Episode #87 Timing for Surgery following COVID-19 Infection and Postoperative Complications

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. Today, we are discussing the hot of the press, recently updated joint guidelines from the ASA and APSF on elective surgery and anesthesia for patients who have had Covid-19. But before we get to that, we have an exciting new segment on our show dedicated to APSF podcast listener comments.

Before we dive into the episode today, we’d like to recognize Acacia Pharma, a major corporate supporter of APSF. Acacia Pharma has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Acacia Pharma – we wouldn’t be able to do all that we do without you!”

Recently, we released several shows related to non-operating room anesthesia or NORA procedures. We had an APSF podcast listener write in with some additional considerations for keeping patients safe in these off-site and often remote locations. Thank you to Tim Graham, an anesthesiologist from Arizona for his contributions to the show today. I am going to read his comments now

“If not already present, I would suggest consideration of a NORA guideline which describes the requirement for support personnel present during a NORA procedure.

At our hospital in Yuma, AZ, we historically had an RN present along with the MRI tech. Due to a shortage of nursing in radiology, we recently ran into the problem of not having a nurse present during MRI’s under anesthesia. We were able to rectify the situation through discussion with the administrator stating that we need a nurse to be available during anesthesia induction and emergence, and readily available to attend to any emergencies that may occur during the procedure.

As background, we have an anesthesiology only practice (not an anesthesia care team). We otherwise are assisted by anesthesia techs and MRI techs who are unable to administer IV medications by state law. We therefore require a nurse to administer IV medications should we be occupied with the airway.

Tim continues, “Obviously all hospitals are affected by nursing shortages. Across the nation, administrators may not understand the need to consistently provide a staff RN who is able to administer IV medications during anesthesia induction and emergencies, and intraprocedural emergencies. This especially would apply when there is a solo anesthesia provider.

A written guideline describing minimal staffing requirements during NORA will lend support to the anesthesia departments across the country.”

This is such an important consideration. Thank you to Graham for highlighting this important issue. We are looking forward to September 2022 when the APSF Stoelting Conference will focus on Non-operating room anesthesia and we will be discussing it further on the podcast in the future.

And now, let’s head over to APSF.org and click on the Patient Safety Resources heading. Then, fourth one down is News and Updates. Our featured article today is from the 22^nd of February. This was released just last week so we really are bringing you the latest in perioperative and anesthesia patient safety. The article is called, “American Society of Anesthesiologists and Anesthesia Patient Safety Foundation Joint Statement on Elective Surgery and Anesthesia for Patients After COVID-19 Infection.” I will include a link in the show notes as well.

The original statement was published on the APSF website on March 9, 2021. This joint statement helps to answer important questions such as when is it safe for patients to undergo anesthesia and elective surgery following a COVID-19 infection and how can we keep patients who have had COVID infections safe when they present to the operating room for elective surgery and anesthesia care. These questions are especially pressing during and following the recent wave of Omicron infections when so many future patients were infected with Covid-19.

Right at the top of the article, you may be tempted to click on the quick links to bring you to the following considerations:

• What is the appropriate length of time between recovery from Covid-19 and surgery/procedure with respect to minimizing postoperative complications
• Categories for the clinical spectrum of SARS CoV-2 Infection

I will include a summary of the recommendations in the show notes as well. These recommendations will go a long way to helping anesthesia professionals, surgeons, proceduralists, hospital administrators, and other members of the perioperative team keep patients safe during surgery and anesthesia care following COVID-19 infection.

The article starts off by highlighting that this is a new consideration that has arisen over the course of the pandemic since patients who have been infected with COVID-19 and recovered may present to the hospital for elective surgery and anesthesia care. We did not have any data to inform our clinical decision when the pandemic first started, but we have learned a lot since then and this joint statement reflects new data from the past year. The preoperative assessment for patients who have recovered from COVID-19 infection is another important consideration since it may be different than if the patient did not have a history of COVID-19 infection.

Here are some questions to ask prior to proceeding with the surgery or procedure and anesthesia care:

1. Is the patient still infectious?
2. For patients who are no long infectious, what is the appropriate length of time to wait between recovery from COVID and the surgery or procedure in terms of the risk to the patient for perioperative complications?

