Version May 2024
INTRODUCTION — Patients infected with the novel coronavirus disease 2019 (COVID-19 or nCoV) may be at increased risk of perioperative complications, and may transmit the virus to clinicians and other patients. This topic will discuss preoperative evaluation and risk assessment and timing of surgery. Perioperative infection control and considerations for airway management in patients with COVID-19 are discussed separately. (See "Overview of infection control during anesthetic care".)
Many United States and international organizations and professional societies have issued guidelines or recommendations for perioperative care during the COVID-19 pandemic. This topic relies heavily on such recommendations, which are based on expert opinion and what is known about transmission of this and other viruses [1-16]. (See 'Society guideline links' below.)
PREOPERATIVE EVALUATION — Preoperative evaluation should include taking a history of COVID-19 infection, severity of infection if applicable, and extent of residual symptoms. (See "COVID-19: Clinical features" and "COVID-19: Evaluation and management of adults with persistent symptoms following acute illness ("Long COVID")".)
Other aspects of the preanesthesia evaluation are discussed separately. (See "Preoperative evaluation for anesthesia for noncardiac surgery".)
Preoperative evaluation should include COVID-19 screening or testing for patients who are not known to have COVID-19. For all patients, risk assessment related to COVID-19 includes not only the likelihood of perioperative morbidity and mortality, but also the risk of spread of the virus to care providers and other patients.
Patients who require surgery soon after a diagnosis of COVID-19 may be taking nirmatrelvir-ritonavir (Paxlovid). Ritonavir is a strong CYP P450 3A inhibitor, and therefore may impair metabolism of a number of drugs used in anesthetic care, including midazolam, ketamine, rocuronium, lidocaine, and bupivacaine [17]. For this reason, dose adjustments or titration to effect should be considered for any patient taking nirmatrelvir-ritonavir, particularly if repeated doses or an infusion are administered. Drug interactions can be determined using the COVID-19 drug interactions program.
Preoperative screening — All patients scheduled for surgery should be screened for exposure to COVID-19, and for symptoms (ie, fever, cough, shortness of breath, muscle pain, sore throat, and/or new loss of taste or smell) within the prior two weeks. Patients with symptoms should be referred for further evaluation. (See "COVID-19: Clinical features", section on 'Clinical manifestations'.)
Preoperative testing — Institutional protocols should be followed for preoperative testing for COVID-19 and the use of transmission precautions. Some institutions are routinely performing COVID-19 testing before scheduling elective surgery, and some states have specific mandates or advisories for testing; these requirements are evolving rapidly as the pandemic wanes. Especially with the prevalence of highly contagious variants of SARS-CoV-2, continued vigilance is warranted even for patients who are vaccinated. (See "COVID-19: Epidemiology, virology, and prevention", section on 'Omicron (B.1.1.529) and its sublineages'.)
Whether protocols for testing and precautions will change now that the World Health Organization and the US Centers for disease control (CDC) have declared an end to the COVID-19 health emergency remains to be determined [18,19].
In December of 2022, the American Society of Anesthesiologists (ASA) and the Anesthesia Patient Safety Foundation (APSF) published a joint statement recommending against routine preoperative universal COVID-19 testing in asymptomatic patients [20]. Instead, the statement recommends perioperative screening for symptoms and contact with COVID-19, robust infection control measures, and targeted testing, taking into account community incidence of COVID-19 and facility layout with respect to ability to distance patients. This updated guidance is consistent with and based on recommendations from the Society for Healthcare Epidemiology of America (SHEA) [21]. The commentary from SHEA points out that asymptomatic screening is associated with potential harms, including procedure delays, strain on laboratory capacity, and additional cost, and is unlikely to provide additional benefit for preventing transmission of COVID-19 if other infection prevention strategies are used.
For patients who have previously tested positive for COVID-19, ASA/APSF recommendations for preoperative testing follow CDC guidelines for discontinuation of precautions, which depend on the severity of illness and the patient’s immunocompetence. CDC guidelines on this issue are discussed in detail separately and are shown in a table (table 1). (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Discontinuation of precautions'.)
