JULY 2022 | The Surgical Technologist | 315 TABLE 2 | Society recommendations on timing of surgery and thromboprophylaxis in acute and convalescent COVID-19 patients. Note this table is not exhaustive, but reflects the diverse and heterogeneous recommendations regarding the timing of surgery and anticoagulation for this patient population. Discipline Association Recommendations Anesthesia American Society of Anesthesiologists (13) • Timing of elective surgery should be delayed based on the symptoms and severity of acute COVID-19 illness. From time of diagnosis: • Four weeks for an asymptomatic patient or those recovering from mild, nonrespiratory symptoms • Six weeks for a patient with respiratory symptoms who was not hospitalized • Eight to 10 weeks for a symptomatic patient who is immunocompromised, diabetic, or was hospitalized • Twelve weeks for a patient who was admitted to an ICU for COVID-19 complications Obstetrics American College of Obstetricians and Gynecologists (124) • Surgery may be delayed when a patient’s health would not be harmed. • Thrombosis risk may be increased with COVID-19 infection • Pregnant patients hospitalized for severe COVID-19 receive prophylactic dose anticoagulation unless contraindicated American Society for Reproductive Medicine (125) • Procedures should not be delayed if patient health is at risk; triage into four periods of surgery: • Cannot be delayed (e.g., hysteroscopy) • Delay up to four weeks (e.g., colposcopy, LEEP) • Delay four to twelve weeks (e.g., TVUS, vulvar biopsy) • Delay beyond twelve weeks (e.g., Botox) Royal College of Obstetricians and Gynecologists (126) • Thromboprophylaxis should still be offered and administered as normally indicated during the COVID-19 pandemic, should be continued if patient contracts COVID-19 • Pregnant women with COVID-19 should be given prophylactic LMWH, unless birth is expected within 12 hours or there is significant risk of hemorrhage • Pregnant women hospitalized with COVID-19 should be offered thromboprophylaxis for 10 days following discharge and longer with thrombophilic co-morbidities • Postpartum patient hospitalized for COVID-19 infection should be offered thromboprophylaxis during hospitalization and for at least 10 days after discharge, and up to 6 weeks of thromboprophylaxis for thrombophilic co-morbidities • Avoid general anesthesia for at least 7 weeks after COVID-19 infection Orthopaedics American Academy of Orthopedic Surgeons (127) • Reschedule elective surgery for individuals with ongoing COVID-19 • Delay elective surgery based on local capacity to care for COVID-19 patients American Association for Hand Surgery (128) • Delay surgery based on local capacity to care for COVID-19 patients American Association of Hip and Knee Surgeons (129) • Prioritize surgery based on clinical need American Orthopaedic Association (130) • Delay surgery based on clinical need and institutional resource availability European Hip Society and European Knee Associates (131) • For infected otherwise healthy individuals, delay elective arthroplasty by 6 weeks • For infected patients with one or more co-morbidity, delay surgery by 8 weeks General Surgery American Society for Metabolic and Bariatric Surgery (132) • Delay surgery based on risk factors, local viral prevalence, and institutional resource availability on an individual basis American Society of General Surgeons (133), American College of Surgeons (134, 135) • Prioritize surgery based on risk factors and patient benefits on an individual basis • Discernment process is streamlined at an institutional level, with final input coming from the surgeon • Defer to Centers for Medicare & Medicaid Services (CMS) tiered framework for urgency of procedures based upon Elective Surgery Acuity Scale (ESAS) Centers for Medicare & Medicaid Services (CMS) (136) • Three-tiered system to decide whether to postpone surgery based upon two factors: acuity of procedure and the health of the patient • Tier 1, low acuity surgery – postpone (e.g., carpal tunnel release, routine colonoscopy) • Tier 2, intermediate acuity surgery – consider postponing (e.g., arthroplasty, elective angioplasty + stent) • Tier 3, high acuity surgery – do not postpone (e.g., trauma, cancers, neurosurgery) (continued) Bunch et al. COVID-19 Immuno-Thrombosis and Surgery Frontiers in Surgery | www.frontiersin.org 11 2022 | Volume 9 | Article 889999
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