procedure. Although the most common manifestation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is COVID-19 pneumonitis, every system in the body is potentially afflicted by an endotheliitis. This endothelial derangement most often manifests as a hypercoagulable state on admission with associated occult and symptomatic venous and arterial thromboembolisms. The delicate balance between hyper and hypocoagulable states is defined by the local immune-thrombotic crosstalk that results commonly in a hemostatic derangement known as fibrinolytic shutdown. In tandem, the hemostatic derangements that occur during acute COVID-19 infection affect not only the timing of surgical procedures, but also the incidence of postoperative hemostatic complications related to COVID-19-associated coagulopathy (CAC). Traditional methods of thromboprophylaxis and treatment of thromboses after surgery require a tailored approach guided by an understanding of the pathophysiologic underpinnings of the COVID-19 patient. Likewise, a prolonged period of risk for developing hemostatic complications following hospitalization due to COVID-19 has resulted in guidelines from differing societies that recommend varying periods of delay following SARS-CoV-2 infection. In conclusion, we propose the perioperative, personalized assessment of COVID-19 patients’ CAC using viscoelastic hemostatic assays and fluorescent microclot analysis. Keywords: COVID-19, elective surgical procedure, immunothrombosis, obstetrics, orthopedic procedures, venous thromboembolism, thrombophilia, fibrinolysis INTRODUCTION: PERIOPERATIVE COVID19 AND POSTOPERATIVE MORBIDITY AND MORTALITY The global impact of the coronavirus disease 2019 (COVID-19) pandemic on surgical procedures was unprecedented (1, 2). After the induction of the national state of emergency in the United States in March 2020, the Centers for Medicare and Medicaid Services (CMS), the American College of Surgeons (ACS), and other international surgical societies recommended postponing, minimizing, and cancelling elective surgical procedures based largely on SARS-CoV-2 transmissibility precautions (3–5). During this time, there was a 50% reduction in the number of surgical procedures performed relative to baseline (1). Five weeks later, a joint recommendation was published that advised the resumption of elective surgical procedures (6). As the demand for elective procedures increased, clinicians were faced with a growing number of patients still recovering from COVID-19, and surgeons had little available evidence for the optimal timing of surgery and postoperative prognosis for those recovering from acute and/or convalescent COVID-19 illness (7). As the pandemic continued and data accrued, postoperative morbidity and mortality were confirmed to be significantly higher for patients with perioperative COVID-19 infection (8). Perioperative COVID-19 infection correlated with higher rates of postoperative pulmonary complications and venous thromboemboli (VTE) (e.g., pulmonary emboli [PE] and deep venous thromboses [DVT]) (9). Notably, those with ongoing symptoms at the time of operation—regardless of length from diagnosis/onset of COVID-19 symptoms—have a significantly greater risk of VTE and associated mortality. VTE has been independently associated with 30-day postoperative mortality (odds ratio 5.4 [95%CI 4.3–6.7]) (9). One prospective cohort study by the COVIDSurg Collaborative evaluated >140,000 surgical patients from 116 countries who underwent elective or emergency surgery during October 2020 (10). Surgical patients with preoperative SARS-CoV-2 infection were compared to those without previous SARS-CoV-2 infection. There was a significant increase in postoperative pulmonary complications and mortality in patients with a recent diagnosis of SARS-CoV-2 infection (10). The calculated 30-day mortality rates were stratified by time between diagnosis of SARS-CoV-2 infection and surgery (groups included those diagnosed 0–2, 3–4, 5–6, and ≥7 weeks prior to surgery). For those patients without SARS-CoV-2 infection, the adjusted 30-day mortality rate was 1.5%. For those patients diagnosed with SARS-CoV-2 infection, 30-day postoperative mortality rates were 9.1% for 0–2 weeks; 6.9% for 3–4 weeks; 5.5% for 5–6 weeks; and 2.0% at ≥7 weeks between diagnosis and surgery. Surgery performed ≥7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline for controls (odds ratio 1.5 [95%CI 0.9–2.1]). Further stratifying this analysis to those patients with ongoing symptoms at time of surgery, it was noted that even after a ≥7 week delay from SARS-CoV-2 infection diagnosis, these symptomatic convalescent patients had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic at operation (6.0% for ongoing symptoms, vs. 2.4% for resolved symptoms, vs. 1.3% for controls). Consequently, the authors recommended that surgery be delayed for at least seven weeks following SARS-CoV-2 infection, and concluded that patients with ongoing symptoms at seven weeks may benefit from even longer delay (10). A recent multidisciplinary consensus statement aligned with these study conclusions, stating that elective surgery should be scheduled seven or more weeks after the diagnosis of COVID19 for patients with asymptomatic or transient SARS-CoV-2 infection, while patients with persistent symptoms (i.e., “Long COVID”) remain at elevated risk for postoperative morbidity and mortality even after seven weeks. It is therefore Bunch et al. COVID-19 Immuno-Thrombosis and Surgery Frontiers in Surgery | www.frontiersin.org 2 2022 | Volume 9 | Article 889999 | The Surgical Technologist | JULY 2022 302
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