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

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Micro-XRF maps of Zn for soil incubated with (a) NanoMAP granule, (b) NanoUrea granule and (c) BulkUrea granules.

<p>The colour scheme represents white-yellow for high concentrations and blue-black for low concentrations of the elements. The dashed area represent the probable location of the fertilizer granules in the soil sample and the marked points in Zn Kα map indicate the locations for which μ-XAS spectra were collected.</p

Relative proportion of Zn species at points of interest on coated fertilizer granules incubated in soil and unexposed coated fertilizer granules determined by linear combination fittings of x-ray absorption fine structure (XAFS) spectra.

<p>^a χ²_red (reduced chi square) = [Σ(fit—data)² / σ²]/(N_data—N_components-1), where σ² is the known variance of fits, N_datais the number of data points and N_components is the number of components in the fit. As indicated, reduced chi square (χ²_red) reported by the Athena software is a measure of the sum of squares of the final misfits (see Athena Users’ Manual for details).</p><p>Relative proportion of Zn species at points of interest on coated fertilizer granules incubated in soil and unexposed coated fertilizer granules determined by linear combination fittings of x-ray absorption fine structure (XAFS) spectra.</p

Transmission electron microscopy (TEM) images of (a) bulk ZnO (nominal diameter less than 1 micro-meter) and (b) ZnO nanoparticles (nominal size of 20 nm).

<p>Transmission electron microscopy (TEM) images of (a) bulk ZnO (nominal diameter less than 1 micro-meter) and (b) ZnO nanoparticles (nominal size of 20 nm).</p

The normalized Zn micro-x-ray absorption near-edge structure (μ-XANES) spectra collected at points of interest on and around the coated MAP fertilizer granules (left) and coated urea fertilizer granules (right) incubated in a highly calcareous soil.

<p>Micro-XANES spectra collected from unexposed coated fertilizer granules also illustrated in the relevant graphs.</p

Scanning electron microscopy (SEM) images of (a) NanoMAP granule, (b) distribution of ZnO nanoparticles at the surface of NanoMAP granule, (c) cross-sectioned NanoMAP granule illustrating the core of MAP granule in dark grey and coated surface with ZnO nanoparticles in light grey in backscatter mode and (d) cross-sectioned BulkMAP granule showing inner granule and rough coated surface with bulk ZnO particles.

<p>Scanning electron microscopy (SEM) images of (a) NanoMAP granule, (b) distribution of ZnO nanoparticles at the surface of NanoMAP granule, (c) cross-sectioned NanoMAP granule illustrating the core of MAP granule in dark grey and coated surface with ZnO nanoparticles in light grey in backscatter mode and (d) cross-sectioned BulkMAP granule showing inner granule and rough coated surface with bulk ZnO particles.</p

Selected physical and chemical properties of the soil.

<p>Selected physical and chemical properties of the soil.</p

Scanning electron microscopy (SEM) images of (a) urea granule coated with bulk ZnO, (b) cross-sectioned NanoUrea granule representing inner urea granule and coated surface of the granule with ZnO nanoparticles, (c) surface of NanoUrea granule showing distribution of ZnO nanoparticles at the surface of urea granule and (d) cross-sectioned BulkUrea granule illustrating coated surface of urea granules with bulk ZnO and also inner urea granule in dark grey.

<p>Scanning electron microscopy (SEM) images of (a) urea granule coated with bulk ZnO, (b) cross-sectioned NanoUrea granule representing inner urea granule and coated surface of the granule with ZnO nanoparticles, (c) surface of NanoUrea granule showing distribution of ZnO nanoparticles at the surface of urea granule and (d) cross-sectioned BulkUrea granule illustrating coated surface of urea granules with bulk ZnO and also inner urea granule in dark grey.</p