ASA and APSF Joint Statement on Elective Surgery/Procedures and Anesthesia for Patients after COVID-19 Infection (2023)

Published March 9, 2021
Updated February 22, 2022

ASA and APSF Joint Statement on Elective Surgery/Procedures and Anesthesia for Patients after COVID-19 Infection (1)ASA and APSF Joint Statement on Elective Surgery/Procedures and Anesthesia for Patients after COVID-19 Infection (2)

ASA and APSF Joint Statement on Elective Surgery/Procedures and Anesthesia for Patients after COVID-19 Infection is also available for download (PDF)

Since hospitals are able to continue to perform elective surgeries while the COVID-19 pandemic continues, determining the optimal timing of procedures for patients who have recovered from COVID-19 infection and the appropriate level of preoperative evaluation are challenging given the current lack of evidence or precedent. The following guidance is intended to aid hospitals, surgeons, anesthesiologists, and proceduralists in evaluating and scheduling these patients. The updated recommendations detailed in this document are based upon new evidence that has come to light over the past year. The recommendations will be subject to continued evolution as new evidence emerges.

Elective surgeries should be performed for patients who have recovered from COVID-19 infection only when the anesthesiologist and surgeon or proceduralist agree jointly to proceed. The decision for surgery/procedure is centered on two factors: 1. Is the patient still infectious? and 2. For patients that are no longer infectious what is the appropriate length of time to wait between recovery from COVID and surgery/procedure in terms of risk to the patient.

What determines when a patient confirmed to have COVID-19 is no longer infectious?

The Centers for Disease Control and Prevention (CDC) provides guidance for physicians to decide when transmission-based precautions (e.g., isolation, use of personal protective equipment and engineering controls) may be discontinued for hospitalized patients, or home isolation may be discontinued for outpatients.1

(Video) "The APSF: Ten Patient Safety Issues We’ve Learned from the COVID Pandemic" - APSF Panel at ASA 2020

Patients infected with SARS-CoV-2, as confirmed by reverse transcriptase-polymerase chain reaction (RT-PCR) testing of respiratory secretions, may be asymptomatic or symptomatic. The National Institutes of Health has recently updated the categories of SARS-CoV-2 infection into the following phenotypic expressions of COVID severity.2 (see Appendix I for full description).

  • Asymptomatic or Presymptomatic Infection
  • Mild Illness.
  • Moderate Illness
  • Severe Illness
  • Critical Illness

Severely immunocompromised patients, whether suffering from asymptomatic or symptomatic COVID-19, are considered separately.

Current data indicate that, in patients with mild to moderate COVID-19, repeat RT-PCR testing may detect SARS-CoV-2 RNA for a prolonged period after symptoms first appear. According to the Centers for Disease Control and Prevention (CDC), it is rare to recover replication-competent virus after 10 days fromonset of symptoms, except in people who have severe COVID-19 or who are moderately or severely immunocompromised.

Considering this information, the CDC recommends that physicians use a time- and symptom-based strategy to decide when patients with COVID-19 are no longer infectious.

For patients with confirmed COVID-19 infection the CDC recommends discontinuing isolation and other transmission-based precautions per the following:1

  • Children and adults withmild, symptomatic COVID-19:Isolation can end at least 5 days after symptom onset and after fever ends for 24 hours (without the use of fever-reducing medication) and symptoms are improving, if these people can continue to properly wear a well-fitted mask around others for 5 more days after the 5-day isolation period. Day 0 is the first day of symptoms.
  • People who are infected but asymptomatic (never develop symptoms):Isolation can end at least 5 days after the first positive test (with day 0 being the date their specimen was collected for the positive test), if these people can continue to wear a properly well-fitted mask around others for 5 more days after the 5-day isolation period. However, if symptoms develop after a positive test, their 5-day isolation period should start over (day 0 changes to the first day of symptoms)*
  • People who havemoderateCOVID-19 illness:Isolate for 10 days.
  • People who are severely ill (i.e., requiring hospitalization, intensive care, or ventilation support):Extending the duration of isolation and precautions to at least 10 days and up to 20 days after symptom onset, and after fever ends (without the use of fever-reducing medication) and symptoms are improving, may be warranted.
  • People who aremoderately or severely immunocompromisedmight have a longer infectious period:Extend isolation to 20 or more days (day 0 is the first day of symptoms or a positive viral test). Use a test-based strategy and consult with an infectious disease specialist to determine the appropriate duration of isolation and precautions.

