Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS-CoV-2 infection. This international, multicentre, prospective cohort study 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 postoperative 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. Among 140,231 patients (116 countries), 3127 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 0-2 weeks, 3-4 weeks and 5-6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3-4.8), 3.9 (2.6-5.1) and 3.6 (2.0-5.2), 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 (0.9-2.1)). After a ≥ 7 week delay in undertaking surgery following SARS-CoV-2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2-8.7) vs. 2.4% (95%CI 1.4-3.4) vs. 1.3% (95%CI 0.6-2.0), respectively). Where 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 further delay.
SARS-CoV-2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri-operative or prior SARS-CoV-2 were at further increased risk of venous thromboembolism. We conducted a planned sub-study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS-CoV-2 diagnosis was defined as peri-operative (7 days before to 30 days after surgery); recent (1-6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre-operative anti-coagulation for baseline comorbidities was not available. Postoperative venous thromboembolism rate was 0.5% (666/123,591) in patients without SARS-CoV-2; 2.2% (50/2317) in patients with peri-operative SARS-CoV-2; 1.6% (15/953) in patients with recent SARS-CoV-2; and 1.0% (11/1148) in patients with previous SARS-CoV-2. After adjustment for confounding factors, patients with peri-operative (adjusted odds ratio 1.5 (95%CI 1.1-2.0)) and recent SARS-CoV-2 (1.9 (95%CI 1.2-3.3)) remained at higher risk of venous thromboembolism, with a borderline finding in previous SARS-CoV-2 (1.7 (95%CI 0.9-3.0)). Overall, venous thromboembolism was independently associated with 30-day mortality ). In patients with SARS-CoV-2, mortality without venous thromboembolism was 7.4% (319/4342) and with venous thromboembolism was 40.8% (31/76). Patients undergoing surgery with peri-operative or recent SARS-CoV-2 appear to be at increased risk of postoperative venous thromboembolism compared with patients with no history of SARS-CoV-2 infection. Optimal venous thromboembolism prophylaxis and treatment are unknown in this cohort of patients, and these data should be interpreted accordingly.
Background: Appendicitis is the most common surgical emergency affecting children. Rurality has been shown to be a predictor of worse surgical outcomes in patients with acute appendicitis compared to urban residents. There are no previously published studies investigating this in Australasia. Methods: A 10-year retrospective study of all patients aged ≤16 years who underwent an acute appendicectomy in Northland, New Zealand, was conducted. The cohort was identified by searching the hospital database for theatre events and admission diagnoses coded as appendicitis. Primary outcome of interest was the difference in the American Association for the Surgery of Trauma (AAST) anatomical severity grading of appendicitis and the Clavien-Dindo complication rate. The role of ethnicity was also examined. Results: A total of 470 children underwent appendicectomy during this period. On multivariate analysis, increased AAST grade was twice as likely in rural patients (odds ratio 2.04). Post-operatively, rural patients had higher Clavien-Dindo complication grade (P = 0.001), longer median length of stay and increased rates of intra-abdominal collection (19% versus 4%; P = 0.018), 30-day readmission (19% versus 4%; P = 0.020) and perforation (27% versus 19%; P = 0.031). M aori children had increased perforation rates (28.9% versus 19.0%; P = 0.014) but ethnicity was not found to be independently associated with increasing AAST grade. Conclusion: Accounting for ethnicity, socio-economic deprivation and age, we implicate rural patient status as being associated with increasing severity and complicated paediatric appendicitis. This work adds to the evolving description of inequities in rural health outcomes. Further prospective studies are needed to confirm these findings at a national level.
Background Appendicitis is the most common reason children undergo emergency general surgery. Worse appendicitis outcomes have been demonstrated in rural, lower socioeconomic, and indigenous populations. These findings are hypothesised to be a result of differential access and delay in presentation to hospital. However, no qualitative study has investigated why prehospital delay may exist. Methods We conducted individual, semi‐structured interviews with the parents of 11 rural children who presented with acute appendicitis between June 2019–January 2020. Utilising grounded theory methodology, we created an exploratory framework. Results Participating families travelled a mean distance of 50.4 km to access hospital, and the median prehospital symptom duration was 42 h. Families with reduced financial or social resources were more likely to ‘watch and wait’ due to the increased relative burden of access. Key considerations were travel, organising childcare and parental income loss in a rural environment. Structural healthcare barriers further dissuaded prompt access and subsequent engagement. These included poor cultural safety, maldistribution of rural health services, and contradictory public health messages. Several families sought informal community‐based health advice to mitigate these barriers, leading to earlier hospital presentation. Conclusion Prehospital delay in rural families occurred most frequently due to an extended decision‐making phase where families evaluated the costs and benefits of accessing hospital‐level care. The utilisation of informal community expertise and whānau advocacy helped circumvent reduced access to health facilities. Cultural safety remains problematic and hinders engagement with Māori families.
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