| The Surgical Technologist | JULY 2022 316 However, correct timing of surgery in patients diagnosed with COVID-19 is difficult to assess (173). As an example of the heterogeneity of recommendations, it has been noted that a delay in fracture fixation of up to three months postinjury is acceptable, allowing for the risks of delayed surgery to be weighed against the risks of early fracture fixation performed during early post-COVID-19 prognosis (170). Therefore, it is generally recommended that clinicians address each post-COVID-19 case individually and tailor a unique treatment plan for each patient based on their severity of injury and COVID-19 prognosis (172, 173). Patients waiting for elective orthopaedic surgery need to be reassessed in orthopaedic pathology, COVID-19 prognosis, surgical fitness, and desire to undergo the procedure with regards to evolving risks and benefits. Robust appraisal during the preoperative period to evaluate fitness for surgery is necessary to mitigate the risk of postoperative complications and decrease strain on postoperative intensive care units (170). Specific orthopaedic society recommendations are outlined in Table 2. The American Association for Hand Surgery suggests delaying surgery based on the capacity to care for COVID-19 patients rather than postoperative prognosis (128). The American Orthopaedic Association offers broad suggestions regarding delay of surgery based on clinical need TABLE 2 | Continued Discipline Association Recommendations American Society of Transplant Surgeons (137) • A positive PCR test should result in delay of procedure • A period of 2-4 weeks of negative serology is required for waitlist reactivation of immunosuppressed candidates after COVID-19 contraction Society of American Gastrointestinal Endoscopic Surgeons (138) • Delay surgery based on risk factors (age and potential comorbidity) and institutional resource availability • Enhanced CMS guidelines: for example, for T3 or higher gastric cancers neoadjuvant chemotherapy can be an alternative, allowing surgical delay up to 3-4 months but is dependent upon the rate of disease progression Neurosurgery European Association of Neurosurgical Societies (139) • Elective Surgery Acuity Scale (ESAS) adapted to neurosurgical procedures • There are three tiers of procedures: • Tier 1, low acuity surgery: postpone (e.g., benign intracranial tumors) • Tier 2, intermediate acuity surgery: postpone if possible (e.g., AV malformation, unruptured aneurysm) • Tier 3, high acuity surgery: do not postpone (e.g., malignant brain or spine tumor) Cardio-toracic & Vascular Surgery Canadian Society of Cardiac Surgeons (140) • Details three phases of ‘ramping up’ cardiac surgery case volume based on hospital capacity • Emphasizes which surgical procedures are emergent or can be delayed for medical or percutaneous interventions Society of Thoracic Surgeons (141) • Describes four tiers of operative capacity, wherein each tier details essential procedures and which should be deferred Society for Vascular Surgery (142) • Links to worldwide society guidelines are provided including adaptations of CMS and ACS protocols European Society for Vascular Surgery Management Guidelines for Acute Limb Ischemia (ALI) (143) • Open and endovascular interventions for acute limb ischemia (ALI) for patients with COVID-19 have a mortality rate of 20.4% • Therapeutic anticoagulation with intravenous unfractionated heparin should be provided for ALI unless significant contraindications, serious bleeding within 48 hours, or recent surgery • No high-quality data to suggest open vs. vascular intervention for COVID-associated ALI • Coagulopathy, hyperinflammation, and endothelial injury increase morbidity postvascular surgery • Heparin resistance is common • COVID-19 patients have abnormal coagulation patterns which may interfere with adequate therapeutic anticoagulation Plastic Surgery American Society of Plastic Surgeons (144) • Focuses mostly on transmissibility precautions • Defers to CMS guidelines for resuming elective practice • Abbreviations: ACS, American College of Surgeons; ALI, acute limb ischemia; AV, arteriovenous; CMS, Centers for Medicare & Medicaid Services; COVID-19, coronarvirus disease 2019; ESAS, elective surgery acuity scale; ICU, intensive care unit; LEEP, loop electrosurgical excision procedure; LMWH, low molecular weight heparin; PCR, polymerase chain reaction; TVUS, transvaginal ultrasound. Bunch et al. COVID-19 Immuno-Thrombosis and Surgery Frontiers in Surgery | www.frontiersin.org 12 2022 | Volume 9 | Article 889999
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