COVID-19 patients who undergo surgery are at increased risk of postoperative death
Patients undergoing surgery after contracting coronavirus are at greatly increased risk of postoperative death, a new global study published in The Lancet reveals. Researchers found that amongst SARS-CoV-2 infected patients who underwent surgery, mortality rates approach those of the sickest patients admitted to intensive care after contracting the virus in the community.
Experts from different institutions including the University of Birmingham-led NIHR Global Research Health Unit on Global Surgery and the Department of Surgery at Massachusetts General Hospital have now published their findings that SARS-CoV-2 infected patients who undergo surgery experience substantially worse postoperative outcomes than would be expected for similar patients who do not have SARS-CoV-2 infection.
Researchers examined data for 1,128 patients from 235 hospitals. A total of 24 countries participated, predominantly in Europe, although hospitals in Africa, Asia, and North America also contributed.
Overall 30-day mortality in the study was 23.8%. Mortality was disproportionately high across all subgroups, including elective surgery (18.9%), emergency surgery (25.6%), minor surgery such as appendicectomy or hernia repair (16.3%), and major surgery such as hip surgery or colon cancer surgery (26.9%).
The study identified that mortality rates were higher in men (28.4%) versus women (18.2%), and in patients aged 70 years or over (33.7%) versus those aged under 70 years (13.9%). In addition to age and sex, risk factors for postoperative death included having severe pre-existing medical problems, undergoing cancer surgery, undergoing major procedures, and undergoing emergency surgery.
Patients undergoing surgery are a vulnerable group at risk of SARS-CoV-2 exposure in hospital. They may be particularly susceptible to subsequent pulmonary complications, due to inflammatory and immunosuppressive responses to surgery and mechanical ventilation.
The study found that overall in the 30 days following surgery 51% of patients developed a pneumonia, acute respiratory distress syndrome, or required unexpected ventilation. This may explain the high mortality, as most (81.7%) patients who died had experienced pulmonary complications.
“The decision in most hospitals to postpone elective surgery was made to both protect our patients as well as increase capacity to take care of the COVID-19 patients during the peak of the pandemic,” says report co-author Haytham Kaafarani, MD, MPH, from the department of surgery at Massachusetts General Hospital and an associate professor of surgery at Harvard Medical School. “The high mortality and morbidity rates of the elective surgery patients in this study is proving that the decision was sound, as we would normally expect mortality for patients having minor or elective surgery to be under 1-3%.”
“We recommend that thresholds for surgery during the SARS-CoV-2 pandemic should be raised compared to normal practice, says Aneel Bhangu, MD, PhD, Senior Lecturer in Surgery at the University of Birmingham, the co-author and overall study lead. “For example, men aged 70 years and over undergoing emergency surgery are at particularly high risk of mortality, so these patients may benefit from their procedures being postponed.”
Pulmonary embolism and COVID-19
Researchers at Henry Ford Health System in Detroit say early diagnosis of a life-threatening blood clot in the lungs led to swifter treatment intervention in COVID-19 patients.
In a new study published recently in the journal Radiology, researchers found that 51 percent of patients found to have a pulmonary embolism, or PE, were diagnosed in the Emergency Department, the entry point for patients being admitted to the hospital.
In Europe, research has shown that most cases of PE were diagnosed in patients admitted to the intensive care unit after being on a ventilator for several days.
In the Henry Ford study, researchers say 72 percent of PE diagnoses were in patients who did not require “ICU-level care,” suggesting that timely diagnosis and use of blood thinners could have played a role in the treatment process.
“Based on our study, early detection of PE could further enhance and optimize treatment for patients first presenting in the Emergency Department,” says Pallavi Bhargava, M.D., an infectious diseases physician involved in the study. “We advise clinicians to think of PE as an additional complication early on during the admission of patients whose symptoms and lab results point to that condition.”
Thomas Song, M.D., a radiologist and the study’s senior author, says a timely pulmonary CT angiography made the difference in the PE diagnosis. “We recommend CT angiography because a traditional CT scan may not pick up the blood clot,” Dr. Song says.
In addition to the early detection finding, other key highlights emerged from the retrospective study of 328 COVID-19 patients who underwent a pulmonary CT angiography between March 16 and April 18 at Henry Ford’s acute care hospitals:
- 22 percent of patients were found to have a pulmonary embolism.
- Patients with a BMI (body mass index) of 30 or higher are nearly three times more at risk for developing a pulmonary embolism. The ideal BMI for adults is 18.5 – 24.9.
- Patients on statin therapy prior to admission were less likely to develop a pulmonary embolism.
- Increased D-dimer and C-reactive protein lab markers, in conjunction with a rising oxygen requirement, may be a predictor of a pulmonary embolism, even when patients are receiving preventive blood thinners.
“Our findings suggest that patients who test positive for COVID-19 should be started on preventive blood thinners early on in their treatment and that the need for CT angiography be assessed on a case by case basis to look for blood clots,” Dr. Bhargava says. “Our ER doctors played a key role in meticulously assessing these patients, evaluating their d-dimer marker value and ordering the right CT scans to identify these blood clots so early in the diagnosis.”
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