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| The Surgical Technologist | MAY 2021 212 limited evidence regarding the optimal timing of surgery following SARS-CoV-2 infection. A prospective cohort study including 122 patients having surgical for cancer, found that surgery ≥ 4 weeks after a positive SARS-CoV-2 swab result was associated with a lower risk of postoperative mortality than earlier surgery [9]. A study in Brazil included 49 patients whose elective surgery was delayed following the pre-operative diagnosis of asymptomatic SARS-CoV-2 infection [10]. These patients subsequently underwent surgery following con fi rmation of a negative SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) nasopharyngeal swab result. The postoperative complication rates were comparable to patients without SARS-CoV-2 infection. However, the study did not assess the optimal duration of delay following SARS-CoV-2 diagnosis. Clinical guidelines support postponing non-emergency surgery for patients with pre-operative SARS-CoV-2 infection, but speci fi c recommendations are con fl icting, recommending delays ranging from1 to 12 weeks [11 – 15]. More granular data are needed urgently to inform clinical practice, especially regarding the signi fi cance of symptomatic vs. asymptomatic pre-operative SARS-CoV-2 infection. The aim of this study was to determine the optimal timing of surgery following SARS-CoV-2 infection. Methods This was an international, multicentre, prospective cohort study that included patients undergoing any type of surgery. The study was registered at each participating hospital in accordance with local and national regulations. Informed patient consent was taken if required by local or national regulations. In the UK, this study was registered as either a clinical audit or service evaluation at each recruiting institution. Co-investigators were required to con fi rm that applicable local and national approvals were in place before uploading data to the online database. The study was compliant with guidelines for the reporting of observational studies [16]. In the conduct of this study, no changes were made to usual patient care. Routine, anonymised data were collected using a secure online database (REDCap, Vanderbilt University, Nashville, TN, USA). Participating hospitals included consecutive patients undergoing elective or emergency surgery for any indication in October 2020. Surgery was de fi ned as any procedure that is routinely performed in an operating theatre by a surgeon. A list of excluded procedures was provided to investigators and is available in online Supporting Information, Appendix S1. Before commencing data collection, hospitals de fi ned which surgical specialties would be participating. Hospitals could choose to collect data in one or multiple surgical specialties, depending on local resources. Data could be collected over up to four blocks of 7 consecutive days (5 October 2020 – 1 November 2020). Patients were classi fi ed as having pre-operative SARS- CoV-2 infection based on any one of the following criteria: (a) positive RT-PCR nasopharyngeal swab taken before surgery (even if the result became available after surgery); (b) positive rapid antigen test performed before surgery; (c) chest computed tomography (CT) scan performed before surgery showing changes consistent with pneumonitis secondary to SARS-CoV-2 infection; (d) positive pre- operative immunoglobulin G or immunoglobulin M antibody test; or (e) clinical diagnosis made before surgery (in the absence of negative RT-PCR swab results). Patients who were diagnosed with SARS-CoV-2 in the period between postoperative days 0 and 30 were not studied. Data were captured on whether patients had experienced SARS-CoV-2 symptoms, and if so, whether these symptoms had resolved by the time of surgery. Both respiratory and non-respiratory symptoms were considered. These were classi fi ed as follows: asymptomatic; symptomatic but symptoms now resolved; or symptomatic with ongoing symptoms. Time from the diagnosis of SARS-CoV-2 infection to day of surgery was collected as a categorical factor and pre-determined to be analysed in the following categories: 0 – 2 weeks; 3 – 4 weeks; 5 – 6 weeks; and ≥ 7 weeks. The primary outcome measure was 30-day postoperative mortality. Patients were followed-up either in- person or by telephone, as soon after postoperative day 30 as possible. If it was not possible to complete 30-day follow- up, in-patient mortality status was recorded. The secondary outcome measure was the incidence of 30-day postoperative pulmonary complications. This was a composite of pneumonia, acute respiratory distress syndrome (ARDS) and/or unexpected postoperative ventilation. Full de fi nitions are available in online Supporting Information, Appendix S1. The following information was collected for each patient: age; sex; ASA physical status; revised cardiac risk index (RCRI); presence of respiratory comorbidities; indication for surgery; grade of surgery (major/minor); and surgical urgency (elective/emergency). For data protection purposes, age was collected as a categorical variable. Consistent with previous analyses, age was categorised as < 70 years or ≥ 70 years [1, 2]. American Society of Anesthesiologists physical status was classi fi ed as grades 1 – 2 or grades 3 – 5. Patients were recorded as having respiratory comorbidities if they had a diagnosis of asthma or chronic obstructive pulmonary disease (COPD). 2 © 2021 The Authors. Anaesthesia published by JohnWiley & Sons Ltd on behalf of Association of Anaesthetists. Anaesthesia 2021 COVIDSurg Collaborative and GlobalSurg Collaborative | Timing of surgery following SARS-CoV-2 infection