Summary Concise guidelines are presented that relate abnormalities of coagulation, whether the result of the administration of drugs or that of pathological processes, to the consequent haemorrhagic risks associated with neuraxial and peripheral nerve blocks. The advice presented is based on published guidelines and on the known properties of anticoagulant drugs. Four separate Tables address risks associated with anticoagulant drugs, neuraxial and peripheral nerve blocks, obstetric anaesthesia and special circumstances such as trauma, sepsis and massive transfusion.

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Summary Maintaining safe elective surgical activity during the global coronavirus disease 2019 (COVID‐19) pandemic is challenging and it is not clear how COVID‐19 may impact peri‐operative morbidity and mortality in this population. Therefore, adaptations to normal care pathways are required. Here, we establish if implementation of a bespoke peri‐operative care bundle for urgent elective surgery during a pandemic surge period can deliver a low COVID‐19‐associated complication profile. We present a single‐centre retrospective cohort study from a tertiary care hospital of patients planned for urgent elective surgery during the initial COVID‐19 surge in the UK between 29 March and 12 June 2020. Patients asymptomatic for COVID‐19 were screened by oronasal swab and chest imaging (chest X‐ray or computed tomography if aged ≥ 18 years), proceeding to surgery if negative. COVID‐19 positive patients at screening were delayed. Postoperatively, patients transitioning to COVID‐19 positive status by reverse transcriptase polymerase chain reaction testing were identified by an in‐house tracking system and monitored for complications and death within 30 days of surgery. Out of 557 patients referred for surgery (230 (41.3%) women; median (IQR [range]) age 61 (48–72 [1–89])), 535 patients (96%) had COVID‐19 screening, of which 13 were positive (2.4%, 95%CI 1.4–4.1%). Out of 512 patients subsequently undergoing surgery, 7 (1.4%) developed COVID‐19 positive status (1.4%, 95%CI 0.7–2.8%) with one COVID‐19‐related death (0.2%, 95%CI 0.0–1.1%) within 30 days. Out of these seven patients, four developed pneumonia, of which two required invasive ventilation including one patient with acute respiratory distress syndrome. Low rates of COVID‐19 infection and mortality in the elective surgical population can be achieved within a targeted care bundle. This should provide reassurance that elective surgery can continue, where possible, despite high community rates of COVID‐19.

Therapeutic study, level IV.

The impact of COVID-19 pandemic on pediatric surgical care systems is unknown. We present an initial evaluation of self-reported pediatric surgical policy changes from hospitals across North America. Methods: On March 30, 2020, an online open access, data gathering spreadsheet was made available to pediatric surgeons through the American Pediatric Surgical Association (APSA) website, which captured information surrounding COVID-19 related policy changes. Responses from the first month of the pandemic were collected. Open-ended responses were evaluated and categorized into themes and descriptive statistics were performed to identify areas of consensus. Results: Responses from 38 hospitals were evaluated. Policy changes relating to three domains of program structure and care processes were identified: internal structure, clinical workflow, and COVID-19 safety/prevention. Interhospital consensus was high for reducing in-hospital staffing, limiting clinical fellow exposure, implementing telehealth for conducting outpatient clinical visits, and using universal precautions for trauma. Heterogeneity in practices existed for scheduling procedures, implementing testing protocols, and regulating use of personal protective equipment. Conclusions: The COVID-19 pandemic has induced significant upheaval in the usual processes of pediatric surgical care. While policies evolve, additional research is needed to determine the effect of these changes on patient and healthcare delivery outcomes.

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Objective Early reports suggest that patients with COVID-19 infection carry a significant risk of altered coagulation with an increased risk for venous thromboembolic events. This report investigates the relationship of significant COVID-19 infection and deep venous thrombosis (DVT) as reflected in the patient clinical/laboratory characteristics. Methods We reviewed demographics, clinical presentation, laboratory/radiological evaluations, Results of venous duplex imaging and mortality of COVID-19 positive patients (18-89 years) admitted to the Indiana University Academic Health Center. Using oxygen saturation, radiological findings and need for advanced respiratory therapies; patients were classified into mild, moderate or severe categories of COVID-19 infection. Descriptive analysis was performed using univariate and bivariate Fisher’s exact and Wilcoxon rank-sum tests to examine the distribution of patient characteristics and compare the DVT outcomes. A multivariable logistic regression model was used to estimate the Adjusted Odds Ratio of experiencing DVT while a Receiver Operating Curve (ROC)analysis to identify the optimal cutoff for d-dimer to predict DVT in this COVID-19 cohort. Time to the diagnosis of DVT from admission was analyzed using log-rank test and Kaplan Meier plots. Results Our study included 71 unique COVID-19 positive patients (mean age 61 years) categorized as having 3% mild, 14% moderate and 83% severe infection and evaluated with 107 venous duplex studies. DVT was identified in 47.8% of patients (37% examinations) at an average of 5.9 days post admission. Patients with DVT were predominantly male (67%, p =0.032) with proximal venous involvement. (29% upper and 39% in the lower extremities with 55% of the latter demonstrating bilateral involvement). Patients with DVT had a significantly higher mean d-dimer of 5447 ng/ml (SD 7032, p=0.0101), and Alkaline Phosphatase (Alk Po4) of 110 IU/L (p=0.0095) than those without DVT. On multivariable analysis, elevated d-dimer (p=0.038) & Alk Po4 (p=0.021) were associated with risk for DVT while age, gender, elevated CRP and ferritin levels were not. ROC analysis suggests an optimal d-dimer value of 2450 ng/ml cutoff with 70% sensitivity, 59.5% specificity, and 61% positive and 68.8% negative predictive values. Conclusion This study suggests that males with severe COVID-19 infection requiring hospitalization are at highest risk for developing DVT. Elevated d-dimers, Alk Po4 along with our multivariable model can alert the clinician to the increased risk of DVT requiring early evaluation and aggressive treatment