COVID-19 Patients At Higher Risk of Dying From Any Surgery: Lancet

Worldwide an estimated 28.4 million elective operations were cancelled due to disruption caused by COVID-19.

4 min read
Worldwide an estimated 28.4 million elective operations were cancelled due to disruption caused by COVID-19.

COVID-19 patients are at a higher risk of dying if they undergo any surgery - even minor or elective surgery.

This finding comes from a new global study published in The Lancet on the risks of postoperative death for COVID-19 patients by experts at the University of Birmingham-led NIHR Global Research Health Unit on Global Surgery who examined data for 1,128 patients from 235 hospitals.

“We would normally expect mortality for patients having minor or elective surgery to be under 1%, but our study suggests that in SARS-CoV-2 patients these mortality rates are much higher in both minor surgery (16.3%) and elective surgery (18.9%). In fact, these mortality rates are greater than those reported for even the highest-risk patients before the pandemic.”
Aneel Bhangu, Report co-author and Senior Lecturer in Surgery at the University of Birmingham

The same study also advises the general public to avoid non-critical surgeries until after the pandemic has passed.

In India, the outbreak shows no sign of slowing down and it may be a while before a vaccine of a treatment module is developed. So how long can non-COVID-19 patients hold of their plans for surgeries?

FIT spoke to Dr Sameer Kaul, an oncologist surgeon at Indraprastha Apollo Hospitals, Delhi to find out more. “For now, elective surgeries have been put on hold and can wait for up to 3-6 months. Semi-critical ones should not wait beyond 1-2 months.”

Dmitri Nepogodiev, report co-author and Research Fellow at the University of Birmingham says,

“Worldwide an estimated 28.4 million elective operations were cancelled due to disruption caused by COVID-19. Our data suggests that it was the right decision to postpone operations at a time when patients were at risk of being infected with SARS-CoV-2 in hospital.”
Dmitri Nepogodiev, Report co-author and Research Fellow at the University of Birmingham

Dr Kaul adds that there is a need to classify the urgency of the study considering the patient and the stage of their illness - and then take a call. “There are clearly laid down guidelines for this, but it does depend on a case-by-case basis.”

For COVID-19 patients, since so much is yet unknown about the disease, it's better to er on the side of caution.

The study cohort included 24 countries participated in the study and they were predominantly in Europe, although hospitals in Africa, Asia, and North America also contributed. While Pakistan took part, the data from India is still awaited, but experts suggest it may “mirror” that of Europe.

It found that those with co-morbidities and who were 70 and above fared worse in postoperative surgeries, with mortality rates being 33.7 per cent in the later. It also found that mortality rates were higher in men (28.4%) versus women (18.2%).

The authors thus recommended that thresholds for surgery during the SARS-CoV-2 pandemic be raised compared to normal practice. For example, men over 70 as a vulnerable group can be identified and they should be advised to postpone their procedures.

‘Non-COVID-19 Patients Should Start Resuming Operations’

“The issue,” says Dr Kaul, “is with non-COVID patients. I would say it is time to generally consider starting surgeries up again.”

It is imperative to have distinct treatment modules, guidelines and messaging for patients with COVID-19 and those without the disease,

India is currently undergoing one of the world’s strictest lockdowns. We have faired fairly well so far, with most of us staying home and social distancing. To achieve compliance, the Modi government doubled down on a fearful messaging about the dangers of COVID-19 and subsequently almost all hospitals are seen as danger zones, festering hotbeds of infection.

“The fearful messaging needs to be tackled now,” says Dr Kaul. People are staying away from hospitals out of fear of contracting the disease, even those who are in a critical condition and need surgeries for other health issues. “Many people have died at home, many young people died at home even with symptoms - the scare is high.”

“There is a lot of misinformation about hospitals, especially ones with a COVID-19 ward. The fear is that the infection will travel, but patients need to understand that hospitals are aware of this and have very different routes, lifts, and entire procedures for COVID and non-COVID wards. COVID wards are completely isolated.”
Dr Sameer Kaul, oncologist surgeon at Indraprastha Apollo Hospitals

He adds that while the entire world is implementing some new guidelines, India needs to ease up restrictions on these kinds of surgeries. “Non-COVID work has reduced globally. In the West, in Canada for example it has fallen by 30-40 per cent. In India, it has reduced by 70 per cent. These cause many preventable deaths.”

The study suggested that there is an “urgent need for investment by governments and health providers into measures to ensure that as surgery restarts patient safety is prioritised. This includes provision of adequate personal protective equipment (PPE), establishment of pathways for rapid preoperative SARS-CoV-2 testing, and consideration of the role of dedicated 'cold' surgical centres."

“I think it is about time the messaging becomes more clear - don’t delay your treatment and hospitals need to be prepared to deal with these types of patients too,” says Dr Kaul.

Another issue to tackle will be of ensuring adequate preparation has taken place in hospitals, as there is a chance the system - which is already flailing - might become even more overburdened after the outbreak.

“When it opens up, patients will come in droves and it will be overwhelming for hospital staff and systems.”
Dr Sameer Kaul, oncologist surgeon at Indraprastha Apollo Hospitals

To avoid this, we need to start preparing to allow patients to come in little by little.

Dr Dhruv Ghosh, Lead of the University Of Birmingham, India hub of Global Surg at Christian Medical College Ludhiana adds that “as we move out of lockdowns across the world, it is imperative to focus research in prophylaxis as well as better treatment of COVID-19 infections to prevent morbidity and mortality following elective surgery. Thus new research in the immediate future will be very important in improving care.”

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