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: Delirium is a common complication after surgery in the elderly that leads to increased length of stay and other adverse outcomes. The aim of this study was to better understand the exact causes of post-operative delirium in patients undergoing surgery for neck of femur (NOF) fractures.Methods: We performed a prospective cohort study of 381 consecutive patients undergoing surgery for NOF fractures at a single institution. Baseline cognitive status and risk factors were recorded on admission. Post-operative cognitive status was assessed at regular intervals until discharge. Binary logistic regression was performed to identify independent predictors of delirium.Results: Patients who developed post-operative delirium (n = 70) were significantly older (average age 83 vs. 78, p = 0.019) and more likely to be female (79% vs. 67%, p = 0.062) than non-affected patients. The presence of delirium was associated with increased length of stay (13 vs. 10 days, p = 0.001) and 1-year mortality (25.7% vs. 15% p = 0.03). Independent predictors of delirium included age ≥65 years (Odds Ratio = 5.8), presence of anaemia (OR = 2.9), hypoxia (OR = 2.86), cardiac disease (OR = 2.8), Chronic Obstructive Pulmonary Disease (OR = 2.5), new onset electrolyte imbalance (OR = 2.2) and renal failure (OR = 1.9).Conclusion: Overall analysis demonstrated an increased incidence of delirium in older females with greater comorbid conditions. It was also found to be associated with increased morbidity and mortality. We recommend clinicians put greater effort into recognising risk factors of delirium and diagnosing it in a timely manner to mitigate its effects.

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BackgroundManagement of displaced mid-shaft clavicle fractures is controversial. Non-operative treatment can lead to shortening, a risk factor for non-union and poor functional outcomes. These inferior results have resulted in authors recommending surgical fixation for fractures with significant shortening. The aim of this systematic review is to analyse the effect of fracture shortening on shoulder function and non-union rate in non-operatively managed displaced mid-shaft clavicle fractures. MethodsA review of the online databases Medline and EMBASE was conducted in accordance with the PRISMA guidelines on the 16 th February 2018. The review was registered prospectively on the PROSPERO database. Clinical studies with mid-shaft clavicle fractures treated non-operatively reporting an evaluation of the degree of clavicle shortening, and either shoulder function and/or non-union were included. The studies were appraised using the Methodological index for non-randomised studies tool. ResultsThe search strategy identified 16 studies eligible for inclusion. Four studies were randomised controlled trials (RCTs) and twelve were non-randomised retrospective comparative studies. Eleven of the twelve case series failed to demonstrate any correlation between shortening and shoulder outcome scores. Of the four RCTs, three reported no significant association between fracture shortening and shoulder outcome *Manuscript Click here to view linked References Shortened, displaced mid-shaft clavicle fractures 2 scores. The studies also failed to demonstrate a significant association between nonunion and the presence of clavicle shortening. ConclusionThere is no significant association between fracture shortening and non-union rates or shoulder outcome scores in displaced mid-shaft clavicle fractures managed nonoperatively.