It is vital that the anesthesiologist and surgery or proceduralist communicate effectively about the timing requirement for the surgery and the risk of complications to reach an joint decision for proceeding to the operating room.

Let’s look at the first question. How do we know when a patient is no longer infectious? This is determined according to recommendations from the Centers for Disease Control and Prevention and is important for deciding on the timing discontinuing transmission-based precautions including patient isolation, use of PPE, and engineering controls. These recommendations apply for patients who have a confirmed SARS-CoV-2 infection confirmed by reverse transcriptase-polymerase chain reaction testing. The categories for illness severity include the following:

• Asymptomatic or Pre-symptomatic Infection
• Mild Illness
• Moderate Illness
• Severe Illness
• Critical Illness

Keep in mind that severely immunocompromised patients have separate considerations.

Data from studies on patients with COVID-19 has shown that repeat reverse transcriptase PCR testing may remain positive for long periods of time, but after 10 days from symptom onset, it is rare for there to be disease present that is capable of replication. As a result, the time from symptom onset is an important consideration.

Here are the recommendations from the CDC related to when isolation and transmission-based precautions are no longer needed and when the patient is unlikely to be infectious. Keep in mind that Day 0 is the first day of symptoms.

• Children and adults with mild, symptomatic COVID-19: Isolation can end at least 5 days after symptom onset and after fever ends for 24 hours (without the use of fever-reducing medication) and symptoms are improving, if these people can continue to properly wear a well-fitted mask around others for 5 more days after the 5-day isolation period.
• People who are infected but asymptomatic (never develop symptoms): Isolation can end at least 5 days after the first positive test (with day 0 being the date their specimen was collected for the positive test), if these people can continue to wear a properly well-fitted mask around others for 5 more days after the 5-day isolation period. However, if symptoms develop after a positive test, their 5-day isolation period should start over (day 0 changes to the first day of symptoms)*
• People who have moderateCOVID-19 illness: Isolate for 10 days.
• People who are severely ill (i.e., requiring hospitalization, intensive care, or ventilation support): Extending the duration of isolation and precautions to at least 10 days and up to 20 days after symptom onset, and after fever ends (without the use of fever-reducing medication) and symptoms are improving, may be warranted.
• People who are moderately or severely immunocompromised might have a longer infectious period: Extend isolation to 20 or more days (day 0 is the first day of symptoms or a positive viral test). Use a test-based strategy and consult with an infectious disease specialist to determine the appropriate duration of isolation and precautions.

Using these guidelines, an important consideration is that for people with mild and asymptomatic disease, they need to be considered infectious for the full 10 days since the additional 5 day isolation with masking period will not be able to be followed when they present to the hospital for an elective procedure.  In addition, our colleagues in infection control may need to be consulted for the duration of transmission-based precautions in patients with severe immunocompromised conditions or severe or critical illness.

Patients with advanced age, diabetes, or end-state renal disease may be immunocompromised, but we do know what the impact is on the duration of infectivity at this time.

Let’s move on to the next question: time between recovery from COVID-19 and surgery to help minimize postoperative complications. At this time, we still do not know what the impact of vaccination is on postoperative complications in patients who had a breakthrough COVID-19 infection or the impact of some of the newer variants, so the recommendations may change over time. The preoperative evaluation and timing are based on the studies over the past year as well as expert opinion and previous data from other post-viral syndromes. Now, its time to dive into the data.