*The additional 5-day isolation period with masking for asymptomatic and mildly symptomatic patients has no practical implication in anesthesia care. Patients in these categories should be considered infectious for anesthesia care purposes for the full 10 days.

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Consultation with infection control experts is strongly advised prior to discontinuing precautions for patients with severe to critical illness or who are severely immunocompromised. Clinical judgment ultimately prevails when deciding whether a patient remains infectious. Maintaining transmission-based precautions and repeat RT-PCR testing may be appropriate if clinical suspicion of ongoing infection exists.

If a patient suspected of having SARS-CoV-2 infection is never tested, the decision to discontinue transmission-based precautions can be made using the symptom-based strategy described above.

Other factors, such as advanced age, diabetes mellitus, or end-stage renal disease, may pose a much lower degree of immunocompromise; their effect upon the duration of infectivity for a given patient is not known.

Ultimately, the degree of immunocompromise for the patient is determined by the treating provider, and preventive actions are tailored to each individual and situation.

What is the appropriate length of time between recovery from COVID-19 and surgery/procedure with respect to minimizing postoperative complications?

Currently there is a backlog of surgical procedures that have been delayed but are necessary to improve the health and quality of life of our patients. Although there is increasing information to address the timing of surgery after COVID-19 infection, studies continue to lag behind the emerging variants and the likelihood that vaccinated patients have a lower a risk of postoperative complications as compared to unvaccinated patients.3 Almost all available data come from study periods with zero to low prevalence of vaccination.

The preoperative preparation of a surgical patient who is recovering from COVID-19 involves evaluation and optimization of the patient’s medical conditions and physiologic status. Since COVID-19 can impact virtually all major organ systems, the timing of surgery after a COVID-19 diagnosis is important when considering the risk of postoperative complications. Heretofore, protocols have been based on limited data specific to SARS-CoV-2, expert opinion, and previous data from other post-viral syndromes.

(Video) RRH Revised COVID 19 Protocols for the OR 6.4.2020

An early limited study of 122 patients found a significantly higher risk of pulmonary complications within the first four weeks after SARS-CoV-2 diagnosis.4 A Brazilian study of 49 patients who underwent surgery with a median delay of 25 days after asymptomatic COVID-19 did not have increased complications when compared to a cohort of patients with a negative SARS-CoV-2 test.5

Subsequently, a multi-country (116 countries), multi-center (1674 hospitals) study, in a mixture of high income and low/middle income countries, followed more than 140,000 patients with 3,127 having COVID-19 infections before surgery. Data were collected from surgery in October 2020, meaning that none of these patients had received even one vaccination. They reported increased risks of mortality and morbidity—especially with pulmonary complications--up to 7 weeks post COVID diagnosis, although the confidence interval for patients in the 5-6 week cohort suggests that there may not be a true difference in this group.6 This data found increased risks to be present at 5-6 weeks regardless of being asymptomatic or symptomatic, older or younger than 70, having major or minor surgery, or undergoing elective or emergency surgery. Mortality data is summarized in the table below. Finally, patients with ongoing symptoms at ≥7 weeks were at increased risk for complications versus patients without symptoms.

Interval Between COVID Diagnosis and Surgery 30-day Mortality Rate for Elective Patients (%, CI)**
No COVID Diagnosis

0.62 (0.57-0.67)

0-2 weeks

3.09 (1.64-4.54)

3-4 weeks

2.29 (1.06-3.53)

5-6 weeks

2.39 (0.87-3.91)

≥7 weeks

0.64 (0.20-1.07)

**With a sensitivity analysis.

A second U.S. study covering a timeline of patients with a COVID-19 diagnosis and surgery up to May 31, 2021 reviewed 5479 surgical patients following COVID-19 infection. Immunization status was not given but the study period ranged from a time of zero vaccination until a period when about 30% of the US adult population had received at least one vaccination. The results corroborate the above findings and report higher postop complications of pneumonia and respiratory failure at 0-4 weeks and continued higher postoperative pneumonia complications 4-8 weeks post PCR diagnosis.7

Of note, a consensus-based statement from the United Kingdom recommends “delaying surgery, whenever feasible for a minimum of 7 weeks after known SARS-CoV-2 infection.”8

To date, there are no robust data on patients recovering from more recent Delta and Omicron variants. According to the CDC, the Omicron variant causes less severe disease,9 and is more likely to reside in the oro- and nasopharynx without infiltration and damage to the lungs. It should also be noted that severity likely varies by vaccination status. Some have extrapolated these facts to a conclusion that risk in patients who are vaccinated and are recovering from Omicron should be less. However plausible, such a conclusion remains unproven. SARS-CoV-2 affects other organ systems beyond the pulmonary system (e.g., thromboembolic events including stroke, myocarditis, renal failure).

