Summaries of Emerging Evidence (SEE) 2021 - Volume 37B Sample Question 2
Your next patient is a 74-year-old man with a bowel obstruction caused by a malignancy. He is coming to the operating room for small bowel resection. Ten days ago, he was diagnosed with COVID-19. According to a recent study of surgical patients with COVID-19, which of the following is MOST likely to increase the mortality risk in this patient? Read the discussion.
(A) Elective surgery
(B) Age of at least 70 years
(C) Preoperative (vs postoperative) COVID-19 diagnosis
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The COVID-19 pandemic has affected the health of millions worldwide. Though people undergoing surgery are among those affected, until recently, there had not been a systematic assessment of mortality and pulmonary morbidity rates among patients with COVID-19 undergoing surgical procedures.
The authors of a recent international, multi-institutional observational study evaluated the records of 1,128 patients undergoing surgery who were diagnosed with COVID-19 within 7 days before or 30 days after surgery. The primary outcome was the 30-day mortality rate. The secondary outcome was pulmonary complications, defined to include pneumonia, acute respiratory distress syndrome (ARDS), and unexpected postoperative ventilation.
The overall mortality rate for patients with COVID-19 undergoing surgery was 23.8% (268 of 1,128 patients). Of those who died, 81.7% experienced a pulmonary complication (129 of 268 patients).
The adjusted analysis revealed the following risk factors for death within 30 days, presented in order of descending odds ratios (ORs):
- American Society of Anesthesiologists (ASA) physical status of III, IV, or V versus I or II (OR, 2.35; 95% CI, 1.57–3.53)
- Age of 70 years or older (OR, 2.30; 95% CI, 1.65–3.22)
- Male sex (OR, 1.75; 95% CI, 1.28–2.40)
- Emergency versus elective surgery (OR, 1.67; 95% CI, 1.06–2.63)
- Malignant versus benign or obstetric diagnosis (OR, 1.55; 95% CI, 1.01–2.39)
- Major versus minor surgery (OR, 1.52; 95% CI, 1.01–2.31)
The timing of COVID-19 diagnosis (preoperative vs postoperative) was not associated with a difference in mortality rate. In the adjusted analysis, the only risk factor for pulmonary complications was an ASA physical status of III, IV, or V.
In conclusion, this study found that men aged 70 years and older with an ASA physical status of III, IV, or V who emergently undergo a major operation for a malignancy appear to be at the highest risk of death. The mortality and pulmonary complication rates in these COVID-19 patients were markedly higher than those reported in prepandemic studies.
- COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet. 2020;396(10243):27-38. doi:10.1016/S0140-6736(20)31182-X
- Myles PS, Maswime S. Mitigating the risks of surgery during the COVID-19 pandemic. Lancet. 2020;396(10243):2-3. doi:10.1016/S0140-6736(20)31256-3