Infectious diseases

Pulmonary complications and mortality high in surgical patients with COVID-19


High rates of respiratory complications suggest that thresholds for surgery should be higher than usual for patients during the COVID-19 pandemic – and especially for older aged men, researchers say.

A study published in The Lancet found postoperative pulmonary complications occurred in about half of patients with SARS-CoV-2 infection who underwent surgery in the first few months of 2020.

Reasons for surgery included benign disease, obstetrics, cancer and trauma.

The study of 1,128 patients across 24 countries found 51.2% of the cohort experienced pulmonary complications including pneumonia, acute respiratory distress syndrome (ARDS), or unexpected postoperative ventilation.

30-day mortality was 23.8% overall and higher in men than women (OR 1.75), people >70 years compared to younger patients (OR 2.30) and those undergoing emergency versus elective surgery (OR 1.67), malignant versus benign surgery (OR 1.55) and major versus minor surgery (OR 1.52).

Patients who developed pulmonary complications also had a higher 30-day mortality than those who did not (38·0% v 8·7%; p<0·0001).

Pulmonary complications were associated with ASA Physical Status grades 3-5.

Postoperative outcomes in SARS-CoV-2-infected patients were substantially worse than pre-pandemic baseline rates of pulmonary complications and mortality. For example, the postoperative pulmonary complications rate in a major European study in 2014-15 was just 8%.

The researchers said their findings had direct implications for clinical practice worldwide.

“The increased risks associated with SARS-CoV-2 infection should be balanced against the risks of delaying surgery in individual patients; this study identified men, people aged 70 years or older, those with comorbidities (ASA grades 3–5), those having cancer surgery, and those needing emergency or major surgery as being most vulnerable to adverse outcomes.”

“During SARS-CoV-2 outbreaks, consideration should be given for postponing non-critical procedures and promoting nonoperative treatment to delay or avoid the need for surgery.”

An accompanying Comment, co-authored by Professor Paul Myles from the Alfred Hospital’s department of anesthesiology and perioperative medicine, said the study’s limitations included the lack of a control group and non-standardised testing.

“Nevertheless, these results are worrying because the rate of poor outcomes exceeded those seen in most types of major surgery. Severe COVID-19 is associated with a marked inflammatory and prothrombotic state. These pathological processes are exacerbated by surgery and immobilisation, leading to a perfect storm detrimental to good postoperative outcomes.”

He and his co-author said the study highlights the need for clear perioperative guidelines for emergency and elective surgery during the pandemic.

Even as many countries were already reopening elective surgery, access to SARS-CoV-2 testing, sufficient trained staff, hospital and ICU beds, PPE, and all other necessary medical supplies would remain important.

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