(Video) Walk the Path of the Patient in COVID-19

Recommendations

  1. Elective surgery should be delayed for 7 weeks after a SARS-CoV-2 infection in unvaccinated patients that are asymptomatic at the time of surgery.
  2. The evidence is insufficient to make recommendations for those who become infected after COVID vaccination. Although there is evidence that, in general, vaccination reduces post-infection morbidity, the effect of vaccination on the appropriate length of time between infection and surgery/procedure is unknown.
  3. Any delay in surgery needs to be weighed against the time-sensitive needs of the individual patient.
  4. If surgery is deemed necessary during a period of likely increased risk, those potential risks should be included in the informed consent and shared decision-making with the patient.
  5. Extending the above delay should be considered if the patient has continued symptomatology not exclusive of pulmonary symptoms.
  6. Any decision to proceed with surgery should consider:
    • The severity of the initial infection
    • The potential risk of ongoing symptoms
    • Comorbidities and frailty status
    • Complexity of surgery

Residual symptoms such as fatigue, shortness of breath, and chest pain are common in patients who have had COVID-19(10,11). These symptoms can be present more than 60 days after diagnosis(11). In addition, COVID-19 may have long term deleterious effects on myocardial anatomy and function(12). A more thorough preoperative evaluation, scheduled further in advance of surgery with special attention given to the cardiopulmonary systems, should be considered in patients who have recovered from COVID-19 and especially those with residual symptoms.

Is repeat SARS-CoV-2 testing needed?

At present, the CDC does not recommend re-testing for COVID-19 within 90 days of symptom onset(13). Repeat PCR testing in asymptomatic patients is strongly discouraged since persistent or recurrent positive PCR tests are common after recovery. However, if a patient presents within 90 days and has recurrence of symptoms, re-testing and consultation with an infectious disease expert should be considered. Once the 90-day recovery period has ended, the patient should undergo one pre-operative nasopharyngeal PCR test ideally ≤ three days prior to the procedure.

These recommendations are under continuous review and will be updated as additional evidence becomes available.

References:

(Video) Anaesthetic Considerations in Post Covid Patients - Dr. Charuta Gadkari

  1. https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html. Accessed February 15, 2022.
  2. https://www.covid19treatmentguidelines.nih.gov/overview/clinical-spectrum. Accessed February 15, 2022.
  3. Prasad NK, Lake R, Englum BR, Turner DJ, Siddiqui T, Mayorga-Carlin M, Sorkin JD, Lal BK. COVID-19 vaccination associated with reduced postoperative SARS-CoV-2 infection and morbidity. Ann Surg. 2022 Jan 1;275(1):31-36. doi: 10.1097/SLA.0000000000005176. PMID: 34417362; PMCID: PMC8678152.
  4. COVIDSurg Collaborative. Delaying surgery for patients with a previous SARS-CoV-2 infection. British Journal of Surgery 2020;107:e601–2. https://doi.org/10.1002/bjs.12050
  5. Baiocchi G, Aguiar S Jr, Duprat JP, Coimbra FJF, Makdissi FB, Vartanian JG, Zequi SC, Gross JL, Nakagawa SA, Yazbek G, Diniz TP, Gonçalves BT, Zurstrassen CE, Campos HGDA, Joaquim EHG, França E Silva IA, Kowalski LP. Early postoperative outcomes among patients with delayed surgeries after preoperative positive test for SARS-CoV-2: A case-control study from a single institution. J Surg Oncol. 2021 Mar;123(4):823-833. doi: 10.1002/jso.26377. Epub 2021 Jan 11. PMID: 33428790; PMCID: PMC8014861.
  6. COVIDSurg Collaborative, GlobalSurg Collaborative. Timing of surgery following SARS-CoV-2 infection: an international prospective cohort study. Anaesthesia 2021;76:748–758. doi: 10.1111/anae.15458. Epub 2021 Mar 9. PMID: 33690889; PMCID: PMC8206995.
  7. Deng JZ, Chan JS, Potter AL, Chen Y-W, Sandhu HS, Panda N, Chang DC, Yang, CF J. The risk of postoperative complications after major elective surgery in active or resolved COVID-19 in the United States. Ann Surg 2022;275:242-246. doi: 10.1097/SLA.0000000000005308. PMID: 34793348; PMCID: PMC8745943.
  8. El-Boghdadly K, Cook TM, Goodacre T, Kua J, Blake L, Denmark S, McNally S, Mercer N, Moonesinghe SR, Summerton DJ. SARS-CoV-2 infection, COVID-19 and timing of elective surgery: A multidisciplinary consensus statement on behalf of the Association of Anaesthetists, the Centre for Peri-operative Care, the Federation of Surgical Specialty Associations, the Royal College of Anaesthetists and the Royal College of Surgeons of England. Anaesthesia 2021;76:940-946. doi: 10.1111/anae.15464. Epub 2021 Mar 18. PMID: 33735942; PMCID: PMC8250763.
  9. https://www.cdc.gov/coronavirus/2019-ncov/variants/omicron-variant.html. Accessed February 21, 2022
  1. Tenforde MW, Kim SS, Lindsell CJ., et al. Symptom Duration and Risk Factors for Delayed Return to Usual Health Among Outpatients with COVID-19 in a Multistate Health Care Systems Network – United States, March-June 2020. MMWR 2020 Jul 31;69(30):993-998.https://dx.doi.org/10.15585%2Fmmwr.mm6930e1.
  2. Carfì A, Bernabei R, Landi F, for the Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19.JAMA.2020;324(6):603–605. doi:10.1001/jama.2020.12603
  3. Puntmann VO, Carerj ML, Wieters I, et al. Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020;5(11):1265-1273. doi:10.1001/jamacardio.2020.3557
  4. https://www.cdc.gov/coronavirus/2019-ncov/hcp/testing-overview.html. Accessed February 15, 2022.

