagus, then releases them into the environment. If a patient has COVID-19, this could expose the OR team. Per the new protocol, an anesthesiologist intubates patients alone in the OR, wearing an N95 mask. All other staff stay outside the room until the air in the OR is allowed to circulate three times, which takes about 18 minutes. Then the team can enter and proceed, wearing standard surgical masks and scrubs.

“Having the anesthesiologist do the intubation alone is a simple change that lowers risk and conserves PPE at the same time,” Dr. Desai says.

Other protections for staff have included a rotating work-from-home schedule, where one coordinator from each organ team — heart, liver and kidney — works a full week in the clinic followed by two full weeks at home.

“This keeps our team as healthy as possible, and it also reduces the risk that we’ll all get infected at the same time and have to interrupt patient care,” Dr. Desai says.

Resuming In-Person Care

Along with the wider reopening of businesses and services across Texas, the transplant team has begun lifting some of its coronavirus-related restrictions. The in-clinic precautions remain in place, but the team is seeing more patients for in-person evaluations.

“With everything we’ve learned since March — including about the multisystem inflammatory disease that many kids have developed — we know that being proactive was the right call,” Dr. Desai says. “Now we’re confident that it’s safe to see people again, and if we have to tighten restrictions again, we’ve proven we can do that quickly and effectively too.”

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