key: cord-0755539-ju3eem3k authors: El‐Boghdadly, K.; Cook, T. M.; Goodacre, T.; Kua, J.; Denmark, S.; McNally, S.; Mercer, N.; Moonesinghe, S. R.; Summerton, D. J. title: Timing of elective surgery and risk assessment after SARS‐CoV‐2 infection: an update: A multidisciplinary consensus statement on behalf of the Association of Anaesthetists, Centre for Perioperative Care, Federation of Surgical Specialty Associations, Royal College of Anaesthetists, Royal College of Surgeons of England date: 2022-02-22 journal: Anaesthesia DOI: 10.1111/anae.15699 sha: 4b990697fa142426e4a0f74570c914f11dcb4a25 doc_id: 755539 cord_uid: ju3eem3k The impact of vaccination and new SARS‐CoV‐2 variants on peri‐operative outcomes is unclear. We aimed to update previously published consensus recommendations on timing of elective surgery after SARS‐CoV‐2 infection to assist policymakers, administrative staff, clinicians and patients. 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. This should include baseline mortality risk calculation and assessment of risk modifiers (patient factors; SARS‐CoV‐2 infection; surgical factors). Asymptomatic SARS‐CoV‐2 infection with previous variants increased peri‐operative mortality risk 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 currently unfounded. 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. We now emphasise that timing of surgery should include the assessment of baseline and increased risk, optimising vaccination and functional status, and shared decision‐making. While these recommendations focus on the omicron variant and current evidence, the principles may also be of relevance to future variants. As further data emerge, these recommendations may be revised. c Patients should be advised that a decision to proceed with surgery within 7 weeks will be pragmatic rather than evidence-based. 8 Patients with persistent symptoms and those with moderate-to-severe COVID-19 (e.g. 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. 9 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. Pre-operative SARS-CoV-2 infection was previously shown to be associated with significantly increased risks of morbidity and mortality. Data in the early phases of the pandemic demonstrated that peri-operative SARS-CoV-2 infection was associated with clinically important increases in mortality, in some cases more than a 10-fold increase [1, 2] . Furthermore, when surgery was undertaken within 6 weeks of infection, postoperative morbidity and mortality were also increased [3] . Notably, increased peri-operative risk remained consistently elevated until 7 weeks after SARS-CoV-2 infection, at which point it returned to baseline. Therefore, recommendations were made to delay elective surgery for 7 weeks after SARS-CoV-2 infection, unless the risks of deferring surgery outweighed the risk of postoperative morbidity or mortality associated with SARS-CoV-2 infection [4, 5] . As the COVID-19 pandemic has progressed, disease therapy and prevention have developed, including vaccination [6] . Variants have emerged that differ in terms of their transmissibility, the severity of illness they cause and their ability to infect vaccinated patients. The omicron SARS-CoV-2 variant in particular has increased transmissibility and the potential to evade immunity acquired through previous SARS-CoV-2 infection, vaccination or both [7] . This variant also leads to less severe clinical illness than previous This document focuses on the omicron variant, which is now strongly dominant in many countries. However, the principles may also be of relevance to future variants. There is no robust evidence demonstrating whether the risks of morbidity and mortality after pre-operative or peri-operative infection with the omicron SARS-CoV-2 variant are lower than with earlier variants. Evidence informing this question is expected [11] A combination of widespread testing and high community infection rates means that it is likely that many surgical patients will present with pre-operative or peri-operative SARS-CoV-2 infection. They might be asymptomatic, mildly symptomatic or pre-symptomatic. Contact tracing data indicate high rates of symptomatic infection, with 89.8% for omicron compared with 85.5% of delta cases [7] . However, the severity of COVID-19 following omicron infection appears to be milder than with previous variants [ complexity of surgery) (Fig. 1, Box 1 ). Understanding these risks should inform shared decision-making between the multidisciplinary team and the patient. Documentation should record the risks and benefits of timing of surgery and the process of decision-making. Ideally, patients should be advised that a decision to proceed with surgery within 7 weeks will not be evidence-based, but pragmatic. The increased risk associated with surgery after SARS-CoV-2 infection does not fall until 7 weeks, thus there is no benefit in partial delay (e.g. the increased risk at 6 weeks is similar to that at 3 weeks). Therefore, decision-making should be dichotomised: defer for 7 weeks or do not defer. Patients with persistent symptoms and those with moderate-to-severe COVID-19 (e.g. those who were hospitalised) remain likely to be at greater risk of morbidity and mortality, even after 7 weeks [3] . Therefore, delaying surgery beyond this point should be considered, balancing this risk against any risks associated with such delay. Specialist assessment and individualised, multidisciplinary peri-operative management are advised. Elective surgery should be avoided during the period that a patient may be infectious (10 days Risk assessments should take place at the time of scheduling surgery. Patients should also be informed that a positive pre-operative SARS-CoV-2 test may trigger a review of risks of proceeding with surgery. This can be supported with a risk communication tool (Fig. 1) . It has been reported that pre-operative isolation for longer than 3 days may be associated with an increased risk of postoperative pulmonary complications [19] . Although there is uncertainty in the interpretation of these results, prolonged pre-operative isolation should be avoided unless clearly indicated. Patients should be advised to increase physical activity where feasible and adhere to prehabilitation principles during isolation and throughout the pre-operative period. This includes pre-operative exercise, nutritional optimisation and smoking cessation [20] . Early evidence suggested no difference in peri-operative outcomes based on the mode of anaesthesia [21] . However, more recent evidence indicates that in patients with recent or peri-operative SARS-CoV-2 infection, local or regional anaesthetic techniques may be associated with a moderate (e.g. point estimates varying between 50-150%) reduction in the risk of postoperative pulmonary complications and mortality when compared with general anaesthesia [19, 22] . It is possible that these data are prone to bias through unmeasured covariates and have yet to be reproduced in the setting of omicron and vaccination. On balance, 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. The necessity to proceed with elective surgical recovery must be balanced with delivering surgery as safely as possible. Previous guidance was more robustly evidencebased [4] and much still applies. However, there is currently a lack of data to specifically inform changes in perioperative risk. Although this information is expected, the anticipated high number of patients with pre-operative SARS-CoV-2 omicron infection with or without previous Figure 1 Communicating risk when considering surgery within 7 weeks of SARS-CoV-2 infection. This is a tool that may be used for patients who are no longer infectious (≥ 10 days after diagnosis). Clinicians should begin by assessing baseline risk, then consider risk modifiers, followed by determining the risk of deferring surgery for 7 weeks after infection. This communication tool should be used in conjunction with our recommendations to support shared decision-making. 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Patient information about timing of elective surgery soon after SARS-CoV-2 infection.