FAQs

How long after Covid can you have general Anaesthetic? ›

We recommend that whenever possible surgery should be delayed for at least seven weeks after a positive SARS-CoV-2 test result, or until symptoms resolve if patients have ongoing symptoms for seven weeks or more after diagnosis.

Can I have an operation after Covid? ›

Preparation for surgery is key to reduce risk presenting from adverse postoperative outcomes and this is especially prevalent in those who have contracted COVID-19. Supporting patients to make positive lifestyle changes to prepare for surgery is the best defence to post-surgical and post-covid complications.

How long should you wait between surgeries? ›

Most healthcare providers will recommend waiting six to 12 weeks between surgeries. Longer wait times are advised for surgeries involving: Significant blood loss. An extensive time under anesthesia.

What is the most common elective surgery? ›

The most common elective surgical procedures include:
  • Plastic surgery. Plastic surgeries are procedures performed to reconstruct or replace parts of the body after an injury or for cosmetic reasons. ...
  • Replacement surgery. ...
  • Exploratory surgery. ...
  • Cardiovascular surgery.
21 Sept 2015

Can you have surgery with an infection? ›

Infections, even from minor cuts or bug bites, can severely increase the risk of surgery. Because of this, most surgeons will wait to perform surgery until after an infection resolves. Your surgeon will give you a thorough evaluation before the procedure to check for any existing infections.

Can Covid affect healing after surgery? ›

Risk for chronic wounds in COVID-19 patients — In addition to the traditional risk factors for developing wounds (see "Risk factors for impaired wound healing and wound complications"), SARS-CoV-2 is associated with physiologic changes that may affect healing.

What's the riskiest surgery? ›

Most Dangerous Surgeries
  • Partial colon removal.
  • Small bowel resection (removal of all or part of a small bowel).
  • Gallbladder removal.
  • Peptic ulcer surgery to repair ulcers in the stomach or first part of small intestine.
  • Removal of peritoneal (abdominal) adhesions (scar tissue).
  • Appendectomy.

How do they wake you up from anesthesia? ›

After the procedure

When the surgery is complete, the anesthesiologist reverses the medications to wake you up. You'll slowly wake either in the operating room or the recovery room. You'll probably feel groggy and a little confused when you first wake.

