Episode #25 Keeping Patients Safe After Covid-19 Infection

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel and I am your host. Thank you for joining us for another show. We are going to return to the APSF Novel Coronavirus Resource Center today to discuss a new release on our website and review some updated recommendations. In the past year, we have learned how to provide safe anesthesia care for patients with Covid-19 infection while keep the anesthesia teams and OR teams safe. But what about patients who have had Covid-19 infection in the past? We are learning how to keep these patients safe as well.

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Now let’s head over to APSF.org and click on the Patient Safety Resources heading. First one down is the Novel Coronavirus Anesthesia Resource Center. If you scroll down to the latest news, you will see the article, “American Society of Anesthesiologists and Anesthesia Patient Safety Foundation Joint Statement on Elective Surgery and Anesthesia for Patients after COVID-19 Infection” which was published on the website on December 8, 2020. I hope that you will check out this joint statement by the ASA and APSF and remember that the material that we talk about on this podcast and that you can find on the website is provided for informational purposes and the information posted in the APSF Coronavirus resource center is evolving so make sure that you check back on the website for updated information.

Have you taken care of a patient who had Covid-19 prior to coming to the OR for a procedure? I am sure that many of you raised your hands just now. Many patients continue to undergo emergent, urgent, and elective surgeries during this pandemic. The big questions for patients who have had Covid-19 and recovered from the infection are:

• What is the optimal time frame for surgery and anesthesia after Covid-19 infection?
• What, if any, additional workup is required for preoperative evaluation?
• How can we optimize patients who have had Covid-19 prior to coming to the OR?
• What should we be telling patients and families about the risks of surgery and anesthesia for patients who have had Covid-19 in the past?

Unfortunately, we do not have all the answers right now and even the information we have now may change as we learn more since this is a new infection and disease state, but the good news is that this joint statement can help to provide very useful information for hospitals, surgeons, anesthesiologists, and proceduralists who are involved in preoperative evaluation and scheduling for surgeries and procedures.

An important general principle is that patients with Covid-19 who remain in isolation and are still deemed to be infectious should not undergo elective, non-urgent procedures. Once patients have recovered from Covid-19 and no longer require transmission precautions, the decision to proceed to with elective surgeries or procedures should only occur after joint discussion between the anesthesia, surgery, and procedure teams.

The first question that the joint statement addresses is “What determines when a patient confirmed to have Covid-19 is no longer infectious?” This is such an important question.  We can turn to the Centers for Disease Control and Prevention, the CDC, for further guidance for when patients with documented infection who are at home or in the hospital no longer require transmission-based precautions. This novel disease is difficult to manage since patients may be symptomatic or asymptomatic.

First, let’s look at asymptomatic patients who are not immunocompromised. The current recommendations are that isolation and transmission-based precautions may be discontinued after at least 10 days out from their first positive test. Remember, this recommendation applies to those patients who tested positive and then did not develop any symptoms over the next 10 days after their first positive test.

Next, we will turn our attention to patients with Covid-19 who developed symptoms. There are 2 groups of symptomatic Covid-19 patients, those with mild to moderate symptoms and patients with severe or critical illness. Table 1 in the article helps to differentiate patients with different symptom severity based on definitions from the National Institute of Health Covid-19 Treatment Guidelines. Symptom severity may change, but it is important to use the highest level symptom classification that a patient experiences while they are symptomatic from Covid-19 infection. Here are the definitions for mild, moderate, severe and critical that were used for the joint statement recommendations:

Mild Illness is signs and symptoms of COVID-19 including fever, cough, sore throat, malaise, headache, muscle pain without shortness of breath, dyspnea, or abnormal chest imaging.

Moderate Illness is defined as evidence of lower respiratory disease by clinical assessment or imaging and oxygen saturation with a SpO2 ≥94 percent on room air at sea level.

Severe Illness is defined as respiratory rate greater than 30 breaths per minute, SpO2 less than 94 percent on room air at sea level or, for patients with chronic hypoxemia, a decrease from baseline of greater than 3 percent, a ratio of arterial partial pressure of oxygen to fractional inspired oxygen (PaO2/FiO2) less than 300 mmHg, or lung infiltrates involving greater than 50 percent of the lung fields.

Now, critical illness is the presence of respiratory failure, septic shock, and/or multiple organ dysfunction.

Another important definition for guiding transmission-based precautions for Covid-19 infection includes patients who are “severely immunocompromised” and these patients need additional considerations. The joint statement offers a definition for these patients to help differentiate these patients which includes the following:

• Currently undergoing chemotherapy for cancer.
• Within 1 year of receiving a hematopoietic stem cell or solid organ transplant.
• Having untreated HIV with a CD4 T lymphocyte count of less than 200.
• Having a combined primary immunodeficiency disorder.
• Treated with prednisone of greater than 20mg per day for more than 14 days.