[Water Splash]

First, from a study published in 2020 that included 122 patients who underwent surgery within 4 weeks of a SARS-CoV-2 diagnosis and had a significantly higher risk of pulmonary complications. Another early study of 49 asymptomatic patients who had surgery about 25 days after diagnosis showed no difference in complications compared to patients with a negative SARS-CoV-2 test prior to the surgery. Let’s broaden our investigation to look at over 140,000 patients from 116 countries and 1674 hospital. 3,127 patients had COVID-19 infection prior to their surgery in October 2020 which was before vaccines were available. The results showed increased risk of mortality and morbidity, especially pulmonary complications in previously infected patients up to 7 weeks following diagnosis. The increased risk occurred in those patients at the 5-6 week time period following diagnosis in asymptomatic and symptomatic patients as well as in patients older and younger than 70 years old undergoing major or minor surgery that was either elective or emergent. In addition, patients with symptoms for more than 7 weeks were at increased risk of complications compared to asymptomatic patients. The 30-day mortality rate for elective surgery patients was 0.62 and 0.64 for patients not infected with COVID-1i9 as well as for patients who were more than 7 weeks out from their diagnosis and no longer had symptoms. The mortality rate increased to about 3, 2.3, and 2.4 for patients who were 0-2 weeks out, 3-4 weeks out, and 5-6 weeks out from their COVID-19 infection respectively.

We have one more study to look at and this one was done in the United States for 5, 479 patients who had COVID-19 infection and surgery up to May 31, 2021. Once again, we see increased risk for postoperative complications especially pneumonia and respiratory failure for patients 0-4 weeks out from their COVID-19 diagnosis as well as higher rates of postoperative pneumonia for patients 4-8 weeks our from their diagnosis.

As we are wrapping up our literature review, I just want to make a quick note that the data and the following recommendations are based on what we have learned prior to the omicron variant and likely even before delta. So, we will just have to continue gathering data and updating our recommendations as we learn more going forward.

The United Kingdom published a consensus-based statement which recommended delaying surgery whenever possible for at least 7 weeks following a known COVID-19 infection. There is a need for continued research in this area to assess the impact of vaccination status as well as variant on the risk for postoperative complications and timing for surgery. Another important consideration is that patient may have an increased risk for pulmonary complications following a COVID-19 infection, but SARS-CoV-2 may impact other organ systems leading to complications such as thromboembolic events and stroke, myocarditis, and renal failure.  Patients with persistent symptoms more than two months after diagnosis or compromised myocardial function may require a preoperative evaluation scheduled prior to surgery with a thorough assessment of the cardiopulmonary symptoms with additional studies such as an echo or consultations with cardiology or pulmonology if needed.

Before we get to our grand finale with the reading of the recommendations, we have one final question to address. Is repeat testing necessary? If the patient is within the 90 days of symptom onset or for asymptomatic patients, repeat PCR testing is not recommended. On the other hand, patient who recovered from their initial symptoms and have new symptoms may need further testing. After the 90 day window following symptom onset, it is recommended to obtain a preoperative nasopharyngeal PCR test within 3 days prior to their surgery or procedure.

Now, get your pencils ready. Here are the recommendations:

1. “Elective surgery should be delayed for 7 weeks after a SARS-CoV-2 infection in unvaccinated patients that are asymptomatic at the time of surgery.
2. The evidence is insufficient to make recommendations for those who become infected after COVID vaccination. Although there is evidence that, in general, vaccination reduces post-infection morbidity, the effect of vaccination on the appropriate length of time between infection and surgery/procedure is unknown.
3. Any delay in surgery needs to be weighed against the time-sensitive needs of the individual patient.
4. If surgery is deemed necessary during a period of likely increased risk, those potential risks should be included in the informed consent and shared decision-making with the patient.
5. Extending the above delay should be considered if the patient has continued symptomatology not exclusive of pulmonary symptoms.
6. Any decision to proceed with surgery should consider:
   1. The severity of the initial infection
   2. The potential risk of ongoing symptoms
   3. Comorbidities and frailty status
   4. Complexity of surgery”

These recommendations are under continuous review and will be updated as additional evidence becomes available.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. In addition, these updated recommendations will continue to be reviewed and updates may be available as we learn more, so keep checking in. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

We hope that you will share this podcast and these recommendations with anyone you know who is interested in anesthesia patient safety including your surgical and procedural colleagues, nurses, and hospital administrators. Are you following these recommendations at your institution? Let us know by connecting with us on twitter @APSForg and using the hashtag #APSFpodcast. You can also connect with us on Facebook, Instagram, and linked in. We would love to hear from you.

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

© 2022, The Anesthesia Patient Safety Foundation