Postoperative pulmonary complications common in COVID-19
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Among patients with COVID-19 who underwent surgery, 30-day mortality was high and approximately half of patients experienced postoperative pulmonary complications, according to an international study.
The observational study, which was recently published in The Lancet, was conducted from Jan. 1 to March 31 and included 1,128 patients with COVID-19 who underwent surgery at 235 hospitals in 24 countries predominantly in Europe and North America. The primary outcome was postoperative 30-day mortality and the main secondary outcome was pulmonary complications, such as pneumonia, acute respiratory distress syndrome and unexpected postoperative ventilation.
SARS-CoV-2 infection was diagnosed within 7 days before or 30 days after surgery using lab testing or, in the absence of lab testing, clinical or radiological findings. Infection was confirmed preoperatively in slightly more than one-quarter of patients.
Of those included in the study, 74% had emergency surgery and 24.8% had elective surgery, with data missing for 13 patients. Reasons for surgery included benign disease (54.5%), cancer (24.6%) and trauma (20.1%), with data missing for eight patients.
High mortality, pulmonary complication rates
Overall, 30-day mortality was 23.8%. After adjustment, the researchers found that risk for death at 30 days was higher for the following:
- men (OR = 1.75; 95% CI, 1.28-2.4);
- patients aged at least 70 years vs. younger than 70 years (OR = 2.3; 95% CI, 1.65-3.22);
- patients with American Society of Anesthesiologists grades 3 to 5 vs. grades 1 to 2 (OR = 2.35; 95% CI, 1.57-3.53);
- patients with a malignant vs. benign or obstetric diagnosis (OR = 1.55; 95% CI, 1.01-2.39);
- patients who underwent emergency vs. elective surgery (OR = 1.67; 95% CI, 1.06-2.63); and
- patients who underwent major vs. minor surgery (OR = 1.52; 95% CI, 1.01-2.31).
“Although the risks associated with COVID-19 need to be carefully balanced against the risks of delaying surgery for every individual patient, our study suggests that the thresholds for surgery should be raised, compared to normal practice,” Aneel Bhangu, MBChB, FRCS, PhD, from the University of Birmingham in the United Kingdom, said in a press release. “Medical teams should consider postponing noncritical procedures and promoting other treatment options, which may delay the need for surgery or sometimes avoid it altogether.”
Results also showed that pulmonary complications occurred in 51.2% of patients — of whom 40.4% had pneumonia, 21.3% had unexpected ventilation and 14.4% had ARDS. Notably, patients who experienced pulmonary complications had a higher 30-day mortality rate than those who did not experience complications (38% vs. 8.7%) and accounted for 82.6% of deaths overall. Additionally, 30-day mortality was highest among those with ARDS (63%) and emergency patients who received a COVID-19 diagnosis after surgery (43.1%). After adjustment, pulmonary complications also appeared to be associated with American Society of Anesthesiologists grades 3 to 5 vs. grades 1 to 2.
Overall, pulmonary complication rates were similar in patients with lab-confirmed and clinically diagnosed COVID-19. Additionally, in a sensitivity analysis restricted to patients with lab-confirmed infection only, 30-day mortality, pulmonary complication rates and predictors of 30-day mortality were comparable to those from the main analysis.
Careful considerations
Guidelines have been published regarding management of surgical patients with COVID-19, but they have been based on expert opinion, according to the researchers. These findings, they noted, help provide more evidence and context.
“When hospitals resume routine surgery, it’s likely it will take place in environments that remain exposed to SARS-CoV-2. Hospital-acquired infection will remain a challenge, but strategies are urgently required to minimize it, as well as to minimize the risk of pulmonary complications for infected patients whose surgery cannot be delayed,” Ana Minaya-Bravo, MD, from the Hospital Universitario del Henares and Universidad Francisco de Vitoria in Spain, said in the release. “Future studies should assess the role that preoperative testing could play in deciding which patients are selected for surgery.”
In a linked comment, Paul S. Myles, MD, MBBS, MPH, DSc, from Alfred Hospital and Monash University in Melbourne, Australia, and Salome Maswime, MD, MMed, PhD, from the University of Cape Town in South Africa, highlighted the study’s limitations, including a lack of a control group as well as a lack of standardized testing, but also acknowledged that the findings are troubling in that the poor outcomes in the study exceeded those seen with most major types of surgery.
“Severe COVID-19 is associated with a marked inflammatory and prothrombotic state. These pathological processes are exacerbated by surgery and immobilization, leading to a perfect storm detrimental to good postoperative outcomes,” they wrote, adding that the data underscore the need for perioperative guidelines during the pandemic and more research into to what extent community spread would threaten hospital capacity and resources as elective surgeries resume.
“Globally, many governments and professional bodies are moving from a position of curtailment to reopening of elective surgery. This requires a low prevalence in the community and access to SARS-CoV-2 testing and ensuring there are sufficient trained staff, hospital and ICU beds, personal protective equipment and all other necessary medical supplies,” Myles and Maswime wrote. “COVID-19 might affect access to safe surgery, especially in low-income and middle-income countries for homeless people, migrants and refugees — this is a great concern that needs to be addressed. Surgery is an essential part of modern medicine, but additional risks during the COVID-19 pandemic must be carefully considered.”