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COVID-19 PeriOperative Considerations

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Ross Hanrahan
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Timing of Surgery Around COVID-19 Infection

Timing of Surgery Around COVID-19 Infection1

Elective Surgery

It is recommended that post PCR confirmation of COVID-19 infection:

  1. non-urgent elective major surgery should be delayed for a minimum of eight weeks
  2. nonurgent elective minor surgery for at least 4 weeks

Provided the patient has returned to baseline function and is symptom free.

Those with ongoing symptoms may benefit from further delay if circumstances allow.

Time-Sensitive Surgery

For time-sensitive surgery (e.g. cancer surgery), the individual risk versus benefit of proceeding and delaying needs to be carefully assessed.

Ideally a plan is formulated based on shared decision making between all involved in the patient’s care, to ensure optimal timing.

From the available evidence, perioperative outcomes start to improve after two weeks predominantly in the asymptomatic group of patients, though the best outcomes are found >=49 days post PCR/RAT confirmation of COVID-19 infection for both asymptomatic and symptomatic patients with resolved symptoms.

Patients with persistent symptoms at seven weeks have worse outcomes.

Quick COVID/ Surgery Date Calculation

Timing of Surgery Around COVID-19 Vaccination

The relevant considerations are:
  1. Differentiation of symptoms attributable to vaccination from those suggesting surgical complications.
    • Government advice is to: “Schedule COVID-19 vaccination at least one week before or after surgeries. This will reduce the chance that adverse events following the vaccination (such as fever) are attributed as surgical complications (such as wound infection)”11.
  2. Ensuring Vaccines have adequate time to offer optimal protection from peri-operative COVID-19 infection
    • Ideally allow 2 weeks after vaccination for protection to develop.
    • Short-term efficacy against symptomatic COVID-19 is about 95% from seven days after the second dose of Pfizer in people aged ≥12 years. – ATAGI 5.
    • Short-term efficacy against symptomatic COVID-19 is approximately 94% from two weeks after the second dose of Moderna in people aged ≥18 years, and similar in adolescents aged 12–17 years 5.
    • Onset of protection from Astra-Zeneca may be somewhat slower than that seen with Pfizer12

Transmission Considerations

How Long are Patients Infectious For?
How Long Are Patients Infectious For?1

In the absence of re-testing, a time-and symptom-based strategy is needed to determine when patients with COVID-19 are no longer infectious.

  1. Patients with mild/asymptomatic COVID-19 infection or with a break-through COVID-19 infection.
    • Patients with mild/asymptomatic COVID-19 infection and fully vaccinated patients with a break-through infection are no longer considered infectious at least 10 days from onset of symptoms and/or first PCR positive test and at least 24 hours since resolution of fever without the use of antipyretic medications and improvement in respiratory symptoms.
    • This time frame is currently reduced to 7 days with the omicron variant.
  2. Severely ill hospitalised patients
    • A small number of severely ill hospitalised patients, especially if immunocompromised, can have culturable virus out to 20 days.
    • Taking an abundantly cautious approach, one can assume that they are no longer infectious after 20 days from onset of symptoms and/or first PCR positive test and at least 24 hours since resolution of fever without the use of antipyretic medications and improvement in respiratory symptoms
How Long After Exposure Are Patients At Risk of Developing COVID?
How Long After Exposure Are Patients At Risk of Developing COVID?13
  • After being exposed to someone with COVID-19, you are at risk of developing it for 14 days.
  • The majority of people who develop COVID-19 will do so in the first 7 days after they are exposed.
  • However, some people still develop COVID-19 between day 8 and 14.

References

  1. PS68A Living guidance - Surgical Patient Safety in Relation to COVID-19 Infection and Vaccination
  2. PS68A Living guidance Document (Live link)
  3. RACS - ANZCA - ASA - RANZCOG Perioperative Guidance post COVID infection - August 2020
  4. SARS-CoV-2 infection, COVID-19 and timing of elective Surgery - Anaesthesia 2021
  5. NSW Health - Evidence Check - COVID-19 Vaccine and Elective Surgery - May 2021
  6. Perioperative Risk Evaluation in Patients Scheduled for Elective Surgery in Close Relation to Their SARS-CoV-2 Vaccination - BJA March 2021
  7. ATAGI - Clinical Guidance on COVID-19 Vaccine in Australia - 29-10-2021
  8. The Risk of Postoperative Complications After Major Elective Surgery in Active or Resolved COVID-19 in the United States - Annals of Surgery 2022
  9. Management of perioperative thromboprophylaxis for surgery following COVID-19 - an expert panel survey - BJA 2021
  10. Timing of elective surgery and risk assessment after SARS-CoV-2 infection - an update - Anaesthesia 2022
  11. https://www.health.gov.au/initiatives-and-programs/covid-19-vaccines/advice-for-providers/clinical-considerations#surgery-and-vaccination-timing
  12. Effectiveness of the Pfizer and AstraZeneca Vaccines on COVID-19 related symptoms hospital admissions and mortality in older adults in England – BMJ 2021
  13. How Long Am I At Risk For? [www.covid19.act.gov.au]
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