Elective Surgery After COVID-19 Infection: New Evaluation Guidance Released

The Oregon Health and Science University (OHSU) has developed new guidelines to help hospitals and surgery centers determine whether patients who have recovered from COVID-19 can safely undergo elective surgery. Specifically, the guidelines are intended to screen for any lingering, systemic symptoms, which may make a procedure riskier.

Elective surgery, also called non-emergent surgery, can be a major or minor procedure that can be scheduled in advance. However, just because surgery is elective does not mean it is optional—it just means it can be scheduled beforehand.

Some common types of minor and major elective surgeries include:

• Plastic surgery
• Knee and hip replacement
• Kidney stone removal
• Exploratory or diagnostic surgery
• Hysterectomy 
• Angioplasty
• Laser surgery

Researchers used worldwide published data to draft a list of recommendations for physicians to pre-screen patients who have recovered from COVID-19 for post-COVID syndrome—a group of symptoms and complications from SARS-CoV-2 that persist well after the virus leaves the body, including muscle atrophy, weakness, fatigue, and inflammation. These people are often referred to as "long-haulers."

“COVID affects so many organ systems and can have subtle or even ‘sneaky’ manifestations of the organ damage it has caused,” Avital O’Glasser, MD, senior author of the study and associate professor of medicine in the OHSU School of Medicine, tells Verywell. “We need to be very thorough in investigating any signs of lingering COVID effects.”

The study was modeled after the recommended protocol and existing evidence-based literature outlining a patient's clinical recovery from a major medical event before elective surgery.

The new guidelines target specific laboratory findings and biomarkers that have historically been good predictors of disease severity to help determine if a patient is at continued risk after COVID-19.

The protocol also factors in the amount of time between the patient's illness and the date of the operation, as well as whether a patient will need general anesthesia. 

The New Recommendations

The suggested guidelines, which were introduced to the OSHU system in August 2020, include a combination of blood tests, diagnostic exams (chest X-ray, EKG, echocardiogram), a patient's functional status and respiratory status, as well as the psychosocial factors that can influence the safety and outcome of the surgery.

The type of surgery (major or minor) and the amount of sedation required are used to help clinicians determine which pre-screening tests need to be administered before the patient can be deemed safe for the operation. 

“This protocol includes many tests that we rarely, if ever perform, in the preoperative setting,” O’Glasser says. “It's also very rare to obtain a chest X-ray in a patient without pulmonary symptoms before surgery. However, because of COVID, we have increased the reliance on a panel of lab tests, EKG, and chest X-ray to investigate lingering effects.”

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What Other Experts Recommend

In December 2020, The American Society of Anesthesiologists (ASA) and the Anesthesia Patient Safety Foundation (APSF) issued a joint statement addressing the need for updated protocols regarding elective surgery and anesthesia for patients who have recovered from COVID-19.

The ASA and APSF highlighted the need for a more detailed preoperative evaluation scheduled far in advance of surgery, with special attention given to the patient's cardiopulmonary systems to assess for residual COVID-19 symptoms.

"We hope that our protocol provides hospitals and surgical centers specific ways to act on this overarching recommendation,” O’Glasser says.

"The pandemic's fascinating and notable feature has been that we are all learning how to provide care in the absence of clear cut data and information. We are doing this separately and together," Cliff Schmiesing, MD, co-director of the Stanford Anesthesia Preoperative Evaluation Clinic, tells Verywell. "We learn every day, refining and improving our care, protocols, and decisions and sharing this more freely and quickly than ever before."

Next Steps

Since the OHSU protocol was approved, approximately 40 participants have been screened using the recommendations. Thus far, the researchers are unaware of any canceled or delayed surgeries because of abnormal findings.

The authors of the study credit proactive partnership between referring surgeons and the strict time-frame requirements outlined in the new guidelines as a possible reason for the good outcomes.

The next steps will be to expand the protocol to include past COVID-19 patients undergoing procedural sedation for minor procedures.

The information in this article is current as of the date listed, which means newer information may be available when you read this. For the most recent updates on COVID-19, visit our coronavirus news page.