Surgery and anaesthesia experts issue update on timing of elective surgery following emergence of omicron variant of SARS-CoV-2
Tuesday 22 February 2022
In March, 2021, long before the emergence of the omicron variant, the COVIDSurg Collaborative (a global collaboration of over 15,000 surgeons and anaesthetists working together to collect a range of data on surgery during COVID-19 pandemic) found evidence of increased risk of mortality and other poor outcomes for those who had tested positive for COVID-19 and had surgery in the period 0-6 weeks after diagnosis. This drove guidance recommending that surgery should be avoided within 7 weeks of a diagnosis, a paper which was published* in Anaesthesia.
Now the journal Anaesthesia is publishing a multidisciplinary consensus statement that updates guidance in this area, on behalf of the Association, Centre for Perioperative Care, Federation of Surgical Specialty Associations, Royal College of Anaesthetists, and the Royal College of Surgeons of England.
“The guidance remains that patients should avoid elective surgery within 7 weeks of infection, unless the benefits of doing so exceed the risk of waiting. We recommend individualised multidisciplinary risk assessment for patients requiring elective surgery within 7 weeks of SARS-CoV-2 infection,” says statement co-author Dr Kariem El-Boghdadly, Consultant in Anaesthesia at Guy’s and St Thomas’ NHS Foundation Trust, London, UK. “This should include baseline mortality risk calculation and assessment of risk factors such as the patient’s age and functional status, the severity, timing and any ongoing symptoms of SARS-CoV-2 infection, and also surgical factors such as risk of disease progression and complexity of surgery. All of this can then be used to help the patient and their medical team decide if surgery within 7 weeks of SARS-CoV-2 is appropriate for their individual case.”
“Asymptomatic SARS-CoV-2 infection with previous variants increased peri-operative mortality risk up to three-fold throughout the 6 weeks after infection, and assumptions that asymptomatic or mildly symptomatic omicron SARS-CoV-2 infection does not add risk are unfounded,” adds co-author Professor Tim Cook (Consultant in Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK, and Honorary Professor, School of Medicine, University of Bristol, UK). “Patients with persistent symptoms and those with moderate to severe COVID-19 may require a longer delay than 7 weeks. Elective surgery should not take place within 10 days of diagnosis of SARS-CoV-2 infection, predominantly because the patient may be infectious, which is a risk to surgical pathways, staff and other patients.”
The consensus statement contains a number of recommendations, some of which may be revised in the coming months as more data on omicron become available. These include:
- Where possible, patients should avoid elective surgery within 7 weeks of SARS-CoV-2 infection, unless the benefits of doing so exceed the risk of waiting. Individualised risk assessment should be provided for patients with elective surgery planned within 7 weeks of SARS-CoV-2 infection. There is as yet no new evidence on the omicron variant that justifies reducing this period – existing evidence shows asymptomatic SARS-CoV-2 infection with previous variants increased mortality risk by up to three-fold throughout the 6 weeks after infection.
- Surgical patients should have received pre-operative COVID-19 vaccination, with three doses wherever possible, with the last dose at least 2 weeks before surgery. Confirming and optimising vaccination status should be actioned as soon as possible, either before primary care referral or at surgical decision making.
- Current measures designed to reduce the risk of patients acquiring SARS-CoV-2 in the peri-operative period should continue and, in view of the increased transmissibility of omicron, should be augmented (e.g. respiratory protective equipment) where evidence supports this.
- Patients should be requested to notify the hospital if they test positive for SARS-CoV-2 infection within 7 weeks of their planned operation date. From there, a conversation should take place between the peri-operative team and the patient about the risks and benefits of deferring surgery.
- Elective surgery should not take place within 10 days of diagnosis of SARS-CoV-2 infection, predominantly because the patient may be infectious, which is a risk to surgical pathways, staff and other patients.
- Patients with persistent symptoms and those with moderate-to-severe COVID-19 (for example those who were hospitalised) remain likely to be at greater risk of morbidity and mortality, even after 7 weeks. Therefore, delaying surgery beyond this point should be considered, balancing this risk against any risks associated with such delay.
- In patients with recent or peri-operative SARS-CoV-2 infection, avoidance of general anaesthesia in favour of local or regional anaesthetic techniques should be considered
“There has been a desire both within the UK and in health systems around the world to increase elective surgical activity to pre-COVID levels to help clear the ever-increasing backlog. However, this must be balanced with delivering that surgery as safely as possible,” explains co-author and consultant surgeon Professor Duncan Summerton, President of the Federation of Surgical Specialty Associations (FSSA) who is based at Leicester General Hospital, UK.
“However, there is currently a lack of data [on the omicron variant and vaccination] that show any concrete changes in peri-operative risk. Although this information is expected in the coming months, our recommendations in this statement are made with what we currently know. We are currently maintaining our recommendation to delay surgery wherever possible for at least seven weeks in any patient who has tested positive for COVID-19 to ensure their safety and that their surgery has the best possible outcome. If delaying surgery to this extent is considered harmful to the patient, then we recommend a full and frank discussion to reach a shared decision to proceed or defer.”
Dr Mike Nathanson, President of the Association, said: “This update about the risks of recent COVID-19 infection in surgical patients is timely. The backlog of surgical cases is a major public health concern. The recent report from NHS England describes an ambition to reduce waiting times in England through a very significant expansion of surgical activity. There are similar plans in other parts of the UK. Patients, and the teams caring for them, need this expert guidance to assist their decision making. The frustration felt by patients is immense and we - the healthcare professionals – want to do our jobs and provide these services when it is safe to do so and with the risks clear to all involved. We look forward to new data being available soon which may further clarify the situation now that the omicron variant is dominant, and most patients are vaccinated.”