COVID: surgery ?inc risk severe case

published 4/8/20

A recent observational study of 34 patients undergoing elective surgery found that those with unknown asymptomatic Covid-19 had stormy courses (see covid surgery inc risk eclinmed2020 in dropbox, or doi.org/10.1016/j.eclinm.2020.100331)

 

Details:

34 patients at 4 hospitals in Wuhan China underwent elective surgeries likely during the incubation period of Covid, and were asymptomatic

-- median age 55, 9% women

-- surgery or was graded by intensity:

    -- level I (low risk, simple procedure, low technical difficulty; e.g. breast mass excision): 1 patient

    -- level II (mild risk, mild complexity of procedures and mild technical difficulty; e.g. laparoscopic appendectomy, debridement): 11 patients, 32%

    -- level III (moderate risk, complex procedures, and more technically difficult; e.g. radical mastectomy, pancreatoduodenectomy): 20 patients, 59%

    -- level IV (high risk, highly complex procedures, high technical difficulty; e.g. laparoscopic radical gastrectomy): 2 patients

 

Results:

-- all patients subsequently tested positive for Covid-19 and developed pneumonia shortly after surgery, with abnormal chest CTs

-- all patients received lopinavir/ritonavir and antibiotic therapy

-- some received steroid therapy (47%) and immunoglobulin therapy (41%)

-- complications: ARDS in 11 (32%), shock 10 (29%), secondary infection 10 (29%), arrhythmia 8 (24%), acute cardiac injury 5 (15%) and acute kidney injury 2 (6%)

-- median time from surgery to symptoms was 2 days, to diagnosis of pneumonia 3 days, to dyspnea 3.5 days, to ARDS 10 days, and to death for non-survivors 16 days

-- symptoms: fever 91%, fatigue 74%, dry cough 3%, dyspnea 44%, myalgias 32%

-- 15 patients (7) were admitted to the ICU during disease progression

    -- 13 of these 15 patients had had level III surgery

--19 patients were not admitted to the ICU

    -- 10 of these were level II, 7 level III

-- 7 patients (21%) died after admission to the ICU, mostly from ARDS, shock, arrhythmia, and acute cardiac injury. All had level III surgery. All had comorbidities: cardiovascular disease in 4, malignancy in 4, hypertension in 3

-- surgical time: median 200 minutes in those admitted to the ICU, vs 70 minutes in those non-ICU

-- those admitted to the ICU were older (55 vs 47 yo), more likely to have underlying comorbidities (80% vs 42%, including hypertension at 60% vs 21% and cardiovascular disease at 40% vs 5%), and had more severe lab abnormalities (increased WBC, lymphopenia)

 

Commentary:

-- the median time from surgery to clinical Covid-19 infection was 2.5 days, shorter than the usual median of 5.2 days from other studies in Wuhan, suggesting that these patients were infected prior to the surgery

-- of note, the proportion of patients in ICU care (44%) was higher than their average of 26% without surgery; simliarly for the mortality rate (21% vs the usual 2% overall and 8% if admitted to the ICU)

-- old age, comorbidities, surgical time, and difficulty of operation all may be risk factors individually and in combination. 

    --BUT there is a real issue in assessing/quantifying comorbidities: as is usual in many studies, there is a binary (yes or no) evaluation. BUT, those having surgery may have had more complex comorbidities than those not having surgery, which might have predisposed them more to adverse consequences of Covid-19. Eg, for those with cancer, there may be a fundamental difference between someone who is basically cured or has a better controlled cancer vs on chemotherapy and severely immunocompromised. or patients with mild valvular heart disease vs those with severe heart failure.....

-- as a potential mechanism: surgery is related to rapid impairment of cell-mediated immunity; and it induces an early systemic inflammatory response and increased circulating inflammatory cytokines (a marker for the severing of illness in those with Covid-19)

So, yet again, another small observational study from which it is hard to draw clear conclusions. However, the time course noted above suggests that these patients were infected prior to surgery and seemed to have had rapidly progressive deterioration. This does suggest a few things:

-- it may be reasonable to check Covid status prior to any operation, for all patients

-- for those who are Covid-positive requiring semi-urgent surgery (e.g. excision of a mass, cancer surgery): perhaps they can have their surgery delayed until their Covid infection is resolved

-- those requiring urgent surgery might benefit from a two-stage procedure: a more rapid, less invasive and shorter initial surgery with subsequent completion after/if they recover fromthe Covid

geoff​

 

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