Timing of elective surgery after COVID-19 infection: Recent consensus recommendations
UK: A recent study in the journal Anaesthesia reports a multidisciplinary consensus statement for the timing of elective surgery and risk assessment after SARS-CoV-2 infection. The update was released on behalf of the Association of Anaesthetists, Centre for Perioperative Care, Federation of Surgical Specialty Associations, Royal College of Anaesthetists, Royal College of Surgeons of England.
K. El-Boghdadly, King's College London, UK, and colleagues aimed to update previously published consensus recommendations on timing of elective surgery after SARS-CoV-2 infection to assist policymakers, administrative staff, clinicians and patients.
Given below are the key recommendations:
- There is currently no evidence on peri-operative outcomes after SARS-CoV-2 vaccination and the omicron variant. Therefore, previous recommendations that, where possible, patients should avoid elective surgery within 7 weeks of SARS-CoV-2 infection remain, unless the benefits of doing so exceed the risk of waiting. We recommend individualised risk assessment for patients with elective surgery planned within 7 weeks of SARS-CoV-2 infection.
- Surgical patients should have received pre-operative COVID-19 vaccination, with three doses wherever possible, with the last dose at least 2 weeks before surgery. Confirming and optimising vaccination status should be actioned as soon as possible, either before primary care referral or at surgical decision-making.
- Current measures designed to reduce the risk of patients acquiring SARS-CoV-2 infection in the peri-operative period should continue and, in view of the increased transmissibility of omicron, should be augmented (e.g. respiratory protective equipment) where evidence supports this.
- Patients should be requested to notify the surgical team if they test positive for SARS-CoV-2 infection within 7 weeks of their planned operation date. From there, a conversation should take place between the peri-operative team and the patient about the risks and benefits of deferring surgery.
- Elective surgery should not take place within 10 days of diagnosis of SARS-CoV-2 infection, predominantly because the patient may be infectious, which is a risk to surgical pathways, staff and other patients.
- Asymptomatic SARS-CoV-2 infection with previous variants increased mortality risk three-fold throughout the 6 weeks after infection. Given the lack of evidence with peri-operative omicron infection, assumptions that asymptomatic or mildly symptomatic infection does not add risk are currently unfounded.
- If elective surgery is considered within 7 weeks of diagnosis of SARS-CoV-2 infection, we recommend multidisciplinary discussions with the patient occur with documentation of the risks and benefits.
- All patients should have their risk of mortality (and complications, where possible) calculated using a validated risk score.
- Risk modifiers based on patient factors (age; comorbid status); SARS-CoV-2 infection (timing; severity of initial infection; ongoing symptoms); and surgical factors (clinical priority; risk of disease progression; complexity of surgery) can then be applied to help estimate how underlying risk would be altered by undertaking surgery within 7 weeks of infection.
- Patients should be advised that a decision to proceed with surgery within 7 weeks will be pragmatic rather than evidence-based.
- Patients with persistent symptoms and those with moderate-to-severe COVID-19 (e.g. those who were hospitalised) remain likely to be at greater risk of morbidity and mortality, even after 7 weeks. Therefore, delaying surgery beyond this point should be considered, balancing this risk against any risks associated with such delay.
- In patients with recent or peri-operative SARS-CoV-2 infection, avoidance of general anaesthesia in favour of local or regional anaesthetic techniques should be considered.
- Rather than emphasising timing alone, we emphasise timing, assessment of baseline and increased risk, and shared decision-making.
- All patients awaiting surgery should address modifiable risk-factors, such as through pre-operative exercise, nutritional optimisation and stopping smoking.
"While these recommendations focus on the omicron variant and current evidence, the principles may also be of relevance to future variants. As further data emerge, these recommendations may be revised," the authors concluded.
Reference:
Timing of elective surgery and risk assessment after SARS-CoV-2 infection: an update, was published in the journal Anaesthesia.
DOI: https://doi.org/10.1111/anae.15699
KEYWORDS: Anaesthesia journal, SARS-CoV-2 infection, elective surgery, risk assessment, peri-operative, K El-Boghdadly, COVID-19, surgery
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