Anesthesia in the News
  • Optimal Timing for Surgery After Covid Infection

    Previously published data has shown that patients with peri-operative SARS-CoV-2 infection are at increased risk of death and pulmonary complications following surgery (CovidSurg Collaborative. Lancet 2020; Glasbey et al. Journal of Clinical Oncology 2021; and Jonker et al. Surgery 2021).  As the cumulative number of individuals who have had SARS-CoV-2 infection rises, it will be increasingly common for patients needing surgery to have previously experienced SARS-CoV-2 infection.

    One large, international study, recently published in the journal Anaesthesia, found that patients operated on within 6 weeks of SARS-CoV-2 diagnosis were at an increased risk of 30-day post-operative mortality and 30-day post-operative pulmonary complications.

    The pandemic bottleneck

    There remains a backlog of elective operations that were cancelled during the COVID-19 pandemic and its variant surges.  Even countries which have implemented widespread and effective vaccination programs, while likely to experience reductions in new COVID case infection rates, already have tens of millions of infection survivors.  Thus, pre-operative SARS-CoV-2 infection is likely to remain a surgical challenge for the foreseeable future.

    In this multicenter, prospective cohort study which included patients undergoing elective or emergency surgery during October 2020, surgical patients with pre-operative SARS-CoV-2 infection were compared with those without previous SARS-CoV-2 infection.

    The primary outcome measure was 30-day post-operative mortality.  Logistic regression models were used to calculate adjusted 30-day mortality rates stratified by time from diagnosis of SARS-CoV-2 infection to surgery.

    Infection, surgery timing, and mortality

    Among 140,231 patients from 116 countries, 3,127 patients (2.2%) had a pre-operative SARS-CoV-2 diagnosis. Adjusted 30-day mortality in patients without SARS-CoV-2 infection was 1.5% (95%CI 1.4-1.5).

    In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was increased in patients having surgery within 0 to 2 weeks, 3 to 4 weeks, and 5 to 6 weeks of the diagnosis (odds ratio [95%CI] 4.1 (3.3 to 4.8), 3.9 (2.6 to 5.1), and 3.6 (2.0 to 5.2), respectively).

    Surgery performed ≥7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline (odds ratio [95%CI] 1.5 [0.9 to 2.1]).

    After a ≥7-week delay in undertaking surgery following SARS-CoV-2 infection, the study found that patients with ongoing COVID symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic.

    The risk-benefit balance

    In summary, the research indicated that, when possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection.  Patients with ongoing symptoms ≥7 weeks from diagnosis may benefit from even further delay.

    While the study authors sought to determine the optimal duration from infection to operation, they emphasize that their study’s findings should support informed and shared decision-making by anesthesia providers, surgeons, and patients.

    “Decisions should be tailored for each patient, since the possible advantages of delaying surgery for at least 7 weeks following SARS-CoV-2 diagnosis must be balanced against the potential risks of delay,” the authors state.  “For some urgent surgical procedures, such as resection of advanced tumors, providers and patients may decide that the risks of delay are not justified.”

    Click through to the complete study, “Timing of surgery following SARS-CoV-2 infection: an international prospective cohort study.” Anaesthesia. 2021 Jun;76(6):748-758., via:

    https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/epdf/10.1111/anae.15458