JULY 2022 | The Surgical Technologist | 317 and institutional availability (130). Most of these orthopedic organizations do not have specific guidelines for delaying surgery to reduce the incidence of VTEs. However, the European Hip Society and European Knee Associates recommend delaying arthroplasty for six weeks following infection for otherwise healthy individuals, and for infected individuals with one or more comorbidities delaying the surgery for at least 8 weeks (131). When compared to anesthesia and non-orthopaedic society recommendations, the recommendations from European societies seem the most judicious provided the well-recognized increases in mortality and VTE complications associated with post-COVID-19 elective surgeries (13, 134). An example ESAS for delaying procedures is provided in Table 3. General Surgery The COVID-19 pandemic resulted in a significant reduction of general surgical procedures, including procedures for both benign and malignant diseases. While elective surgery for benign disease was intentionally halted during the pandemic, the reduction in procedures for malignancies was likely an unintentional consequence of reduced patient access to clinical examinations and diagnostic testing as a result of limited capacity of healthcare systems (174). At the beginning of the pandemic, it was recommended that emergent cases be individualized based on patient risk, urgent cases be delayed at least until COVID-19 infection clears, and elective cases not be performed and potentially delayed for months (175). Emergency surgery was performed on patients regardless of their COVID-19 infection status. The ACS and the American Society of General Surgeons initially published guidelines based on risk factors and patient benefits related to SARS-CoV-2 transmissibility during acute infection. These guidelines are heterogeneous and do not specifically address hemostatic complications related to elective and acute surgery during acute and convalescent COVID-19 (133, 134). These two associations adopted the CMS 3-tiered framework for urgency of procedures based on the ESAS (134, 136). This three-tiered system is defined by Tier 1, elective surgery which is to be postponed; Tier 2, intermediate acuity surgery postpone if possible; and Tier 3, indications for acute surgery where postponement is not an option (136). Table 4 specifically defines example surgical procedures based on this three-tiered system. With regards to transplant surgery, COVID-19 infection following organ implantation is associated with increased mortality (176, 177). Pre-vaccination prior to transplant has been suggested to reduce the risk of mortality (178). In the context of receiving an organ from a COVID-19 positive donor, there is growing evidence that viral transmission from abdominal organs is a nearly negligible risk (179). This has led to a call for increased use of COVID-19 positive donors without evidence of systemic disease, as the low risk of transmission does not appear to outweigh the potential lifesaving benefit from organ transplantation (180). However, a positive PCR test in a recipient should delay the procedure, and a delay of at least two to four weeks of negative serologies is required for waitlist reactivation of immunosuppressed candidates after COVID-19 contraction. The Society of American Gastrointestinal Endoscopic Surgeons has provided specific guidelines for gastrointestinal cancers similar to the ESAS (138). A large study of over four million cancer patients found that most oncological procedures can be delayed by four weeks without a significant impact on patient morbidity or mortality (181, 182). However, a patient’s age and comorbidities are critical for weighing the relative benefit and risk of potentially exposing the patient to COVID-19 as opposed to choosing alternative options. The resources available to the surgeon must also be considered, since the pandemic has caused large fluctuations in patient acuity, volume, and hospital resources (183). In COVID-19 positive patients with primary or secondary cancer, elective liver or adrenal resection should be delayed until patients fully recover from acute COVID-19. In cases of jaundice or infection, percutaneous transhepatic biliary drainage (PTBD) or endoscopic retrograde cholangiopancreatography (ERCP) should be first implemented as a bridge therapy (184). Neurosurgery The literature concerning timing of neurosurgical procedures has mostly considered SARS-CoV-2 transmissibility and healthcare worker safety (185–188). For example, it has been TABLE 3 | Orthopaedics Elective Surgery Acuity Scale (ESAS). All candidates for surgery should be assessed for surgical fitness on an individual basis. This is an example ESAS and not comprehensive. Procedure acuity for the individual patient may shift among tiers based upon acuity of illness, severity of COVID-19 infection and coagulopathy, and hospital surgical capacity (135). For specific length of operative delay, please see the text and Association of Anesthesiologists guidelines (13). Tier 1 Low Acuity Delay Tier 2 Intermediate Acuity Delay if possible Tier 3 High Acuity Do not delay Trauma n/a Fractures >4 weeks old Chronic infections All new fractures Acute infections Malunion/nonunion Patellar or quad tendon rupture Orthopaedic Oncology Benign tumor biopsy and removal Aggressive benign tumor (e.g., giant cell tumor) Pathologic fracture Joints Elective joint arthroplasty Chronically infected hardware Hip fracture or dislocation Acutely infected hardware Bunch et al. COVID-19 Immuno-Thrombosis and Surgery Frontiers in Surgery | www.frontiersin.org 13 2022 | Volume 9 | Article 889999
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