Timing of surgery and elective perioperative management of patients with previous SARS-CoV-2 infection: a SIAARTI expert consensus statement

Abstract

Background The appropriate timing of surgery and perioperative management of patients with previous SARS-CoV-2 infection are open issues. The purpose of this document is to support the clinical decision-making process regarding the patient with previous Sars-CoV-2 infection to undergo elective surgery. The recipients of this document are physicians, nurses, healthcare personnel, and other professionals involved in the patient’s surgical process. Methods The Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) selected 11 experts to reach a consensus on key aspects of this theme in adult and pediatric population. The methods of this process document were in accordance to the principles of rapid review of the scientific literature and modified Delphi method. The experts produced statements and supporting reasons in the form of an informative text. The overall list of statements was subjected to a vote in order to express the degree of consent. Results Patients should not undergo elective surgery within 7 weeks of infection unless there is the risk of a negative evolution of the disease. To mitigate the risk of postsurgical mortality, a multidisciplinary approach seemed useful in addition to the use of validated algorithms to estimate the risk of perioperative morbidity and mortality; the risk related to SARS-CoV-2 infection should be added. The risk of potential nosocomial contagion from a positive patients should also be considered when deciding to proceed with surgery. Most of the evidence came from previous SARS-CoV-2 variants, so the evidence should be considered indirect. Conclusion A balanced preoperative multidisciplinary risk–benefit evaluation is needed in patients with previous infection by SARS-CoV-2 for elective surgery.

Pre-assessment and management of long COVID patients requiring elective surgery: challenges and guidance

“…Multiple organisations worldwide have developed guidelines for patients with prior COVID-19 infection who subsequently require elective surgery (Noll et al 2022 ; El-Boghdadly et al 2022 ; Cortegiani et al 2022 ; American Society of Anesthesiologists and Anesthesia Patient Safety Foundation 2022 ; Australian and New Zealand College of Anaesthetists 2022 ). As summarised in Table 1 , these largely focus on the suggested time interval between infection and surgery and recommendations for preoperative assessment if surgery is required before this.…”

“…As summarised in Table 1 , these largely focus on the suggested time interval between infection and surgery and recommendations for preoperative assessment if surgery is required before this. The expert consensus from the UK, Italy and Germany advises delaying elective procedures until at least 7 weeks post-COVID-19 infection and until symptom resolution, due to the aforementioned increased risk of postoperative mortality and pulmonary complications (COVIDSurg Collaborative, GlobalSurg Collaborative 2021 ; Noll et al 2022 ; El-Boghdadly et al 2022 ; Cortegiani et al 2022 ). However, the American Society of Anaesthesiologists (ASA) only recommends this delay for unvaccinated, asymptomatic patients, stating that there is insufficient evidence for those who have unresolved symptoms or are vaccinated and subsequently infected (American Society of Anesthesiologists and Anesthesia Patient Safety Foundation 2022 ).…”

“…However, postoperative outcomes were not directly investigated within this study, and whilst elective surgery may indeed be safer after a shorter delay for patients who have recovered from these less virulent strains, this remains speculative. Additionally, guidance on the timing of elective surgery for long COVID patients is limited, with organisations tentatively encouraging consideration of further delay beyond 7 weeks based on a multidisciplinary risk-versus-benefit discussion (El-Boghdadly et al 2022 ; Cortegiani et al 2022 ). Optimal timing will therefore depend on patients’ presenting symptoms and other comorbidities, balanced against their need for surgery and the likelihood of a prolonged delay worsening their functional status or quality of life.…”

“…In terms of the conduct of anaesthesia, avoiding a general anaesthetic in favour of regional or local techniques seems sensible where possible, particularly in those with severe respiratory pathology. This is also recommended for those with post-COVID-19 respiratory sequelae in consensus statements from organisations in the UK, Italy and India (El-Boghdadly et al 2022 ; Cortegiani et al 2022 ; Malhotra et al 2021 ). Additionally, postoperative venous thromboembolism (VTE) is more common in patients with recent COVID-19, and those undergoing general anaesthesia may be at an increased risk (COVIDSurg Collaborative, GlobalSurg Collaborative 2022 ).…”

Anesthesia Management and Perioperative Infection Control in Patients with the Novel Coronavirus

“…Prior to any elective surgery or operation requiring general anaesthesia, individuals who have tested positive for SARS-CoV-2 must first receive a thorough preoperative history and physical examination [47].…”