Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS-CoV-2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre-operative SARS-CoV-2 infection were compared with those without previous SARS-CoV-2 infection. The primary outcome measure was 30-day postoperative mortality. Logistic regression models were used to calculate adjusted 30-day mortality rates stratified by time from diagnosis of SARS-CoV-2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre-operative SARS-CoV-2 diagnosis. Adjusted 30-day mortality in patients without SARS-CoV-2 infection was 1.5% (95%CI 1.4-1.5). In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was increased in patients having surgery within 0-2 weeks, 3-4 weeks and 5-6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3-4.8), 3.9 (2.6-5.1) and 3.6 (2.0-5.2), respectively). Surgery performed ≥ 7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9-2.1)). After a ≥ 7 week delay in undertaking surgery following SARS-CoV-2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2-8.7) vs. 2.4% (95%CI 1.4-3.4) vs. 1.3% (95%CI 0.6-2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay.

SARS-CoV-2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri-operative or prior SARS-CoV-2 were at further increased risk of venous thromboembolism. We conducted a planned sub-study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS-CoV-2 diagnosis was defined as peri-operative (7 days before to 30 days after surgery); recent (1-6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre-operative anti-coagulation for baseline comorbidities was not available. Postoperative venous thromboembolism rate was 0.5% (666/123,591) in patients without SARS-CoV-2; 2.2% (50/2317) in patients with peri-operative SARS-CoV-2; 1.6% (15/953) in patients with recent SARS-CoV-2; and 1.0% (11/1148) in patients with previous SARS-CoV-2. After adjustment for confounding factors, patients with peri-operative (adjusted odds ratio 1.5 (95%CI 1.1-2.0)) and recent SARS-CoV-2 (1.9 (95%CI 1.2-3.3)) remained at higher risk of venous thromboembolism, with a borderline finding in previous SARS-CoV-2 (1.7 (95%CI 0.9-3.0)). Overall, venous thromboembolism was independently associated with 30-day mortality ). In patients with SARS-CoV-2, mortality without venous thromboembolism was 7.4% (319/4342) and with venous thromboembolism was 40.8% (31/76). Patients undergoing surgery with peri-operative or recent SARS-CoV-2 appear to be at increased risk of postoperative venous thromboembolism compared with patients with no history of SARS-CoV-2 infection. Optimal venous thromboembolism prophylaxis and treatment are unknown in this cohort of patients, and these data should be interpreted accordingly.

Background: Moderate to severe pain is common despite the use of potent opioids during craniotomies. Non-opioid agents such as dexmedetomidine reduce undesirable opioid effects and are successfully used as primary analgesic during bariatric surgeries. This study assessed the feasibility of conducting a large randomised controlled trial comparing fentanyl with dexmedetomidine for perioperative analgesia during craniotomy. Methods:This was a prospective single-centre randomised controlled feasibility trial.Twenty-four consenting adult patients undergoing supratentorial craniotomy at NIMHANS, Bangalore, India, were recruited after ethical approval in March and April 2018. They received either fentanyl 1 µg kg −1 h −1 (n = 12) or dexmedetomidine 0.5 µg kg −1 h −1 (n = 12) as primary intraoperative analgesic drug. Patient, anaesthesiologist, outcome assessor and data analyst were blinded to the study intervention.Our feasibility outcomes (primary) were recruitment and adherence rates. We also explored the potential efficacy of intervention and adverse events. Results:We recruited 24 out of 30 eligible patients and had 100% protocol adherence, thereby demonstrating the feasibility of a larger randomised controlled trial. All 24 patients completed the study. The demographic and clinical parameters were similar between the groups. Compared between fentanyl and dexmedetomidine, there was no difference in the intraoperative fentanyl (top-up) consumption (µg), expressed as median and interquartile range: 25 (0-50) and 0 (0-50); P = 0.844; and no difference in postoperative pain at 15 and 60 minutes. Adverse events were few and similar with fentanyl and dexmedetomidine. Conclusions:A large-scale randomised controlled trial of perioperative dexmedetomidine versus fentanyl is feasible. Dexmedetomidine has the potential to be non-inferior to fentanyl for perioperative analgesia during craniotomies.

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Airway dimensions were similar during dexmedetomidine and propofol sedation, except for the transverse diameters at soft palate, and for cross-sectional area difference at the base of tongue in spontaneously breathing children with neurological disabilities. Airway complications were less frequent and the quality of sedation was better with dexmedetomidine.