Abstract and Introduction
Abstract
Background: There are limited data to detail the perioperative anesthetic management and the incidence of postoperative respiratory complications among patients requiring an anesthetic procedure while being SARS-CoV-2 positive or suspected.
Methods: An observational multicenter cohort study was performed including consecutive patients who were SARS-CoV-2 confirmed or suspected and who underwent scheduled and emergency anesthesia between March 17 and May 26, 2020.
Results: A total of 187 patients underwent anesthesia with SARS-CoV-2 confirmed or suspected, with ultimately 135 (72.2%) patients positive and 52 (27.8%) negative. The median SOFA score was 2 [0; 5], and the median ARISCAT score was 49 [36; 67]. The major respiratory complications rate was 48.7% (n = 91) with 40.4% (n = 21) and 51.9% (n = 70) in the SARS-CoV-2–negative and –positive groups, respectively (p = 0.21). Among both positive and negative groups, patients with a high ARISCAT risk score (> 44) had a higher risk of presenting major respiratory complications (p < 0.01 and p = 0.1, respectively).
Discussion: When comparing SARS-COV-2–positive and –negative patients, no significant difference was found regarding the rate of postoperative complications, while baseline characteristics strongly impact these outcomes. This finding suggests that patients should be scheduled for anesthetic procedures based on their overall risk of postoperative complication, and not just based on their SARS-CoV-2 status.
Introduction
While the SARS-CoV-2 epidemic continues spreading around the world, and some countries already face a third or fourth wave, more and more patients will require anesthesia while being SARS-CoV-2 positive for either emergency or scheduled procedures that cannot be postponed. As a result, many caregivers will remain involved in the perioperative management of SARS-CoV-2–positive patients.
However, general anesthesia, particularly when associated with intubation and mechanical ventilation, is a situation that involves a risk of postoperative pulmonary complications.[1] This risk needs to be particularly acknowledged in the current pandemic context. SARS-CoV-2 has indeed been reported to induce an intense systemic inflammation response[2,3] with a preferential pulmonary tropism.[4,5] The pulmonary vulnerability of SARS-CoV-2–positive patients is therefore likely to have a major impact on postoperative outcomes, and especially on early pulmonary complications.[6]
When the pandemic struck, the containment resulted in the cessation of all nonurgent hospital activities, while the surge of intensive care unit (ICU) patients led to the immediate transfer of operating rooms' medical and paramedical staff to newly opened ICUs. While a fourth or even fifth peak is now a reality in many countries, and while surgical activity needs to be maintained and protected as much as possible, several issues are arise. One of them is the need to define structured health-care pathways for SARS-CoV-2 patients who require an anesthesia procedure while or after being symptomatic. To answer this question, stakeholders need to be able, for each patient, to have an accurate understanding of the risk–benefit balance with, on one hand, a potential risk of pulmonary complications and, on the other hand, the risk in postponing carcinologic, vascular, cardiac, or neurosurgical procedures, with a consequent significant morbidity.[7] This understanding will allow physicians to propose an informed decision-making and a truthful informing of patients, and to anticipate the required resources for the optimal care of their patients. In the literature, several publications detailing the perioperative management of SARS-CoV-2 patients are available, but mostly focus on surgical management and outcomes or report a small collective of patients.[8–11]
The first main aim of this study was to compare the incidence of major respiratory complications between SARS-CoV-2–positive and –negative patients. The second main aim was to describe preoperative conditions and perioperative management of SARS-CoV-2 patients.MateriAl and methodS.
This observational multicenter cohort study used medical data collected anonymously. To avoid selection bias, all centers were committed to include consecutive patients only. Each center included patients between March 17 and May 26, 2020. In this study, 19 centers in France and Belgium participated. This report follows the STROBE statement for the reporting of observational studies (Supplementary material 1).[12]
Ethics
Ethical approval for this study (IRB 00,010,254-2020-049) was provided by the Ethical Committee of Société Francaise d'Anesthésie Réanimation, Paris, France (Chairperson Prof. J.E. Bazin) on March 31, 2020. This study has been registered in the Registre des traitements de l'Assistance Publique des Hôpitaux de Paris, n°20,200,716,194,220. Informed consent was obtained from all participants.
Study Population
Non-obstetrical adult patients undergoing scheduled or emergency procedures were included if they required anesthesia while being SARS-CoV-2 positive or suspect at the time of the inclusion. Anesthesia could be undertaken for multiple reasons, including surgery, endoscopic, or interventional radiologic procedures. Ventilated patients who underwent scheduled surgical tracheotomy were excluded, since they were all symptomatic for more than 3 weeks and were already ventilated in an intensive care unit at the time of the surgery.
