Challenges of Surgery in the COVID-19 Era
The full extent of the impact of COVID-19 on provision of surgical services if only now becoming apparent. In this article Dr Edward Lent, an anaesthetic trainee from Bristol, outlines the current evidence and guidelines for delivering perioperative care.
What is COVID-19?
A novel respiratory virus causing pneumonia was identified in Wuhan China in December 2019. The virus was named Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-Cov-2) , and the respiratory disease caused by this virus has been named COVID-19.
Since its detection in Wuhan in late 2019, the virus has rapidly spread across the globe and is classified by the WHO as public health emergency of international concern . SARS-Cov-2 is known to spread via direct contact, respiratory droplets and aerosol from infected individuals. Tens of millions of individuals have been infected globally and it presents ongoing challenges for healthcare providers and systems.
Perioperative mortality and morbidity risk for patients who contract COVID-19 in the perioperative period
The mortality and morbidity associated with SARS-Cov-2 infection has been seen to vary depending on a wide variety of factors. As our understanding of COVID-19 has improved, so has our understanding of risk factors that predict a more severe disease course and increased mortality .
Several factors have been established which are associated with increased mortality; increased age, hypertension, diabetes, and South Asian or Black ethnicity.
The COVIDsurg Study
The COVIDsurg Collaborative published in the Lancet  examined perioperative mortality in patients who were infected with SARS-Cov-2 in the perioperative period. This was the first observational study to examine the impact of SARS-Cov-2 infection on patients undergoing both elective and emergency surgery. It demonstrated some important findings which are likely to impact practice during the pandemic and in the subsequent years.
Increased mortality in all patients undergoing both elective or emergency surgery infected with SARS-Cov-2 in the week prior to surgery or 3 weeks post-operatively
Post-operative pulmonary complications occurred in approximately 50% of all patients with SARS-Cov-2 infection undergoing surgery, and were associated with the high mortality.
Patients cohorts at the highest risk of adverse outcomes were males, aged >70 years old, ASA 3-5, cancer surgery, emergency surgery and major surgery.
The overall mortality of all patients in this study was high at 23.8%
Even patients having minor or elective surgery were observed to have increased mortality in the 30 days post-operatively if infected; 16.9% and 18.3% respectively. This is significant raised compared to previous studies of mortality in these groups.
The authors recognise there are limitations to this study and it is susceptible to some bias. However, it likely represents a real and significant increase in morbidity and mortality associated with SARS-Cov-2 infection in the perioperative period, even if it is an overestimation.
The authors use their data to make several suggestions:
- Firstly: during the pandemic the thresholds for performing any surgery should be increased, considering the altered risk benefit balance during this time and that non-urgent surgery should be delayed.
- Secondly: those who fall into the highest risk groups should be specifically counseled against the higher risk of pulmonary complications and death in the post-operative period if infected with SARS-Cov-2.
- Finally: the resumption of routine surgery will require modifications to perioperative practice including screening of patients pre-operatively and strategies to minimize post-operative intra-hospital transmission.
COVID-19 NICE Guidelines
In August 2020, the UK’s National Institute of Clinical Excellence (NICE) produced new guidance; reflecting the changes that are required to safely assess and manage patients in the peri-operative period.
Discuss risks of undergoing surgery in time of SARS-Cov-2 pandemic versus risk of delaying surgery
Discuss individual risk factors for severe Sars-Cov-2 infection (e.g. age >70 years old, gender, ethnicity)
Agree clear plan for admission, discharge and follow up
Explain their surgery may be postponed if they test positive for SARS-Cov-2 infection, have symptoms of SARS-Cov-2, are self-isolating or are not clinically well enough to undergo the procedure
To follow comprehensive social distancing and handwashing as a minimum for 14 days prior to planned care
Organise testing for SARS-Cov-2 infection from 3 days prior to admission and ensure results are available before admission
Self-isolate from the day of testing until time of admission
Advise they may wish to self-isolate for 14 days prior to procedure depending on their individual risk
Follow Department of Health guidelines for personal protective equipment (PPE), and infection prevention and control
If at all possible, cohort patients and staff into low risk and high risk pathways that do not overlap, reducing the risk of transmission during the delivery of care
Continue to follow guidelines on PPE use and infection control.
Minimise visitors to inpatient settings
Ensure SARS-Cov-2 test is performed prior to discharge to another care setting
The re-starting of planned care now the first phase of the Covid-19 pandemic has passed is complex. Although there remains an abundance of patients awaiting surgery, and healthcare professionals prepared to offer perioperative care, most prior surgical pathways have been significantly disrupted or redistributed by the pandemic .
Furthermore, the demands on wider healthcare systems will likely remain elevated moving into an endemic phase of SARS-Cov-2; new pathways will need to be developed and refined over time.
As further evidence emerges and the pandemic evolves, recommendations and pathways are likely to continue to change. Thus it is important to retain an element of flexibility within the systems we design to allow them to adapt to future demands and challenges.
What challenges have you come across in trying to re-establish elective surgery during the pandemic? What policies have you followed to protect staff as well as patients? Share your experiences and discuss in the comments section.