02.06.2020

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Prognosis PulmonologyTransversal
Nepogodiev D et al
Lancet

Main result

  •     Inclusion of 1128 patients infected with SARS-CoV-2 perioperatively and follow-up for 30 days: 54% men, 81% over 50 years old and even 50% over 70 years old.
  •     Diagnosis of COVID-19 in pre-operative in 26% of patients, 74% emergency surgery, 25% carcinological surgery, 20% trauma surgery with 33% visceral surgery and 27% orthopaedic surgery. 75% of the surgeries were considered minor.
  •     The mortality at 30 days post-operatively was 23.8% in the whole sample. Men had an increased risk of death (OR=1.75, 28.4% vs. 18.2%, p<0.001), as did patients over 70 years of age (OR=2.30, p<0.001), those with an ASA score greater than or equal to 3 (OR=2.35, p<0.001) and those operated on for cancer surgery (OR=1.55, p=0.047).
  •     Mortality at 7 days was 5.2% and only ASA score (OR=2.52, p=0.029) or COVID-19 post-operative diagnosis (OR=0.25, p<0.001) were associated with this mortality.
  •     Pulmonary complications occurred in 51% of cases with 40% pneumopathy, 21% post-operative ventilation and 14% acute respiratory distress syndrome. These patients had an increased risk of mortality at 30 days (38% vs. 9%, p<0.001), particularly in patients with high ASA scores. Thus, 82% of the patients who died had a pulmonary complication.
  •     Pulmonary embolisms were present in 2% of cases without an increased risk of death.

Takeaways

  •     In perioperatively infected patients with SARS-CoV-2, post-operative pulmonary complications occur in half of the cases with a 7-day mortality of 5% and a 30-day mortality of 24%.
  •     Patients most at risk are men over 70 years of age operated on for cancer with an ASA score greater than or equal to 3 and whose infection occurred preoperatively.

Strength of evidence Moderate

- Large, well-conducted observational cohort study
- Significant percentage of missing data and lack of methodology to take into account
- Data collection sometimes retrospective on file (the proportion of this data is not known)

Objectives

Evaluate 30-day mortality and post-operative pulmonary complications for patients infected with SARS-CoV-2 during surgery.

Method

  •     Observational study of a retrospective multicentre, multinational cohort
  •     Inclusion of patients infected with CACOV-2-SARS, confirmed by PCR on clinical suspicion, perioperatively = 7 days before or within 30 days after surgery
  •     Surgery = any act performed by a surgeon in an operating room whatever the method of anaesthesia, the surgical indication, the age of the patient.
  •     Collection of demographic, clinical, surgical, severity, etc. data
  •     Primary endpoint = 30-day mortality (D0 = day of surgery)
  •     Secondary endpoints = adapted composite endpoint of "Prevention of Respiratory Insufficiency after Surgical Management trial", including pulmonary complications such as pneumonia, ARDS or unplanned post-operative ventilation (ventilation episode after extubation or failure to extubate) + pulmonary embolism + resuscitation admission + need for revision surgery + 7-day mortality + length of hospital stay
  •     Statistics: no headcount calculation then mixed effect model of logistic regression with calculation of ORs and the country is taken as a random effect. Adjustment on preoperative variables influencing mortality at 30 days for the main model, then adjustment on preoperative variables influencing mortality at 7 days + pulmonary complications for the secondary model.
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