At their arrival, patients were classified as positive cases if the suspicion was confirmed with laboratory testing based on viral RNA detection by quantitative RT-PCR. Patients were classified as suspect cases if they were not yet confirmed but a physician had decided to treat them as if they were positive until a confirmation was obtained. All patients were retrospectively categorized (positive or negative) based on their RT-PCR SARS-CoV-2 status on the preoperative nasopharyngeal swab.
Both positive and suspected cases received the same immediate postoperative management, including recovery in the operating room and dedicated ICU rooms, depending on the center of inclusion, and the same prescriptions and follow-up.
Patients without SARS-COV-2 status confirmation during their hospital stay were also excluded. If a single patient underwent multiple consecutive anesthetic procedures, we included the first procedure.
Study Outcomes
We used as the main outcome the proportion of patients having a major respiratory complication up to 7 days (re-intubation or unexpected noninvasive ventilation requirement or unexpected high-flow oxygen therapy during the first 6 h, respiratory failure up to 7 days, or pneumonia up to 7 days).[13] Respiratory failure was defined as a SpO2 < 92%,[14] the need for more than 3 L of oxygen per minute, or mechanical ventilation with a FiO2 > 0.6. Pneumonia was defined as the decision of a physician to treat a pulmonary infection with antibiotics.
Secondary outcomes were the proportion of patients discharged alive up to both 7 and 28 days, in-hospital mortality up to both 7 and 28 days, the proportion of patients having an AKIN score ≥ 2 up to 7 days,[15] and the proportion of patients who required ICU admission immediately after surgery.
Data Collection
Descriptive data of SARS-CoV-2 symptoms (fever, signs of pneumonia, date of the first symptoms), of surgery (type of surgery, emergency, length of stay in operating room) as well as patients' baseline characteristics (American Society of Anesthesiology physical score [ASA-PS], treatments, history of hypertension, diabetes or obesity), scores (Sequential Organ Failure Assessment [SOFA],[16] ARISCAT risk groups,[1] and Surgery Risk Stratification[17]) and biology at admission (serum creatinine, hemoglobin, leukocytes, lymphocytes) were collected. Therapeutic measures implemented in the operating room (type of anesthesia, ventilation mode, main ventilatory parameters, unexpected requirement of a recruitment maneuver, transfusion, use of vasoactive drugs, locoregional anesthesia), especially those relative to SARS-CoV-2 guidelines (rapid sequence induction, use of a closed loop aspiration system, use of a video laryngoscope), were also collected.[18] We also collected oxygen support and treatments required during the first 6 h after the surgery (noninvasive ventilation, high-flow oxygen therapy, emergency intubation). The SpO2/FiO2 ratio was used as an oxygenation parameter.[19] The FiO2 was calculated for non-intubated patients based on the oxygen flow (L/min) delivered with nasal cannula or face mask (see correspondence in Supplementary material 2).[20]
During the first 7 days after surgery, local investigators used medical and administrative records to identify major medical events (intensive care admission, pneumonia, acute kidney injury), the proportion of patients still in hospital, and 7 days' all-cause mortality. We also evaluated 28 days' all-cause mortality and the proportion of patients still being hospitalized at day 28.
Data Analysis
First, a descriptive analysis was performed using number and percentage for qualitative variables and median and interquartile range (IQR) for quantitative variables.
Second, patients confirmed as SARS-CoV-2 positive ("SARS-CoV-2–positive groups") were compared to those who were finally ruled out from the diagnosis ("SARS-CoV-2–negative groups"). All data were censored on day 28 after the procedure. Comparisons between groups were performed using the Mann–Whitney test or Fisher test when adapted. All comparisons were two-tailed.
Third, we conducted a subgroup analysis to explore, among the SARS-CoV-2–positive and –negative patients, the impact of the preoperative risk of major respiratory complications based on the ARISCAT risk groups (with ARISCAT < 26 being considered as low risk, 26–44 as intermediate risk, and > 44 as high risk).[1]
Missing data were reported for each variable. No imputation was made except for the primary outcome, as the lack of reporting of complications was classified as "no complication." A sensitivity analysis was then performed, excluding these patients with a lack of reporting of complications.
To address multiplicity, p values were not calculated to describe the study population, and using the Bonferroni method, we considered a p value < 0.001 for significance. All analyses were conducted with R v.4.0.2 (http://www.R-project.org).
BMC Anesthesiol. 2022;22(47) © 2022 BioMed Central, Ltd.
