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.

Postoperative delirium (POD) is a well-recognized postoperative complication and is associated with increased morbidity and mortality. We investigated whether the preoperative neutrophil-lymphocyte ratio (NLR) could be an effective predictor of POD after head and neck free-flap reconstruction. This was a single-center, retrospective, observational study. We analyzed the perioperative data of patients who had undergone elective head and neck free-flap reconstruction surgery. POD was assessed with the Intensive Care Delirium Screening Checklist (ICDSC) during admission to our intensive care unit (ICU). POD was defined as an ICDSC score ≥4. Risk factors for POD were evaluated by univariate and multivariate logistic regression analysis. We included 97 patients. The incidence of POD was 20.6% (20/97). Significantly longer ICU stays were observed in the patients with POD compared to those without POD (median [interquartile range]: 5 [4–6] vs. 4 [4–5], p = 0.031). Higher preoperative NLR values (3 <NLR ≤4 and 4 <NLR) were significantly associated with higher ICDSC scores compared to NLR ≤1 (4 [2–4] vs. 1 [1–1], p = 0.027 and 4 [1–4] vs. 1 [1–1], p = 0.038, respectively). The multivariable logistic regression analysis revealed that only a preoperative NLR >3.0 (adjusted Odds Ratio: 23.6, 95% Confidence Interval: 6.6–85.1; p<0.001) was independently associated with POD. The multivariate area under the receiver operator curve was significantly greater for the E-PRE-DELIRIC model with NLR compared to the E-PRE-DELIRIC model (0.87 vs. 0.60; p<0.001). The preoperative NLR may be a good predictor of POD in patients undergoing head and neck free-flap reconstruction.

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BackgroundIt has been reported that prolonged intensive care unit (ICU) stay after cardiac surgery is associated with poor patient outcome. In addition, prolonged stay can block the efficient use of ICU beds with an increase in expenditure of health-care costs. The aim of the present study was to retrospectively determine which pre- and intra-operative factors could significantly affect ICU-free survival days (IFSD) which has been suggested to reflect postoperative patients’ outcome, as well as variables significantly associated with the main predictors of IFSD.FindingsWe reviewed anesthesia charts and medical records of 145 patients undergoing cardiac surgery under cardiopulmonary bypass (CPB) in our hospital from January 2014 to October 2015, and 72 patients’ records were finally used for the analysis. IFSD was a median of 25 days (95% CI 24–26). The multiple regression analysis indicated that preoperative estimated glomerular filtration rate, differences between preoperative mean arterial pressure and mean CPB pressure, and blood lactate level at 2 h after CPB (CPB-2 h) were independently associated with IFSD (β regression coefficients 0.086, −0.083, and −3.601, respectively).ConclusionIn addition to preoperative renal function and differences between preoperative MAP and CPB pressure, the lactate level at CPB-2 h could be a major predictor of postoperative outcome in patients undergoing cardiac surgery.