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When should patients be operated on post-SARS-CoV-2 infection?

RANZCO has warned that patients diagnosed with SARS-CoV-2 in close proximity to their elective surgery may be at risk of post-operative complications, as it released new guidelines on the appropriate timing for surgery on patients who have recovered from active infection.

Despite there not yet being a full understanding of the long term effects of SARS-CoV-2 infection, the college is recommending that previously diagnosed patients are symptom-free for a minimum of two months before undergoing surgery, and that the cardiac and respiratory systems are subjected to a clinical review.

The updated advice, which does not preclude cataract surgery, was published on 5 August by RANZCO president Associate Professor Heather Mack and Victorian branch chair Dr David van der Straaten. It was formed in conjunction with their counterparts from The Royal Australasian College of Surgeons, The Australian and New Zealand College of Anaesthetists and The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Heather Mack.

Entitled ‘Guidance on delay to elective surgery post recovery from SARS-COV-2 infection’, the document is said to provide “good guidance for all our members in a rapidly developing field”. It is particularly relevant to specialists in Victoria where there are some 14,700 active cases.

The colleges point out that the severity and duration of SARS-CoV-2 infection is variable between individuals. However, there is increasing evidence of post infection impairment despite significant gaps in understanding how long the respiratory, cardiovascular and other systems may be affected.

They also state that infection (communicability) recovery appears to be much quicker than physiologic recovery.

“Available evidence suggests patients who had SARS-CoV-2 infection diagnosed within seven days before or up to 30 days after surgery are at significant risk of post-operative complications including increased morbidity and mortality,” the guideline states.

“There are insufficient additional data to provide universal recommendations on the optimum timing of necessary, planned surgery following recovery from active infection with SARS-CoV-2. Therefore, a cautious approach is recommended. Decisions regarding surgical timing will require careful consideration of the possible sequelae of the infection, the urgency of the required surgery and the expected physiological impact on the patient.”

As such, RANZCO and other medical colleges recommended patients are symptom free for a minimum of eight weeks prior to undergoing all but minor elective surgical procedures.

They recommended that patients have a formal clinical review prior to surgery that addresses the state of the cardiac and respiratory systems. This is recommended for all patients post-known SARS-CoV-2 infection and is especially important for those who have persisting symptoms (including fatigue) or who were hospitalised for care.

The college added: “If, on careful consideration of the nature and severity of any persisting problems, delay is considered the safer course of action for an individual patient, we recommend treatment is delayed until the balance of risks and benefits are more in the patient’s favour, even for a Category 1 (within 30 days) case.”

The document was generated out of a meeting chaired by Professor David Watters of Safer Care Victoria. Each Friday, he heads a meeting of all the surgical groups in the peri-operative space in Victoria where they learn about the state supply of personal protective equipment and experiences of the various hospital networks, among other things.

The guidance will be updated when more evidence of the longer term’s effects of infection with SARS-CoV-2 is available, RANZCO stated.

The guidelines can be found here.

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