No surprise that the topic of this month's column focuses on coronavirus disease 2019 (COVID-19). For months now, we have been inundated with information about the novel coronavirus disease. Researchers, committed to understanding, treating, and preventing this tenacious enemy offer, in my opinion, our best hope.
In conjunction with several European scientific and professional associations, the National Institute for Health Research in the United Kingdom conducted this comprehensive assessment to provide evidence (vs expert opinion only) on which surgery-related decisions could be made during and following the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also known as COVID-19, pandemic.
Mortality and Pulmonary Complications in Patients Undergoing Surgery with Perioperative SARS-CoV-2 Infection: An International Cohort Study. COVIDSurg Collaborative. The Lancet 2020;396(10243):4-10. https://doi.org/10.1016/S0140-6736(20)31182-X
Background and Purpose
Surgical patients represent a group at risk for SARS-CoV-2 and possibly postoperative pulmonary complications. After the World Health Organization declared the pandemic in March 2020, temporary pauses limited the number of surgeries, particularly elective and nonurgent procedures. Nonetheless, evidence-based guidelines did not exist for providers and patients to navigate decisions surrounding surgery in light of the dangers associated with SARS-CoV-2. The purpose of this study was to describe the 30-day mortality and pulmonary complication rates of perioperative patients diagnosed with SARS-CoV-2, thereby providing patient-level outcomes data.
Method
Patients with SARS-CoV-2 infection who underwent surgery at 235 hospitals in 24 countries were included in this observational cohort study. Consideration for protection of human subjects occurred in ways consistent with local, state, and national research ethics committees. Participating hospitals reported all patients (children and adults) diagnosed with SARS-CoV-2 infection within 7 days before surgery or 30 days after surgery.
To ensure validity, investigators at the respective sites received training and written materials. All researchers were invited to virtual meetings and online groups for troubleshooting, guidance, and shared learning. Predetermined definitions for diagnosis of the infection assured continuity across sites.
An electronic data capture Web application recorded age, sex, and American Society of Anesthesiologists (ASA) classification. Time of SARS-CoV-2 diagnosis (preoperative or postoperative) and clinical symptoms for emergency admissions were collected. Other variables included respiratory rate, heart rate, blood pressure, organ failure assessment score, type of surgery (elective or emergency), primary procedure, and anesthesia used (regional or general).
Outcomes
Two main outcomes guided the study:
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1.
Thirty-day postoperative mortality, with the day of surgery defined as day 0.
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2.
Pulmonary complications (pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation).
Results
Patients who had surgery between January 1, 2020 and March 31, 2020 were screened for inclusion, and a total of 1,128 were enrolled. Most were men (53.6%) and people 70 years or older (49.5%). Only 26.1% were diagnosed preoperatively. Most surgeries were classified as major (74.6%) or emergency (74.0%) procedures.
For the first outcome, 30-day mortality was 23.8% overall and significantly higher (P < .0001) in men (28.4% or 172 of 605) compared with women (18.2% or 94 of 517). The oldest group (70 years and older) experienced significantly higher mortality (P < .0001) than those younger than 70 years, with 33.7% (188 of 558) versus 13.9% (79 of 567), respectively. Mortality increased following emergency surgery (25.6% or 214 of 835) compared with elective surgery (18.9% or 53 of 208). Analyses determined the following predictors of 30-day mortality: male, 70 years or older, ASA classes III to V, cancer diagnosis, emergency, and major surgery.
On the second outcome, 51.2% (577) of 1,128 patients had a pulmonary complication: pneumonia (40.4%), unexpected mechanical ventilation (21.3%), and acute respiratory distress syndrome (14.4%). Pulmonary complications occurred in 219 of 268 patients (81.7%) who died. In addition, pulmonary complications were associated with ASA classes III to V.
Conclusions
More than half of patients with perioperative SARS-CoV-2 infection experienced pulmonary complications postoperatively. Men, 70 years and older, ASA classes III to V, having emergency or major surgery for cancer face the highest risk of poor outcomes. Therefore, clinical implications include providing nonsurgical treatment for these patients to delay or avoid surgery. In this study, patient mortality occurred mainly in those with postoperative pulmonary complications, and they represented more than half (51.2%) of all patients, drastically higher compared with prior reports of pulmonary complication rates of 8%. Overall, postoperative outcomes for patients with SARS-CoV-2 are much worse than baseline rates of mortality and pulmonary complications prepandemic.
Perianesthesia Nursing Implications
Although we have spent little time celebrating 2020 as the Year of the Nurse, nurses have undoubtedly retained their position of high public trust throughout the challenges of COVID-19. This new study gives fresh evidence for navigating future decision-making in the perianesthesia settings. Therefore, nurses must first know the evidence. Next, we have to use our knowledgeable voices to advocate for patients facing surgery. Advocacy may exist in patient and family education, discussing evidence with physician and nurse colleagues, engaging in policy action, integrating evidence into practice, and participating or leading research.
When people ask us as nurses, “What do you think?” we step into a cautiously regarded space. As noted in the background of this study, expert opinion provided the only information we had on clinical guidelines for patients with COVID-19 for months. Just as this collaborative filled a gap in evidence by conducting generalizable research, our opinion as nurses will only take us so far. Perianesthesia nurses—situated at the intersection of patients, surgeons, and anesthesia providers—need to be armed with evidence and compassion to carefully and accurately respond to our patients.
Footnotes
Conflict of interest: None to report.