Log in to MyACC
Pulmonary Complications in SARS-CoV-2 Patients Undergoing Surgery
Quick Takes
- Patients with SARS-CoV-2 infection who underwent elective and emergent surgery had increased mortality and pulmonary complications.
- Age ≥70 years, male sex, and higher ASA grade were associated with worse outcomes.
Study Questions:
What is the 30-day mortality and incidence of pulmonary complications in patients with severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection who undergo surgery?
Methods:
This is an international, multicenter, observational cohort study conducted among 235 hospitals in 24 countries. All patients, both children and adults, diagnosed with SARS-CoV-2 infection within 7 days before or 30 days after surgery were enrolled. Infection was determined by quantitative reverse transcriptase polymerase chain reaction (RT-PCR) of viral RNA or was based on clinical (symptoms of fever, cough, myalgia) or radiological findings on chest computed tomography. Patients who were included based on clinical or radiographic findings and who later tested negative by RT-PCR were excluded. A set of pre-, intra-, and postoperative variables was collected online in a web application. The primary outcome was 30-day mortality. Secondary outcome was incidence of pulmonary complications, including pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Additional outcomes were 7-day mortality, pulmonary embolism, intensive care unit admission, re-operation, and hospital length of stay. Multilevel logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) with country as a random effect and hospital nested within country. An adjusted model with preoperative models identified predictors of 30-day mortality.
Results:
Between January 1 and March 31, 2020, 1,128 patients with SARS-CoV-2 infection underwent surgery. Infection was diagnosed in 294 (26.1%) patients preoperatively and 806 (71.5%) postoperatively (missing in n = 28) and was confirmed by laboratory testing in 969 (85.9%). Patients who underwent surgery were more likely to be male (n = 605, 53.6%). Five hundred fifty-eight patients (49.5%) were ≥70 years. The vast majority (n = 344, 88.4%) were American Society of Anesthesiologists (ASA) grade 1 or 2. Emergency surgery was performed in 835 patients (74.0%). Indication for surgery was benign disease in the majority of patients (n = 615, 54.5%), with cancer as the indication in 278 (24.6%) and trauma in 227 (20.1%). Most operations fell in the “major” category (n = 841, 74.6%) and were gastrointestinal/general (n = 373, 33.1%), or orthopedic (n = 302, 26.8%).
Thirty-day mortality was 23.8% (n = 268). Predictors of 30-day mortality were male sex (OR, 1.75; 95% CI, 1.28-2.40; p < 0.001), age ≥70 years versus younger (OR, 2.30; 95% CI, 1.65-3.22; p < 0.0001), ASA grades 3-5 versus grades 1-2 (OR, 2.35; 95% CI, 1.57-3.53; p < 0.0001), emergency versus elective surgery (OR, 1.67; 95% CI, 1.06-2.63; p = 0.026), major versus minor surgery (OR, 1.52; 95% CI, 1.01-2.31; p = 0.047), and malignant versus benign/obstetric diagnosis (OR, 1.55; 95% CI, 1.01-2.39; p = 0.046). Pulmonary complications occurred in 51.2% (n = 577) and those patients had higher 30-day mortality than those who did not (38.0% vs. 8.7%, p < 0.0001).
Conclusions:
Patients with SARS-CoV-2 infection who undergo surgery are at risk for increased mortality and pulmonary complications postoperatively, especially men and patients who are older and have higher ASA grade.
Perspective:
SARS-CoV-2 infection and coronavirus disease 2019 (COVID-19) are new realities in the surgical landscape that surgeons and patients must learn to navigate. This important study examines surgical outcomes in patients with SARS-CoV-2 infection who underwent many different surgical operations of both elective and emergent status. Their outcomes are worse, especially for men, older patients, and those with higher ASA grade at the time of surgery. Of note, all patients in this study who underwent surgery had SARS-CoV-2 infection; the study does not include patients who underwent surgery but did not have SARS-CoV-2 infection, so historical results are used for general comparison. However, during this time period, patients without SARS-CoV-2 infection likely did not undergo as much surgery as pre-COVID, as many hospitals markedly decreased the number of elective procedures in order to preserve personal protective equipment and to save hospital beds for the onslaught of COVID-19 patients.
According to ASA grade, most of the patients in this study were “normal healthy patients” or had “mild systemic disease.” Does this mean they had asymptomatic SARS-CoV-2 infection and were only mildly affected by the diagnosis/indication for surgery? Did the patients who were ASA grade 3, 4, or 5 have COVID-19? Or was their classification mostly related to the comorbidities and indication for surgery? Would patients who had advanced pulmonary disease from COVID be offered an operation at all given the high risk for mortality?
Although cardiothoracic and vascular operations comprised only 11.6% (n = 131) of operations, mortality was highest for those patients with SARS-CoV-2 infection who underwent these procedures (42.9% for thoracic, 40% for vascular, and 34% for cardiac), and pulmonary complications occurred in 94.1% of patients who had cardiac surgery. Many centers are routinely testing patients preoperatively prior to such “high-risk” operations and delaying operations in those who test positive unless it is immediately life-threatening. Results from this study and others can inform guidelines for testing and proceeding with surgery as hospitals ramp up to pre-COVID volumes.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, COVID-19 Hub, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Vascular Medicine, Cardiac Surgery and Arrhythmias, Interventions and Imaging, Interventions and Vascular Medicine, Computed Tomography, Nuclear Imaging
Keywords: Cardiac Surgical Procedures, Coronavirus Infections, COVID-19, Length of Stay, Myalgia, Neoplasms, Orthopedic Procedures, Pneumonia, Pulmonary Embolism, Radiology, Respiratory Distress Syndrome, Reverse Transcriptase Polymerase Chain Reaction, Secondary Prevention, severe acute respiratory syndrome coronavirus 2, Minor Surgical Procedures, Tomography, X-Ray Computed, Treatment Outcome, Thoracic Surgery
< Back to Listings
