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Created January 20, 2022, last updated over 2 years ago.
Collection: 150, Score: 771, Trend score: 0, Read count: 1154, Articles count: 4, Created: 2022-01-20 07:46:30 UTC. Updated: 2022-01-28 03:21:32 UTC.Notes
In 2020 the COVID Surg Collaborative demonstrated a shockingly-increased post-operative mortality among patients undergoing surgery during an active COVID infection.
This naturally led to questions regarding timing of elective surgery after COVID-19 recovery.
Although data is scant, the COVID Surg Collaborative again leads the way with a large multicenter study showing increased 30 day mortality even when surgery is delayed 5-6 weeks after COVID infection.
Various guidelines and recommendations exist, but summarising:
Surgery should be delayed for at least 7 weeks after COVID, although those with persistent COVID symptoms will still have more than twice the 30-day mortality than those without. (COVID Surg Collaborative 2021)
After recovery from SARS-CoV-2 infection, minor surgery should be delayed 4 weeks and major surgery delayed 8-12 weeks. (Kovoor 2021)
Elective surgery should not be scheduled within 7 weeks of a SARS-CoV-2 infection. (El-Boghdadly 2021)
Several studies note that these periods are minimum recommended delays, and that patients with persisting symptoms still experience higher 30-day mortality even after delaying seven weeks. El-Boghdadly et al. suggests that this period should be used for functional prehabilitation for these patients.
Daniel Jolley
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Collected Articles
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Multicenter Study
Timing of surgery following SARS-CoV-2 infection: an international prospective cohort study.
Surgery should be delayed for at least 7 weeks after COVID, although those with persistent COVID symptoms will still have more than twice the 30-day mortality than those without.
pearl -
After recovery from SARS-CoV-2 infection, minor surgery should be delayed 4 weeks and major surgery delayed 8-12 weeks.
pearl -
Elective surgery should not be scheduled within 7 weeks of a SARS-CoV-2 infection.
pearl -
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.
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