• Lancet · Jul 2020

    Multicenter Study

    Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study.

    This massively-multicenter (235 hospitals, 24 countries; mainly Europe & N. America) cohort study investigated post-operative morbidity and mortality in those with confirmed SARS-CoV-2 infection.

    Why is this significant?

    Early data suggested that COVID-19 patients who underwent even minor elective surgery suffered worse post-operative outcomes, particularly higher mortality.

    This large cohort study confirms these concerns and will assist decision making around the timing of surgery for COVID-19 patients and the process for re-commencing elective surgery in communities hardest hit by the pandemic.

    What did they do?

    Over a 3 month period in early 2020 the researchers analysed 1,128 patients who underwent emergency (74%) or elective (25%) surgery across 24 countries. Patients diagnosed with COVID seven days pre-op or 30 days post-op were included, although the majority of patients (74%) had SARS-CoV-2 infection diagnosed post-operatively.

    And they found?

    30-day mortality was extremely high (24%).

    Pulmonary complications (pneumonia, ARDS or unexpected post-op ventilation) were very common (51%) and were associated with an even higher mortality (38%; and 83% of all deaths).

    Mortality was unsurprisingly associated with older age ≥ 70 years, male sex, ASA ≥ 3, emergency surgery, major surgery, and malignancy.

    Other interesting observations...

    • Nonetheless 'lower-risk' groups still suffered significant 30-day mortality rates, eg. 30-49 year olds (6%), women (18%), ASA 1-2 (12%), no-comorbidities (7%).
    • Being asymptomatic at admission did not have a significant protective effect (22% vs 27% mortality).
    • Dyspnoea and/or sputum on admission were the only symptoms associated with worse outcomes.
    • 20% of patients suffered ARDS, with a 63% mortality rate.
    • Although emergency surgery was higher risk, elective surgery still carried a 19% mortality rate. Even minor surgery resulted in a 16% mortality rate!
    • Even obstetrics (2% mortality) and gynaecology (5%) demonstrated orders of magnitude-higher mortality than expected.
    • There was no statistically significant difference between local, regional or general anaesthesia.
    • Pulmonary embolus was only seen in 2% at 30 days and when present did not appear to impact mortality.

    Why such high post-operative COVID mortality?

    The authors suggest this could be due to the combination of pro-inflammatory cytokine and immunosuppressive responses to surgery, and/or mechanical ventilation associated with general anaesthesia (although the later was not significantly associated with higher mortality).

    Implications

    Surgery for those with known or suspected COVID-19 should be avoided or delayed until after recovery from infection, as allowed by the underlying surgical pathology. When surgery cannot be delayed less-invasive surgery is preferable, and post-operative recovery should be closely monitored.

    Keep in mind

    Although RT-PCR testing was the main diagnostic test, in some settings clinical criteria (6%) and/or chest CT (7%) were instead used for diagnosis. Additionally, hospital data collection during a pandemic emergency carries higher risk of error, although this should not effect the broad validity of the research conclusions.

    summary
    • COVIDSurg Collaborative.
    • Lancet. 2020 Jul 4; 396 (10243): 27-38.

    BackgroundThe impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection.MethodsThis international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation.FindingsThis analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28-2·40], p<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65-3·22], p<0·0001), American Society of Anesthesiologists grades 3-5 versus grades 1-2 (2·35 [1·57-3·53], p<0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01-2·39], p=0·046), emergency versus elective surgery (1·67 [1·06-2·63], p=0·026), and major versus minor surgery (1·52 [1·01-2·31], p=0·047).InterpretationPostoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery.FundingNational Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.

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    Notes

    summary
    1

    This massively-multicenter (235 hospitals, 24 countries; mainly Europe & N. America) cohort study investigated post-operative morbidity and mortality in those with confirmed SARS-CoV-2 infection.

    Why is this significant?

    Early data suggested that COVID-19 patients who underwent even minor elective surgery suffered worse post-operative outcomes, particularly higher mortality.

    This large cohort study confirms these concerns and will assist decision making around the timing of surgery for COVID-19 patients and the process for re-commencing elective surgery in communities hardest hit by the pandemic.

    What did they do?

    Over a 3 month period in early 2020 the researchers analysed 1,128 patients who underwent emergency (74%) or elective (25%) surgery across 24 countries. Patients diagnosed with COVID seven days pre-op or 30 days post-op were included, although the majority of patients (74%) had SARS-CoV-2 infection diagnosed post-operatively.

    And they found?

    30-day mortality was extremely high (24%).

    Pulmonary complications (pneumonia, ARDS or unexpected post-op ventilation) were very common (51%) and were associated with an even higher mortality (38%; and 83% of all deaths).

    Mortality was unsurprisingly associated with older age ≥ 70 years, male sex, ASA ≥ 3, emergency surgery, major surgery, and malignancy.

    Other interesting observations...

    • Nonetheless 'lower-risk' groups still suffered significant 30-day mortality rates, eg. 30-49 year olds (6%), women (18%), ASA 1-2 (12%), no-comorbidities (7%).
    • Being asymptomatic at admission did not have a significant protective effect (22% vs 27% mortality).
    • Dyspnoea and/or sputum on admission were the only symptoms associated with worse outcomes.
    • 20% of patients suffered ARDS, with a 63% mortality rate.
    • Although emergency surgery was higher risk, elective surgery still carried a 19% mortality rate. Even minor surgery resulted in a 16% mortality rate!
    • Even obstetrics (2% mortality) and gynaecology (5%) demonstrated orders of magnitude-higher mortality than expected.
    • There was no statistically significant difference between local, regional or general anaesthesia.
    • Pulmonary embolus was only seen in 2% at 30 days and when present did not appear to impact mortality.

    Why such high post-operative COVID mortality?

    The authors suggest this could be due to the combination of pro-inflammatory cytokine and immunosuppressive responses to surgery, and/or mechanical ventilation associated with general anaesthesia (although the later was not significantly associated with higher mortality).

    Implications

    Surgery for those with known or suspected COVID-19 should be avoided or delayed until after recovery from infection, as allowed by the underlying surgical pathology. When surgery cannot be delayed less-invasive surgery is preferable, and post-operative recovery should be closely monitored.

    Keep in mind

    Although RT-PCR testing was the main diagnostic test, in some settings clinical criteria (6%) and/or chest CT (7%) were instead used for diagnosis. Additionally, hospital data collection during a pandemic emergency carries higher risk of error, although this should not effect the broad validity of the research conclusions.

    Daniel Jolley  Daniel Jolley
    pearl
    1

    Post-operative mortality in patients with SARS-CoV-2 infection having surgery is extremely high, even among low-risk patient or surgical groups, or those initially asymptomatic.

    Daniel Jolley  Daniel Jolley
    comment
    0

    Related editorial in Anaesthesia (May 2020) from Cook & Harrop-Griffiths:

    Kicking on while it's still kicking off - getting surgery and anaesthesia restarted after COVID-19.

    Daniel Jolley  Daniel Jolley

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