RISK OF SURGERY IN PATIENTS WITH COVID-19 — The risks of perioperative morbidity and mortality may be increased in patients with COVID-19, and for some time after recovery [22-31]. Thus, the decision to perform surgery must balance this risk against the risks of delaying or avoiding the planned procedure. Most retrospective studies have found increased risks of pulmonary complications and mortality after surgery performed up to seven or eight weeks after a diagnosis of COVID-19.
Overall risk
●High rates of postoperative pulmonary complications and mortality were reported in an observational international study of 1128 patients with perioperative COVID-19 (ie, diagnosed within 7 days before or up to 30 days after surgery) who underwent a variety of surgical procedures [22]. Pulmonary complications occurred in 51 percent of patients; among those patients, 30-day mortality was 38 percent. Overall mortality was higher after emergency surgery compared with elective surgery (26 versus 19 percent), and was higher in men, patients >70 years of age, and those with American Society of Anesthesiologists (ASA) Physical Status grade ≥3. Of the 280 patients who had elective surgery, 22 were diagnosed with COVID-19 preoperatively and two of them died.
●In a similar prospective multicenter study of 1581 adults with perioperative COVID-19 in the United States, postoperative pulmonary complications occurred in 39.5 percent, and mortality occurred in 11 percent of patients [28]. Independent predictors of mortality were age ≥70 years (odds ratio [OR] 2.46, 95% CI 1.65-3.69), male sex (OR 2.26, 95% CI 1.53-3.35), ASA Physical Status grade ≥3 (OR 3.08, 95% CI 1.60-5.95), emergency surgery (OR 2.44, 95% CI 1.31-4.54), malignancy (OR 2.97, 95% CI 1.58-5.57), respiratory comorbidities (OR 2.08, 95% CI 1.30-3.32), and higher Revised Cardiac Risk Index (OR 1.20, 95% CI 1.02-1.41).
Risk related to timing after infection — Multiple large observational studies suggest that perioperative risks of pulmonary complications and mortality are highest within seven to eight weeks following COVID-19 infection [20,26,29,30,32-34]. However, the absolute risks of such complications are unclear. Estimates of perioperative complications and mortality come from observational studies suffer from high risk of confounding, without granular data on patient characteristics, type of surgery, or anesthetic management. These studies also could not account for changing viral strains, number and types of vaccinations, and changing institutional policies regarding preoperative screening. Examples of relevant studies include the following:
●An international cohort study using the COVIDSurg database included over 140,000 patients who underwent surgery early in the pandemic (during October of 2020), of whom approximately 3100 had a preoperative COVID-19 diagnosis. Surgery within seven weeks of the diagnosis of COVID-19 was associated with increased odds of 30-day postoperative mortality and pulmonary complications [29]. Risk of mortality was greater in patients who had been symptomatic with COVID infection, and was greatest in patients with ongoing symptoms at the time of surgery. Mortality data from this study are shown in a table (table 2).
●In a multicenter United States database study of >5400 patients with COVID-19 who underwent major nonemergency surgery from March, 2020 through May, 2021, patients who had surgery in the first four weeks after the diagnosis of COVID-19 had higher risks of postoperative pneumonia (adjusted odds ratio [aOR] 6.6, 95% CI 4.1-10.3), respiratory failure (aOR 3.4, 95% CI 2.2-5.1), sepsis (aOR 3.7, 95% CI 2.2-6.2), and pulmonary embolism (aOR 2.7, 95 1.4-5.5) compared with patients who had surgery more than 30 days prior to the COVID diagnosis [26]. Surgery within four to eight weeks was associated with increased risk of pneumonia (aOR 2.4, 95% CI 1.2-5.0). Surgery ≥8 weeks after diagnosis was not associated with increased risk of complications. Most patients had mild to moderate COVID-19. There were no data on COVID-19-related symptoms at the time of surgery, or on postoperative mortality.