Now that we have these definitions, let’s start with patients who had Covid-19 infections and suffered from mild or moderate symptoms. At this point, we know that these patients may continue to have positive PCR tests for SARS-CoV-2  RNA for a long time after development of symptoms, but the good news is that the part of the virus that is responsible for replication and thus transmitting infections has not been present after 10 days from the development of symptoms. As a result, the CDC recommends a time and symptoms based strategy for these patients to make decisions about virus transmission potential. This strategy is applicable for patients who do not meet criteria for severe immunocompromise and who display mild or moderate symptoms. According to the CDC, the isolation and transmission-based precaution time period may end after 10 days from first symptom onset as well as over 24 hours without a fever and without the use of fever-reducing medications, and after the patient displays improvement in their symptoms.

Now, what about our patients who developed severe or critical illness? And what about our patients with severe immunocompromise? The criteria for end of isolation or transmission based precautions are different. In this subset of patients, the replication-competent virus was not found after 20 days from symptom onset and actually in 95% of these patients, the replication-competent virus was not found after 15 days. The recommendations for these patients from the CDC for the end of isolation and the transmission-based precautions includes the following: at least 10 days, but may consider up to 20 days since symptom onset and over 24 hours without a fever and without the use of a fever-reducing medication while displaying improvement in symptoms. It is important to remember all of the components of the recommendations since just because 10 days has passed, if a patient is experience persistent symptoms without improvement or worsening symptoms, then that is not an appropriate time to discontinue isolation or additional transmission-based precautions.

Epidemiologists and infection control experts have been working hard throughout this pandemic and consultation with these specialists at your institution may be necessary for patients with severe or critical illness or those patients who are severely immunocompromised for decisions about isolation and infection transmission precautions. These patients may have an ongoing infection with longer duration of precautions and may require repeat testing depending on the clinical course.

For patients with symptoms attributed to Covid-19, but who were not tested, it is important to use the symptom-based strategy that we just talked about depending on the severity of their symptoms.  There is still so much that we do not know about this disease. Are older patients or those with diabetes or end-stage renal disease or heart failure for example infectious for longer periods of time since they may have some immunocompromise? At this point, we do not, but it is important to assess the patient and keep these additional factors in mind when making decisions.

The next question that the joint statement addresses is “What is the appropriate length of time between recovery from Covid-19 and surgery with respect to minimizing postoperative complications?” This is such an important question and one that will likely come up frequently in clinical practice. We have talked about preoperative optimization before on this podcast and patients who have recovered from Covid-19 also require optimization of their medical co-morbidities including any new medical conditions due to Covid-19, such as a blood clot or deconditioning, or changes in renal function before going to the OR for non-emergent surgery. We are still learning about the recovery process from Covid-19. One study reported a higher risk for pulmonary complications for patients diagnosed within 4 weeks of the surgery. In the past, similar results have been seen in patients with upper respiratory infections within 4 weeks of surgery and increased postoperative complications. Drawing on data from the 2009 pandemic, patients with H1N1 Influenza A infections and ARDS required up to 3 months for lung function recovery. The joint statement offers a guide for timing of elective surgery after recovery from Covid-19 infection. Patients who remain asymptomatic or who have only mild, non-respiratory symptoms (such as a headache) should wait 4 weeks. Patients with respiratory symptoms treated as outpatients at home should wait 6 weeks prior to elective surgery. Patients with symptoms who required hospitalization or those with diabetes or immunocompromise should wait 8-10 weeks after recovery before undergoing elective surgery. Finally, symptomatic patients who required ICU admission should wait 12 weeks after recovery prior to undergoing elective surgery. Remember, this is a guide, but it is also important to consider the surgical procedure, other co-morbidities, and the risk/benefit for delaying surgery. When considering the preoperative evaluation, patients may continue to endorse fatigue, shortness of breath and chest pain and we are learning about the effects of Covid-19 on myocardial anatomy and function so patients may need additional cardiac evaluations including ECG, echocardiography, additional lab work, and cardiology consultation.

One more question that the joint statement addresses revolves around repeat SARS-CoV-2 testing. Do we need it? The current recommendations from the CDC includes no need to repeat testing for Covid-19 after a positive test and within 90 days of symptoms onset. In addition, asymptomatic, PCR-positive patients do not need repeat testing since the test may continue to be positive even after recovery and when patients are no longer infectious. However, repeat testing may be considered for an asymptomatic patient who develops new symptoms or if patient develops recurrent symptoms. These patients may also benefit from an infectious disease consultation. After completing a 90 day recovery time period, if a patient requires surgery, a repeat preoperative PCR test within 3 days of the procedure should be considered.

Well, that’s all the time we have for today. Thank you for joining us for our last show of 2020 and we hope that you will join us in 2021 as we continue to bring you the latest information and news in perioperative  and anesthesia patient safety. If you have any questions or comments from today’s show, please email us at [email protected].

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Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

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