What surgery has the longest recovery time? ›

These procedures below do take the longest to recover.
  • Liposuction (up to three months) ...
  • Tummy Tuck (2-3 months) ...
  • Facelift (two months) ...
  • Breast Reduction (two months) ...
  • Breast Augmentation (six weeks) ...
  • Rhinoplasty (six weeks)

› news › surgery-after-covid ›

Studies suggest that elective surgeries should be delayed, when possible. surgical nurse with patient before surgery.
To the Editor—The coronavirus disease 2019 (COVID-19) pandemic has created unprecedented challenges for infection prevention experts, healthcare providers, and ...
Keeping surgery on hold for at least 7 weeks after a positive coronavirus test was associated with lower mortality risk compared with no delay, a large internat...

How long after Covid Can I Have surgery UK NHS? ›

Recently having a COVID-19 infection can impact your hospital admission. If you have had COVID-19 in the last 4 weeks please let your clinical team know. Undergoing an elective procedure is your choice and always carries associated risks and benefits.

How long after Covid Can I Have surgery Victoria? ›

If you're having non-urgent surgery (classified as category 2 and 3), it's recommended that you wait 7 weeks after your first COVID-19 positive test. This applies to people who were asymptomatic (no symptoms) or symptomatic.

Can you have surgery with an infection? ›

Infections, even from minor cuts or bug bites, can severely increase the risk of surgery. Because of this, most surgeons will wait to perform surgery until after an infection resolves. Your surgeon will give you a thorough evaluation before the procedure to check for any existing infections.

Can you have surgery with a sinus infection? ›

A sinus infection, whether it's viral or bacterial, will result in postponing surgery. Fever: Any fever indicates your body is fighting off some type of infection or illness and will require us to reschedule your surgery.

What is the difference between planned and elective surgery? ›

Planned or unplanned surgery

Elective surgery is the term for operations planned in advance. Emergency surgery is the term used for operations that require immediate admission to hospital, usually through the accident and emergency department.

How do I know if I should have surgery? ›

Your doctor should only recommend surgery if it's essential, you've exhausted your other options, your pain is getting worse, and/or your quality of life is being affected by your pain or condition.

How long are you in recovery for after an operation? ›

You will spend 45 minutes to 2 hours in a recovery room where nurses will watch you closely. You may stay longer depending on your surgery and how fast you wake up from the anesthesia. Your nurse will watch all of your vital signs and help you if you have any side effects.

Are you still contagious after 7 days? ›

If you are significantly immunosuppressed, you are more likely to be infectious for longer than 7 days and may still be able to spread the virus. Follow these measures until day 14 following your positive test result to further reduce any remaining risk of spreading the virus.

Can Covid affect healing after surgery? ›

Risk for chronic wounds in COVID-19 patients — In addition to the traditional risk factors for developing wounds (see "Risk factors for impaired wound healing and wound complications"), SARS-CoV-2 is associated with physiologic changes that may affect healing.

How long does Covid last in your body? ›

Most people with COVID-19 get better within a few days to a few weeks after infection, so at least four weeks after infection is the start of when post-COVID conditions could first be identified. Anyone who was infected can experience post-COVID conditions.

In what situation might surgery be delayed? ›

Surprisingly, absenteeism is one of the top reasons for surgical delays. Surgeons can be absent due to emergencies, poor scheduling, or other reasons. Patients can also contribute to the issue. If a patient arrives late or does not show up for a procedure, a reschedule affects other patients.

Why would they cancel your surgery? ›

Reasons Your Surgery May Be Cancelled or Postponed

Incomplete or abnormal lab results. Any abnormality or incomplete results from your preadmission testing will need to be further investigated before surgery can begin. Failure to comply with pre-operative instructions.

What can prevent you from having surgery? ›

Examples of Conditions that May Delay Surgery Include:
  • Cold or sinus infection within two weeks before surgery.
  • Pneumonia or bronchitis within a month before surgery.
  • Stomach virus or flu.
  • Fever.
  • Asthma attack or wheezing within two weeks before surgery.
  • Chest pain which is worse than usual.

Can you go under anesthesia with congestion? ›

Sometimes even minor illness, such as a cough, runny nose or fever, can cause problems during surgery and anesthesia. If this is the case, your anesthesiologist may decide to postpone surgery.

What happens if you go under anesthesia with a cold? ›

For some people with colds, general anesthesia heightens the existing symptoms. Some will cough more, and those with runny noses may produce more mucus. Others may develop additional symptoms like breathing difficulty, requiring extended hospitalization.

How do they wake you up from anesthesia? ›

After the procedure

When the surgery is complete, the anesthesiologist reverses the medications to wake you up. You'll slowly wake either in the operating room or the recovery room. You'll probably feel groggy and a little confused when you first wake.

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