SARSCoV2 infection, COVID19 and timing of elective surgery



## Summary
The scale of the COVID-19 pandemic means that a significant number of patients who have previously been infected with SARS-CoV-2 will require surgery. Given the potential for multisystem involvement, timing of surgery needs to be carefully considered to plan for safe surgery. This consensus statement uses evidence from a systematic review and expert opinion to highlight key principles in the timing of surgery. Shared decision-making regarding timing of surgery after SARS-CoV-2 infection must account for severity of the initial infection; ongoing symptoms of COVID-19; comorbid and functional status; clinical priority and risk of disease progression; and complexity of surgery. For the protection of staff, other patients and the public, planned surgery should not be considered during the period that a patient may be infectious. Precautions should be undertaken to prevent pre-and peri-operative infection, especially in higher risk patients. Elective surgery should not be scheduled within 7 weeks of a diagnosis of SARS-CoV-2 infection unless the risks of deferring surgery outweigh the risk of postoperative morbidity or mortality associated with COVID-19. SARS-CoV-2 causes either transient or asymptomatic disease for most patients, who require no additional precautions beyond a 7-week delay, but those who have persistent symptoms or have been hospitalised require special attention. Patients with persistent symptoms of COVID-19 are at increased risk of postoperative morbidity and mortality even after 7 weeks. The time before surgery should be used for functional assessment, prehabilitation and multidisciplinary optimisation. Vaccination several weeks before surgery will reduce risk to patients and might lessen the risk of nosocomial SARS-CoV-2 infection of other patients and staff. National vaccine committees should consider whether such patients can be prioritised for vaccination. As further data emerge, these recommendations may need to be revised, but the principles presented should be considered to ensure safety of patients, the public and staff. Introduction SARS-CoV-2 infection has contributed to more than 118 million infections globally and more than 2.6 million deaths from COVID-19. The impact of COVID-19 has been particularly significant in the UK, with more than 4.2 million cases and 125,000 people dying within 28 days of a positive SARS-CoV-2 test. The scale of the pandemic has created substantial pressures on healthcare systems globally, leading to sustained reductions in surgical activity. An estimated 28 million operations were cancelled in 12 weeks of the first pandemic surge [bib_ref] Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to..., Nepogodiev [/bib_ref] , with millions of patients still waiting for surgery. To support delivery of surgical services throughout the pandemic, prioritisation of different procedures has been undertaken.
One of the challenges of surgery during the COVID-19 pandemic is the peri-operative risk of morbidity and mortality to patients with active SARS-CoV-2 infection.
Evidence suggests a 19.1% 30-day mortality in elective (planned) and 26.0% 30-day mortality in emergency surgical patients, with around half of patients having surgery when infected with SARS-CoV-2 experiencing postoperative pulmonary complications [bib_ref] Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection:..., Collaborative [/bib_ref]. In addition, given the scale of the pandemic, peri-operative outcomes after a previous SARS-CoV-2 infection are an important concern, as a significant number of patients who have previously been infected (estimated at 15-20% of the UK populationwill require surgery.
Surgery after a previous SARS-CoV-2 infection should be timed to ensure the safest delivery of peri-operative care.
SARS-CoV-2 infection may cause multisystem disease with both short and long-term sequelae, including chronic pulmonary dysfunction, myocardial inflammatory states, renal impairment, psychological distress, chronic fatigue and musculoskeletal deconditioning [bib_ref] Screening of healthcare workers for SARS-CoV-2 highlights the role of asymptomatic carriage..., Rivett [/bib_ref] [bib_ref] 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study, Huang [/bib_ref] [bib_ref] Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent symptoms in patients after..., Carf I [/bib_ref] [bib_ref] Follow-up study of the pulmonary function and related physiological characteristics of COVID-19..., Zhao [/bib_ref]. These short

## Protection of others
Elective surgery after SARS-CoV-2 infection must be safe for staff, other patients and the public [bib_ref] Peri-operative COVID-19 infection in urgent elective surgery during a pandemic surge period:..., Kane [/bib_ref] [bib_ref] Airborne transmission of severe acute respiratory syndrome coronavirus-2 to healthcare workers: a..., Wilson [/bib_ref] [bib_ref] Kicking on while it's still kicking off -getting surgery and anaesthesia restarted..., Cook [/bib_ref] [bib_ref] Risks to healthcare workers following tracheal intubation of patients with COVID-19: a..., El-Boghdadly [/bib_ref]. Therefore, adherence to self-isolation guidelines is imperative.
Symptoms of COVID-19 present 4-5 days following infection with SARS-CoV-2, and it is most contagious in the 2 days before and the 5 days after the onset of symptoms [bib_ref] Duration of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infectivity: When is..., Rhee [/bib_ref]. In asymptomatic and mild to moderately symptomatic patients, it is rare for the virus to be cultured beyond 10 days after symptom onset, which underlies

## Timing of elective surgery after sars-cov-2 infection

## Symptoms and severity of disease
The phases of COVID-19and the scale of clinical severity [bib_ref] A minimal common outcome measure set for COVID-19 clinical research, Marshall [/bib_ref] are both important factors in planning surgery and are summarised in.
It is important to note that for the majority of patients infected with SARS-CoV-2, it is either a transient or asymptomatic disease followed by full recovery [fig_ref] 1 02: [/fig_ref].
Approximately 15% of infected patients are hospitalised, 5% require advanced oxygen therapies and around 1% of all cases require critical care admission [fig_ref] 1 02: [/fig_ref] also been reported in smaller patient cohorts [bib_ref] Periprocedural complications in patients with SARS-CoV-2 infection compared to those without infection:..., Lal [/bib_ref].
Notably, symptomatic patients are at greater risk of 30day mortality than patients whose symptoms have resolved or those who have asymptomatic infection, even beyond a Phases of COVID-19.