●In the United Kingdom OpenSAFELY database study described below, rates of morality and postoperative complications were lower than those reported in the COVIDSurg database study described above, but still steadily declined as surgery was performed from 2 weeks to >7 weeks after infection [34].
Several studies suggest that vaccination may reduce perioperative risk [33-35].
●A large database study used data from the OpenSAFELY platform from the National Health Service in the United Kingdom to evaluate postoperative outcomes in patients who had tested positive for COVID-19 prior to surgery [34]. The study compared outcomes in patients who had surgery before the pandemic (March 2018 to March of 2020), during the pandemic prior to availability of vaccines (March 2020 until January of 2021), and after the availability of vaccines (January 2021 until March of 2022).
•In patients who had surgery prior to the availability of vaccines, 30-day postoperative mortality in patients with prior COVID-19 infection was 4.1 percent for surgery within 14 days of infection, and declined steadily to 0.9 percent for surgery performed >7 weeks after infection. Thirty-day mortality for this time period in patients without prior infection was lower, at 0.3 percent.
•In patients who had surgery after the widespread availability of vaccines, 30-day postoperative mortality was 1.1 percent after surgery performed within 2 weeks of infection, and declined to 0.2 percent after surgery >7 weeks after infection, the same rate as patients without preoperative COVID-19 infection.
These mortality rates are significantly lower than those that were reported in the COVIDSurg study described above, and reasons are unclear. Conclusions are limited by the small number of COVID-19 positive patients who had surgery, and lack of confirmation of patient vaccine status.
●A retrospective cohort study found that postoperative complications were not increased in vaccinated patients who had surgery within four weeks of COVID-19 infection, but were modestly increased in patients who were not fully vaccinated and in patients who had general anesthesia for the surgery [33].
Limited data suggest that postoperative risks may be lower in pediatric patients with the Omicron variant. In a single institution retrospective study, 285 children who tested positive for COVID-19 in early 2022 (likely Omicron) subsequently underwent surgery [36]. Very few intra or postoperative complications occurred, even when surgery was performed at two to four weeks after infection. Most children had mild or asymptomatic COVID-19. Approximately 42 percent underwent otolaryngologic surgery, but no further detail was provided on other types of surgery.
Timing of surgery after COVID-19 infection — Elective procedures should not be performed in patients who are symptomatic with COVID-19 or who are suspected of having COVID-19. For patients who have had COVID-19, elective procedures should ideally be delayed until the patient has recovered to baseline cardiopulmonary status and is no longer infectious.
Patients with severe COVID-19 may have significant cardiopulmonary compromise long after the acute illness [37,38]. The decision to proceed with elective surgery after COVID-19 infection must be individualized, taking into account both the risks of complications after surgery and the risks of delaying surgery [39]. (See 'Risk of surgery in patients with COVID-19' above.)
The consensus among many clinicians is that as clinical infection with COVID-19 has become less severe, the impact of prior infection on perioperative risk has gone down. Going forward, it is likely that only patients who survive a severe bout of COVID-19 pneumonia (eg, required mechanical ventilation) will be assessed and managed according to the guidelines described below, or will be managed as if they had survived any other cause of severe ARDS.
●Recovery from COVID-19 – The time to resolution of symptoms and complete recovery from COVID-19 varies widely. Young healthy patients with mild COVID-19 may recover completely within several weeks. However, patients with comorbidities or severe infection may have a prolonged recovery lasting eight weeks or longer. Some patients have protracted changes in pulmonary function, multiorgan system involvement, including stroke, myocarditis, and kidney dysfunction, fatigue, and psychologic or cognitive problems (see "COVID-19: Evaluation and management of adults with persistent symptoms following acute illness ("Long COVID")"). Similar to other viral illnesses, decisions about the timing of elective procedures should be based on the type of procedure to be performed, patient comorbidities, and residual symptoms, including exercise tolerance relative to baseline.
