Safety: When Can COVID-19 Patients Undergo Surgery?

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Questions persist about delaying elective procedures following infection.


NOT SO SIMPLE Although the largest surgical study in history advises a delay of seven weeks between a positive COVID-19 diagnosis and elective surgery, numerous variables make that recommendation far from universal.

There is currently no clear consensus for when it’s safe to operate on patients who are recovering from COVID-19. A baseline was set in March with the publication of an international, multicenter study by the enormous COVIDSurg and GlobalSurg Collaboratives (osmag.net/AEg5Xs). The largest collaborative surgical study to date compared more than 140,000 patients in 116 countries who underwent elective or emergency surgeries in October 2020, with the goal of determining the optimal length of delay for recovering COVID-19 patients to undergo surgery.

The data overwhelmingly identified the sweet spot as seven weeks from initial diagnosis. For patients who had surgery within zero to two weeks of infection, the adjusted 30-day mortality rate was 4.1%. At three to four weeks, it was 3.9%. At five to six weeks, it dropped to 3.6%. With surgeries performed seven or more weeks after infection, however, the rate plummeted to 1.5% — essentially the same rate of non-infected patients involved in the study. These findings were consistent across patients who would be considered low-risk and high-risk before the pandemic due to age and ASA physical status scores.

“This study’s findings should support informed shared decision-making by anesthetists, surgeons and patients,” write the researchers. “Decisions should be tailored for each patient, since the possible advantages of delaying surgery for at least seven weeks following COVID-19 diagnosis must be balanced against the potential risks of delaying surgery.”

In January, researchers at Oregon Health and Science University (OHSU) published a protocol  that establishes strict timelines and extensive screening for patients recovering from COVID-19 (osmag.net/5rtJFQ). Paying particular attention to COVID “long haulers” — patients who have not fully recovered weeks or months after being infected — they screen for fatigue, respiratory problems, joint and chest pain, cognitive and sleep issues, and loss of taste and/or smell to better determine risk. Here’s how it works:

• Patients scheduled for elective surgeries under general anesthesia who have had a positive COVID-19 test undergo a comprehensive preoperative history and physical examination. COVID-19 symptoms must be completely resolved, with a minimum recovery time of four weeks for asymptomatic patients and six to eight weeks for symptomatic patients.

• The provider and the patient discuss the individual’s personal course with the disease, while the provider logs signs and symptoms of potential subclinical coronavirus-related complications and determines whether the patient has returned to a pre-COVID-19 baseline of health. Functional capacity is assessed, and oxygen saturation is measured. Patients older than 65 years and those previously hospitalized for COVID-19 undergo an Edmonton Frail Scale assessment.

• Patients are objectively tested based on the severity of symptoms they experienced, the complexity of the surgery and the need for general anesthesia. Cardiopulmonary function, coagulation status, markers of inflammation and nutritional status are tested because they have been shown to be disturbed by COVID-19. Abnormal values, the researchers say, may indicate incomplete resolution of the disease, which could lead to increased risk of surgical complications.

• Patients with normal results proceed to surgery after the minimum wait period, while those displaying any significant abnormalities trigger multidisciplinary discussion and consultation with other specialties as appropriate. These patients are provided detailed risk-benefit counseling and goals-of-care discussions before proceeding to surgery. 

“We know that patients who undergo surgery with active COVID-19 infection fare significantly worse, but the timeline for recovery remains nebulous,” say the OHSU researchers. “The onus is on providers to view contracting and recovering from COVID-19 as they do any other serious medical event, with appropriate presurgical evaluation to prepare and optimize these patients for elective surgery.” OSM

 

How Long Should Surgery Be Postponed?
NATIONAL GUIDELINES

Some of the leading surgical organizations have weighed in on how long elective surgeries should be delayed for patients recovering from COVID-19. Here’s a round-up of their recommendations:  

• American Society of Anesthesiologists. The ASA issued a joint statement with the Anesthesia Patient Safety Foundation (APSF) that suggests delaying surgery after infection for four weeks for asymptomatic patients or recovering patients who suffered only mild nonrespiratory disease; six weeks for patients with respiratory symptoms who weren’t hospitalized; eight to 10 weeks for symptomatic patients who are diabetic, immunocompromised or were hospitalized; and 12 weeks for patients who were admitted to ICUs (osmag.net/YH9Vey). However, those timelines are not definitive. “Each patient’s risk assessment should be individualized, factoring in surgical intensity, patient comorbidities, and the benefit/risk ratio of further delaying surgery,” advises the statement.

The groups warn to account for COVID-19’s impact on major organs throughout the body, citing in particular patients with upper respiratory infections and diabetes as exceptionally risky, and express concern about postoperative pulmonary complications. They also address common residual symptoms of COVID-19 such as fatigue, shortness of breath and chest pain, which can be present more than two months after diagnosis, as well as long-term deleterious effects on myocardial anatomy and function. “A more thorough preoperative evaluation, scheduled further in advance of surgery with special attention given to the cardiopulmonary systems, should be considered in patients who have recovered from COVID-19 and especially those with residual symptoms,” says the statement.

• American College of Surgeons. The organization has not issued an official recommendation about the optimal length of delay. To help inform the decision-making of its members, ACS points to a March study in the British Journal of Surgery that recommends prioritizing vaccination of patients preparing to undergo elective surgeries (osmag.net/FtZW9s). 

• American Academy of Orthopedic Surgeons. The AAOS stands by its own recommendations, which don’t provide clear guidance on how long surgery should be delayed for recovering patients. The recommendations do note that patients who undergo surgery while suffering from COVID-19 are at increased risk of mortality and morbidity, and cases in these instances should be delayed until the infection is resolved (osmag.net/s6nNYQ). 

• American Academy of Ophthalmology. The AAO also points to its own recommendations, originally posted last May but updated in late March, which provide guidance for numerous specific eye procedures (osmag.net/9EpkYD). These guidelines cite recommendations from ASA and APSF. —JP

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