key: cord-0826946-p2aisrc3
authors: Aminian, Ali; Safari, Saeed; Razeghian-Jahromi, Abdolali; Ghorbani, Mohammad; Delaney, Conor P.
title: COVID-19 Outbreak and Surgical Practice: Unexpected Fatality in Perioperative Period
date: 2020-03-25
journal: Ann Surg
DOI: 10.1097/sla.0000000000003925
sha: 6686fce5074d595018de56189364470b5792220d
doc_id: 826946
cord_uid: p2aisrc3

Little is known about surgical practice in the initial phase of coronavirus disease 2019 (COVID-19) global crisis. This is a retrospective case series of 4 surgical patients (cholecystectomy, hernia repair, gastric bypass, and hysterectomy) who developed perioperative complications in the first few weeks of COVID-19 outbreak in Tehran, Iran in the month of February 2020. COVID-19 can complicate the perioperative course with diagnostic challenge and a high potential fatality rate. In locations with widespread infections and limited resources, the risk of elective surgical procedures for index patient and community may outweigh the benefit.

The fourth case was a patient with severe obesity from Qom who had been scheduled for bariatric surgery on February 22. One day before the scheduled surgery he was taken to the emergency department with severe acute respiratory distress which rapidly progressed to cardiopulmonary arrest [ Table 1 ].

This case series show the challenges facing surgical practice in the initial phase of COVID-19 outbreak. The effects of surgical and anesthesia stress, perioperative medications, and postoperative change (e.g. occurrence of lung atelectasis) on predisposition to new infection or exacerbation of current infection are not known. Based on current evidence, while it is believed that the fatality of COVID-19 is between 1-3%, most fatalities have occurred in elderly patients with underlying cardiopulmonary conditions, diabetes, and obesity [1] [2] [3] .

Although the current series may bias reporting toward more severe outcomes, postoperative patients might be another group of patients in which COVID-19 would have a high fatality rate.

A complicated postoperative course may especially be seen more in elderly patients with underlying health conditions.

In the postoperative period, development of fever or pulmonary complications can lead to a diagnostic challenge and can complicate the recovery of patients from elective surgery. In patients with postoperative fever, several diagnostic tests are usually necessary to determine the source. Other forms of infectious pneumonia, aspiration pneumonia, pulmonary embolism, pulmonary edema and other conditions are among the differential diagnoses in patients with postoperative pulmonary symptoms. During the current progressive outbreak, a high index of suspicious for COVID-19 is necessary to make a correct diagnosis and to take correct actions to treat the index patient and to prevent the spread of virus.

The diagnostic accuracy of RT-PCR in the postoperative setting needs to be determined.

Notably, in a recent series from China of over 1000 patients to assess the diagnostic accuracy of different tests, chest CT scan had sensitivity of 98% compared with RT-PCR sensitivity of only Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

71% [4] . Furthermore, identification of biomarkers and development of clinical prediction models that predict severity and outcomes of COVID-19 in postoperative period would be extremely helpful. Some preliminary data suggest that severe lymphopenia and elevated levels of C-reactive protein (CRP), interleukin-6, cardiac troponin I, and D-dimer correlate with the severity of hypoxemia and may predict hospital mortality [5, 6] . Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. infection. 5 During the ICU admission, he developed lymphopenia (984 per µL, normal range: 1000-4000), CRP (+3), elevated ESR (58 mm/hr, normal range: 2-20) and biomarkers of cardiac injury including CKMB (63, normal range 6-25 IU/L) and Troponin I (>50 ng/ml, normal range <0.06). 6 Resulted postdischarge. 7 For severe obesity (weight=198 kg, body mass index=69 kg/m 2 ). 8 On the last preoperative phone conversation on February 19, patient did not mention any problems. 9 Occurred on February 21, 2 days after official announcement of first case in Iran which started from the city of Qom and 1 day before the scheduled bariatric surgery. 10 RT-PCR was not performed due to rapid progressive course of disease, and insufficient testing capacity in initial phase of epidemic. 

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