●Infectivity – Both the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) have provided recommendations for determining when a patient diagnosed with COVID-19 is no longer infectious. They provide options based on either testing or time from both initial symptoms and resolution of symptoms, or for patients who were asymptomatic, time since a positive test. The specifics of symptom and time based strategies for discontinuation of precautions are shown in a table (table 1).
•For patients who are asymptomatic or with mild symptoms, the decision to discontinue precautions should be based on time and symptom-based criteria.
•For patients who are immunocompromised and patients who are severely ill with COVID-19, testing should be managed in consultation with an infectious disease specialist.
Testing for infectivity is discussed in detail separately. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Discontinuation of precautions'.)
●Guidelines from anesthesia societies – The Anesthesia Patient Safety Foundation (APSF) and the ASA issued a 2023 updated joint statement on elective surgery after COVID-19 infection [40]. Their guidelines on timing of elective surgery are based on an individualized assessment of surgical risk including the complexity of surgery, severity of COVID-19 infection and ongoing symptoms, and shared decision making. Briefly, the guidelines state the following:
•Elective surgery should not be performed on patients who are still infectious with COVID-19.
•Elective surgery should not be performed within two weeks of the diagnosis of COVID-19.
•For patients who are low risk having low risk surgery, surgery can be scheduled between two and seven weeks after infection, balancing the risk of proceeding against the risk of delay.
•For patients with continued COVID-19 symptoms, or for whom the risk of performing surgery exceeds the risk of delay, surgery should be delayed beyond seven weeks after infection.
A group of anesthesia and surgical societies in the United Kingdom also published an updated consensus statement on the timing of surgery after COVID-19 infection, which is generally similar to the ASA and APSF statement [41]. It states that there is no evidence supporting delay of elective surgery beyond seven weeks after a diagnosis of COVID-19 for patients who had mild COVID-19 or who have fully recovered from the infection. (See 'Society guideline links' below.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: COVID-19 – Index of guideline topics".)
SUMMARY AND RECOMMENDATIONS
●Preoperative evaluation
•Preoperative screening – All patients should be screened preoperatively for symptoms of COVID-19 and for contact with infected persons. Patients who screen positive should be referred for further evaluation prior to elective surgery. (See 'Preoperative screening' above.)
•Preoperative testing – As the COVID-19 pandemic has waned, the American Society of Anesthesiologists (ASA) and the Anesthesia Patient Safety Foundation (APSF) no longer recommend universal preoperative COVID-19 testing. Instead, they recommend targeted and risk-based testing, taking into account community incidence of COVID-19 and facility layout with respect to ability to distance patients. (See 'Preoperative testing' above.)
For patients who have previously tested positive for COVID-19, ASA/APSF recommendations for preoperative testing follow the Centers for Disease Control and Prevention (CDC) guidelines for discontinuation of precautions, which depend on the severity of illness and the patient’s immunocompetence. CDC guidelines on this issue are discussed in detail separately and are shown in a table (table 1). (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Discontinuation of precautions' and 'Preoperative testing' above.)
●Surgical risk – The risks of perioperative morbidity and mortality may be increased in patients with COVID-19, and for some time after recovery. Thus, the decision to perform surgery must balance this potential risk against the risks of delaying or avoiding the planned procedure. (See 'Risk of surgery in patients with COVID-19' above.)
●Timing of surgery
•Elective procedures should not be performed in patients who are symptomatic with COVID-19 or who are suspected of having COVID-19.(See 'Timing of surgery after COVID-19 infection' above.)
•For patients who have had COVID-19, elective procedures should ideally be delayed until the patient has recovered to baseline cardiopulmonary status and is no longer infectious.
•Most retrospective studies have found increased risks of pulmonary complications and mortality after surgery performed up to seven or eight weeks after a diagnosis of COVID-19. Whether risks differ after infection with the most recent SARS-CoV-2 variants or in patients who have been vaccinated are unclear, though some studies suggest that vaccination may be protective. (See 'Risk related to timing after infection' above.)
•Existing symptoms and the severity of the initial illness should be considered when assessing perioperative risk for patients who have had COVID-19. (See 'Risk related to timing after infection' above.)
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