## Phase definition

## Acute covid-19 symptoms and signs of covid-19 for up to 4 weeks after infection ongoing symptomatic covid-19 symptoms and signs of covid-19 from 4 weeks up to 12 weeks after infection
Post-COVID-19 syndrome Symptoms and signs that develop during or after an infection consistent with COVID-19, continue for more than 12 weeks and are not explained by an alternative diagnosis. It usually presents with clusters of symptoms, often overlapping, which can fluctuate and change over time and can affect any system in the body. Post-COVID-19 syndrome may be considered before 12 weeks while the possibility of an alternative underlying disease is also being assessed.
Long COVID Symptoms and signs that continue or develop after acute COVID-19, which includes both ongoing symptomatic COVID-19 (from 4 to 12 weeks) and post-COVID-19 syndrome (12 weeks)
Resolved COVID-19 Previous symptoms and signs of acute COVID-19 that have completely resolved. 7-week delay. Moreover, patients with resolved symptoms are also at greater risk of 30-day mortality than those who had asymptomatic infection [bib_ref] Periprocedural complications in patients with SARS-CoV-2 infection compared to those without infection:..., Lal [/bib_ref] [bib_ref] Early postoperative outcomes among patients with delayed surgeries after preoperative positive test..., Baiocchi [/bib_ref]. Thus, both the previous and current clinical condition of patients appear to influence postoperative outcomes.
Timing of surgery in patients who have been in critical care requires special consideration. In addition to residual pathophysiological sequelae, many will be deconditioned and require physical rehabilitation. Many will also have had

## Box 1
Prioritisation of urgency of surgical procedures.
Categories P5 (patient wishes to postpone surgery due to COVID-19 concerns) and P6 (patient wishes to postpone surgery due to non-COVID-19 concerns) were added in October 2020 as part of the national validation of waiting lists. The complexity and the nature of surgery is a further consideration, as more complex surgery is consistently associated with increased postoperative morbidity and mortality, including in patients with COVID-19 [bib_ref] Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection:..., Collaborative [/bib_ref]. Validated risk prediction tools account for complexity and urgency of surgery, and can be used to aid decision-making regarding timing of surgery after SARS-CoV-2 infection [bib_ref] Developing and validating subjective and objective risk-assessment measures for predicting mortality after..., Wong [/bib_ref].

## Anaesthetic technique
There is currently no strong evidence that anaesthetic technique is associated with an alteration in postoperative outcome in patients who have had peri-operative SARS-CoV-2 infection [bib_ref] Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection:..., Collaborative [/bib_ref]. In patients with persistent respiratory pathophysiological changes after severe COVID-19, the benefits of avoiding general anaesthesia are likely to be the same as in other respiratory disease. The use of local or regional anaesthetic techniques may have outcome and resource-utilisation benefits, but this is not specific to patients with previous or current SARS-CoV-2 infection.

# Discussion
As the population of patients requiring surgery following SARS-CoV-2 infection grows, so will the need to ensure safe peri-operative care for this cohort. The same general principles of safe and effective peri-operative care as for patients with no history of SARS-CoV-2 infection apply.
However, timing of surgery must also be sensitive to the impact of SARS-CoV-2 on both patients and others. In after discharge, need to continue while this remains a significant risk. As further data emerge, these recommendations may need to be revised.
[fig] 3: Surgery within 7 weeks of SARS-CoV-2 infection is associated with increased morbidity and mortality. Elective surgery should not be scheduled within 7 weeks of a diagnosis of SARS-CoV-2 infection, unless outweighed by the risk of deferring surgery such as disease progression or clinical priority. [/fig]
[fig] 4: Most patients infected with SARS-CoV-2 have either transient or asymptomatic disease and require no additional precautions beyond a 7-week delay, but those who have persistent symptoms or have been hospitalised require special attention. [/fig]
[fig] 5: Patients with persistent symptoms of COVID-19 are at increased risk of postoperative morbidity and mortality even after 7 weeks. Therefore, delaying surgery beyond this point should be considered, balancing this risk against their risk of disease progression and clinical priority. Specialist assessment and personalised, multidisciplinary peri-operative managementis required. [/fig]
[fig] 6: The time before surgery should be used for functional assessment, rehabilitation from severe illness, prehabilitation and multidisciplinary optimisation. [/fig]
[fig] 7: Vaccination several weeks before surgery will reduce risk to patients and might lessen the risk of nosocomial SARS-CoV-2 infection of other patients and staff. National vaccine committees should consider whether such patients can be prioritised for vaccination. [/fig]
[fig] 8: As a result of the increased risk of morbidity and mortality of peri-operative COVID-19, precautions to prevent admission of patients who are incubating SARS-CoV-2 and infection within the hospital should continue. These recommendations are based on evidence available at the time of writing and may be subject to future review. [/fig]
[fig] 1 02: (0.66-1.56)). The timings of these mortality risks are also consistent in elective surgery, and when stratified by patient demographics, complexity of surgery and urgency of surgery. A similar trajectory is also seen in postoperative pulmonary complications, with risks being greater for the first 6 weeks after SARS-CoV-2 infection when compared with no infection, but returning to comparable rates beyond 7 weeks. Similar time-dependent findings have [/fig]
[fig] Figure 1: Estimated population distribution of SARS-CoV-2 presentation. NIV, non-invasive ventilation; HFNO, high-flow nasal oxygen. [/fig]
[fig] Priority 1a: Emergency procedures to be performed in < 24 h. Priority 1b: Procedures to be performed in < 72 h Priority 2: Procedures to be performed in < 1 month Priority 3: Procedures to be performed in < 3 months Priority 4: Procedures to be performed in > 3 months 944 [/fig]