Timing of elective surgery after COVID-19 infection: Recent consensus recommendations

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.