| The Surgical Technologist | JULY 2022 318 demonstrated that tracheostomies may be safely delayed two weeks, whereas craniectomy and tumor resections, as well as evacuation of subdural hematomas, need to be evaluated on a case-by-case basis (188, 189). Surgical treatment of chronic subdural hematoma, a usually successful intervention with a reported mortality rate of 3.7%, has a markedly increased mortality risk in COVID-19 positive surgical patients (190). Further investigation attributes multiple factors to this mortality rate, including thrombocytopenia, immune system impairment, and interstitial pneumonia progression postsurgery (191). Like other surgical societies, there is heavy reliance on the modified ESAS for determining the timing of neurosurgical procedures for COVID (139). A similar 3-tiered system has been proposed regarding low, intermediate, and high acuity indications for neurosurgical intervention. Examples of surgeries that are divided into these three tiers are Tier 1, benign intracranial tumors which are low acuity; Tier 2, unruptured cerebral aneurysms and AV malformations as intermediate acuity; and Tier 3, malignant brain and spinal tumors for high acuity surgery where postponement is not an option (139). Table 2 and 5 summarizes current neurosurgical guidelines regarding the timing of surgery for COVID-19 patients. Cardiothoracic and Vascular Surgery Cardiothoracic and vascular surgery society guidelines have likewise adapted the CMS recommendations as well as ESAS guidelines for determining the timing of surgery during the COVID-19 pandemic (140, 141). The cardiothoracic guidelines have also benefited from the cardiology literature, which recommends adherence to standard anticoagulation procedures for patients with post-acute sequelae of COVID-19 who are undergoing percutaneous coronary intervention with or without angioplasty for ST segment elevation myocardial infarcts (192). During the acute period of COVID-19 infection, adherence to standard heparin boluses, anti-platelet, and intravenous and oral anti-factor agents is recommended without any change (193). For those patients whose intervention is complicated by a hypercoagulable state, treatment should be titrated with a personalized medicine approach and the use of VHAs to guide anticoagulation has been suggested (194–196). Acutely ill patients with severe coronary artery disease and valvular pathology not amenable to non-surgical interventions can either be operated immediately or temporized with a left ventricular assist device, intra-aortic balloon pump, or extracorporeal membrane oxygenation while waiting for the cytokine storm to abate if clinically possible (197). These guidelines are heterogeneous and likewise founded on the ASA and ACS three-tiered system of classifying patients with COVID-19 who require surgery (13, 134). Provided the protracted nature of this pandemic, cardiac surgery programs must continue to proactively manage every patient on their waitlist with re-expansion of case volumes. TABLE 4 | General Surgery 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 (134–136). 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 Abdominal/ pelvic Acute hemorrhoidal thrombosis/ necrosis Perianal or perirectal abscess Soft tissue infections Appendicitisa Percutaneous cholecystectomy for severe acute cholecystitis Diverticulitis Bariatric Primary gastric bypass Gastric sleeve Gastric band Duodenal switch Revisions for dysphagia Severe GERD Slipped band Anastomotic leak Gastric perforation Obstruction Breast Excision of benign lesions Duct excisions Discordant biopsies likely to be benign Clinical stage T1N0 ER+/PR +/HER2- tumors Any cancer that can receive neoadjuvant or hormonal therapy prior to surgery Neoadjuvant patients finishing treatment Triple negative or HER2 + patients Excision of malignant recurrence Discordant biopsies likely to be malignant Clinical stage T2 or N1 ER+/PR+/HER2tumors Colorectal cancer Prophylactic indications for hereditary conditions Large, benign appearing asymptomatic polyps Small, asymptomatic carcinoids Locally advanced resectable colon cancer viable to neoadjuvant chemotherapy Rectal cancer with clear evidence of downstaging from neoadjuvant chemoradiation therapy Perforated, obstructed, septic, or actively bleeding cancers Malignant polyps Abbreviations: ER, estrogen receptor; GERD, gastroesophageal reflux disease; HER2, human epidermal growth factor receptor 2; PR, progesterone receptor. aEvolving data suggests some careful selection for antibiotic treatment over surgery for uncomplicated appendicitis without appendicolith. Bunch et al. COVID-19 Immuno-Thrombosis and Surgery Frontiers in Surgery | www.frontiersin.org 14 2022 | Volume 9 | Article 889999
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