The impact of the COVID-19 pandemic on perioperative safety and surgical activity

Early reports from hospitalised medical patients indicated that severe COVID-19 was associated with high mortality rates. In March 2020 there was no high-quality evidence to inform surgical practice during the pandemic. This thesis reports four studies investigating the impact of the COVID-19 pandemic on perioperative safety and surgical activity. To characterise the outcomes of surgery in patients with perioperative SARS-CoV-2 infection, an international cohort study of 1,128 patients who underwent surgery during the first COVID-19 wave (January to March 2022) was undertaken. It identified that perioperative SARS-CoV-2 infection was associated with increased risk of both 30-day postoperative pulmonary complications and mortality. These data indicated that whenever possible, surgery should be avoided in patients with acute SARS-CoV-2 infection. To determine the optimal timing of surgery following SARS-CoV-2 infection an international, prospective cohort study was undertaken. This included 140,231 patients in October 2020. Whereas patients operated 0–2 weeks, 3–4 weeks, and 5–6 weeks after a SARS-CoV-2 diagnosis were at increased risk of adverse events, patients operated ≥7 weeks after SARS-CoV-2 diagnosis were not at increased risk compared to patients who had not had a SARS-CoV-2 infection. Subsequent to this study SARS-CoV-2 vaccines were rolled out and the Omicron SARS-CoV-2 variant emerged. To characterize the applicability of the previous findings to the period of Omicron SARS-CoV-2 variant dominance a further international, prospective cohort study was undertaken to capture surgical outcomes for 19,684 patients with perioperative SARS-CoV-2 infection (December 2021 to February 2022). This found that mortality and 30-day postoperative pulmonary complications had substantially reduced compared to outcomes during the first COVID-19 wave. The findings support initiatives to relax some COVID-19 mitigations measures. To inform planning of strategies to address pandemic elective care backlogs, the need for elective care in England was modelled and forecast forward to 2030. This estimated that in March 2022 4.3 million people needed elective procedures in England. Even in the most optimistic scenario, 2.6 million people would still be on waiting lists for elective procedures in 2030

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARSCoV- 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<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p<0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p<0·0001), 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.pre-print450 K

Predicting the effects of introducing an emergency transport system in low-income and middle-income countries: a spatial-epidemiological modelling study

Introduction: Many low-income and middle-income countries lack an organised emergency transportation system, leaving people to arrange informal transport to hospital in the case of a medical emergency. Estimating the effect of implementing an emergency transport system is impractical and expensive, so there is a lack of evidence to support policy and investment decisions. Alternative modelling strategies may be able to fill this gap. Methods: We have developed a spatial-epidemiological model of emergency transport for life-threatening conditions. The model incorporates components to both predict travel times across an area of interest under different scenarios and predict survival for emergency conditions as a function of time to receive care. We review potentially relevant data sources for different model parameters. We apply the model to the illustrative case study of providing emergency transport for postpartum haemorrhage in Northern Ghana. Results: The model predicts that the effects of an ambulance service are likely to be ephemeral, varying according to local circumstances such as population density and road networks. In our applied example, the introduction of the ambulance service may save 40 lives (95% credible interval 5 to 111), or up to 107 lives (95% credible interval −293 to –13) may be lost across the region in a year, dependent on various model assumptions and parameter specifications. Maps showing the probability of reduced transfer time with the ambulance service may be particularly useful and allow for resource allocation planning. Conclusions: Although there is scope for improvement in our model and in the data available to populate the model and inform parameter choices, we believe this work provides a foundation for pioneering methodology to predict the effect of introducing an ambulance system. Our spatial-epidemiological model includes much oppurtunity for flexibility and can be updated as required to best represent a chosen case study