The week before Brian Colvin was scheduled for shoulder surgery in November, he tested positive for Covid-19. What he initially thought was a cold had turned into shortness of breath and chest congestion associated with deep fatigue and loss of balance.
Now seven months have passed and Colvin, 44, is still waiting to feel well enough to have the operation. His surgeon is worried about risking anesthesia with his lingering breathing problems, while Colvin worries about losing his balance and falling onto his shoulder before he heals.
“The last time I spoke with the surgeon, he told me to let him know when I would be ready,” Colvin said. “But with all the symptoms, I never felt ready for surgery. “
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As the number of people who have had Covid-19 increases, medical experts are trying to determine when it is safe for them to have elective surgery. In addition to concerns about respiratory complications from anesthesia, Covid-19 can affect multiple organs and systems, and clinicians are still learning the implications for surgery. A recent study compared the death rate within 30 days of surgery in patients who had Covid-19 infection and those who did not. He found that waiting for surgery for at least seven weeks after a Covid-19 infection reduced the risk of death to that of people who were not infected in the first place. Patients with persistent symptoms of Covid-19 should wait even longer, the study suggested.
But, as Colvin’s experience illustrates, such beacons may be of limited use with a virus whose effect on individual patients is so unpredictable.
“We know that Covid-19 has persistent effects even in people who have had relatively mild illness,” said Dr Don Goldmann, professor at Harvard Medical School, senior researcher and scientific director emeritus at the Institute for Healthcare Improvement. “We don’t know why. But it’s reasonable to assume, when deciding how long to wait before performing elective surgery, that a person’s respiratory or other systems can still be affected. “
The study, published in the journal Anesthesia in March, looked at the 30-day postoperative mortality rate of more than 140,000 patients in 116 countries who had elective or emergency surgery in October. The researchers found that patients who had surgery within two weeks of being diagnosed with Covid-19 had an adjusted death rate of 4.1% at 30 days; the rate declined to 3.9% in those diagnosed three to four weeks before surgery, and dropped again, to 3.6%, in those who had surgery five to six weeks after their diagnosis. Patients whose surgery took place at least seven weeks after their diagnosis with Covid-19 had a 1.5% mortality rate 30 days after surgery, the same as for patients who were never diagnosed with the virus.
Even after seven weeks, however, patients who still had symptoms of Covid-19 were more than twice as likely to die after surgery as people whose symptoms were gone or who had never had symptoms.
Some experts have said seven weeks is too arbitrary a threshold to schedule surgery for patients who have had Covid-19. In addition to the patients’ state of recovery from the virus, the calculation will be different for an older patient with chronic illnesses who needs major heart surgery, for example, than for a generally healthy person in the region. twenties who need a simple hernia repair.
“Covid-19 is just one thing to consider,” said Dr. Kenneth Sharp, member of the board of regents at the American College of Surgeons and vice chair of the department of surgery at Vanderbilt University Medical Center .
In December, the American Society of Anesthesiologists and the Anesthesia Patient Safety Foundation released these guidelines for timing surgery for former Covid-19 patients:
• Four weeks if a patient was asymptomatic or had mild non-respiratory symptoms.
• Six weeks for a symptomatic patient who was not hospitalized.
• Eight to 10 weeks for a symptomatic diabetic, immunocompromised or hospitalized patient.
• Twelve weeks for a patient who has spent time in an intensive care unit.
These guidelines are not final, according to the groups. The operation to be performed, the condition of the patients and the risk of delaying surgery should all be taken into account.
“Long covid” patients like Colvin who continue to have debilitating symptoms months after 12 weeks have passed require further evaluation before surgery, said Dr. Beverly Philip, president of the company.
Now that Covid-19 has been brought to a halt in many areas and vaccines are widely available, hospital operating rooms are bustling again.
“Talking to surgical colleagues, hospitals are very busy now,” said Dr. Avital O’Glasser, medical director of the preoperative outpatient clinic at Oregon Health and Sciences University in Portland. “I’ve seen patients with delayed knee replacements, bariatric surgery, more advanced cancer. “
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At the start of the pandemic, surgical volumes dropped dramatically as many hospitals canceled non-essential procedures and patients avoided facilities filled with Covid-19 patients.
From March to June 2020, the number of inpatient and outpatient surgeries in U.S. hospitals was 30% lower than the same period the previous year, according to the McKinsey & Company Quarterly Healthcare System Volume Survey. By May 2021, surgical volumes had mostly rebounded and were only 2% lower than their May 2019 totals, according to the May survey.
A year ago, clinicians at Oregon Health and Sciences University developed a protocol to allow any patient with Covid-19 to undergo elective surgery. When obtaining patient medical histories and physical examinations, clinicians look for signs of complications from Covid-19 that are not readily identifiable and determine whether patients have returned to their pre-Covid-19 level of health. .
The preoperative examination also includes lab tests and other tests that assess cardiopulmonary function, coagulation status, markers of inflammation, and nutrition, all of which can be disrupted by Covid-19.
If the assessment does not raise any red flags, patients may be allowed to have surgery after they have waited at least seven weeks since being diagnosed with Covid-19.
Originally, the minimum wait for surgery was four weeks, but clinicians reduced it to seven after the international study was published, O’Glasser said.
“We’re still learning about covid, and uncertainty in medicine is one of the biggest challenges we face,” O’Glasser said. “Right now our team is erring on the side of caution. “
At Memorial Sloan Kettering Cancer Center in New York City, doctors don’t follow a specific protocol. “We take each patient one at a time. There are no hard and fast rules at this facility, ”said Dr. Jeffrey Drebin, president of surgery.
Clinicians are struggling to strike a balance between the urgency of cancer surgery and the need to allow sufficient time to ensure recovery from Covid-19, he said.
For Brian Colvin, whose right rotator cuff is torn, delaying surgery is painful and can make the tear worse. But the rest of his life is also on hold. A sales representative for an auto parts company, he has not been able to work since he fell ill. His balance issues make him reluctant to move away from his home in Crest Hill, Illinois, a Chicago suburb where he lives with his wife and 15-year-old son.
Some days he has more energy and is not as short of breath as others. Colvin hopes this is a sign that he is slowly improving. But at this point, it’s hard to be optimistic about the virus.
“It’s always something,” he said.
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