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Published March 9, 2021
Updated February 22, 2022
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.
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
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).
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 from onset 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
*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.
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.
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.
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).
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.
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.
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