Anaesthesia 2023 Timing of Elective Surgery and Risk Assessment

Anaesthesia 2023, 78, 1147–1152 doi:10.1111/anae.
16061
Guidelines
Timing of elective surgery and risk assessment after

SARS-CoV-2 infection: 2023 update
A multidisciplinary consensus statement on behalf of the Association of Anaesthetists,
Federation of Surgical Specialty Associations, Royal College of Anaesthetists and
Royal College of Surgeons of England
K. El-Boghdadly,1,2 T. M. Cook,3,4 T. Goodacre,5 J. Kua,6,7 S. Denmark,8 N. Mercer,9

S. R. Moonesinghe10 and D. J. Summerton11,12
1 Consultant, 6, Trainee, Department of Anaesthesia and Peri-operative Medicine, Guy’s and St Thomas’ NHS Foundation
Trust, London, UK
2 Honorary Senior Lecturer, King’s College London, London, UK
3 Consultant, Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation
Trust, Bath, UK
4 Honorary Professor, University of Bristol, Bristol, UK
5 Consultant, Department of Plastic and Reconstructive Surgery, Manor Hospital, Oxford, UK
7 Fellow, 10 Professor and Head, Centre for Peri-operative Medicine, University College London, London, UK
8 Chair, Patient Lay Group, Royal College of Surgeons of England, London, UK
9 Emeritus Consultant, Cleft Unit of the South West of England, Bristol Dental School, Bristol, UK
11 Consultant, Department of Urology, Leicester General Hospital, Leicester, UK
12 Honorary Professor, University of Leicester, Leicester, UK
Summary
Guidance for the timing of surgery following SARS-CoV-2 infection needed reassessment given widespread
vaccination, less virulent variants, contemporary evidence and a need to increase access to safe surgery. We,
therefore, updated previous recommendations to assist policymakers, administrative staff, clinicians and, most
importantly, patients. Patients who develop symptoms of SARS-CoV-2 infection within 7 weeks of planned surgery,
including on the day of surgery, should be screened for SARS-CoV-2. Elective surgery should not usually be
undertaken within 2 weeks of diagnosis of SARS-CoV-2 infection. For patients who have recovered from SARS-
CoV-2 infection and who are low risk or having low-risk surgery, most elective surgery can proceed 2 weeks
following a SARS-CoV-2 positive test. For patients who are not low risk or having anything other than low-risk
surgery between 2 and 7 weeks following infection, an individual risk assessment must be performed. This should
consider: patient factors (age; comorbid and functional status); infection factors (severity; ongoing symptoms;
vaccination); and surgical factors (clinical priority; risk of disease progression; grade of surgery). This assessment
should include the use of an objective and validated risk prediction tool and shared decision-making, taking into
account the patient’s own attitude to risk. In most circumstances, surgery should proceed unless risk assessment
indicates that the risk of proceeding exceeds the risk of delay. There is currently no evidence to support delaying
surgery beyond 7 weeks for patients who have fully recovered from or have had mild SARS-CoV-2 infection.
.................................................................................................................................................................
Correspondence to: K. El-Boghdadly
Email: [email protected]
.................................................................................................................................................................
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© 2023 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists. 1147
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Anaesthesia 2023, 78, 1147–1152 El-Boghdadly et al. | SARS-CoV-2 infection and timing of surgery
Accepted: 31 May 2023

Keywords: complications; COVID-19; SARS-CoV-2; surgery; timing
Supported by the American Society of Anesthesiologists and Anesthesia Patient Safety Foundation.
Twitter: @elboghdadly; @doctimcook; @justin_kua; @NigelMercer; @rmoonesinghe
Recommendations In the pre-vaccine, wild-type phase of the COVID-19

1 Surgical patients should ideally be up to date with pandemic, postoperative morbidity and mortality increased
COVID-19 vaccinations. If not, this should be arranged significantly with peri-operative SARS-CoV-2 infection [1, 2].
in the community at the point of referral for Moreover, pre-operative infection was associated with
consideration of surgery, with the most recent adverse outcomes, particularly when surgery was undertaken
vaccination ideally administered at least 2 weeks before within 6 weeks of SARS-CoV-2 infection [3]. This drove
planned surgery. recommendations to delay elective surgery for 7 weeks
2 Patients with known SARS-CoV-2 infection who require following SARS-CoV-2 infection unless the risks of deferring
urgent surgery should be managed in dedicated surgery outweighed the potential risks of surgery associated
pathways, isolated from others who are not infected with with pre-operative SARS-CoV-2 infection [4–6]. However,
SARS-CoV-2 and with staff taking appropriate there was evolving evidence demonstrating reduced clinical
precautions. severity associated with the Omicron SARS-CoV-2 variant,
3 Patients who develop symptoms consistent with SARS- particularly in the context of widespread vaccination [7, 8].
CoV-2 infection within 7 weeks of planned surgery, Updated recommendations emphasising individual patient
including on the day of surgery, should be screened for risk assessment and shared decision-making to determine
SARS-CoV-2 infection. the timing of surgery were published [9], but these relied on
4 Patients should be requested to notify the hospital if limited data regarding the peri-operative implications of
they test positive for SARS-CoV-2 infection within vaccination and were outlined early in our understanding of
7 weeks of their planned operation date. In this event, a the impact of the Omicron variant.
discussion must take place between the peri-operative Since then, numerous sublineages of Omicron SARS-
team and the patient about the risks and benefits of CoV-2 have emerged [10], and data have emphasised that
deferring surgery. severity of clinical illness was relatively favourable
5 To avoid disease transmission, and because the course compared with wild-type and delta variants [11, 12].
of each infection is uncertain, elective surgery should be National programs have successfully vaccinated large
avoided for 2 weeks after a positive SARS-CoV-2 test, proportions of the population with safe and effective
unless there is a clear indication to waive this precaution. vaccines [13]. The increasing scale of the surgical backlog
6 After 2 weeks and up to 7 weeks after SARS-CoV-2 and implications for population health of delayed access to
infection, surgery can proceed if the patient and surgery surgical care have underscored the need for mitigating
are low risk. barriers to surgery [14–16], although the overall impact of
7 Where either the patient or surgery is not low risk, delayed care due to SARS-CoV-2 guidance is thought to be
an individual risk assessment must be performed. small [17]. Finally, data have begun to emerge on the impact
This should consider: patient factors (age; comorbid and of peri-operative infection on postoperative outcomes in
functional status); infection factors (severity of infection; the Omicron variant and vaccination era [18–20].
ongoing symptoms; vaccination); and surgical factors Therefore, there was a need to reassess existing
(clinical priority; risk of disease progression; grade of guidance in the current context to determine if it currently
surgery). This assessment should include the use of an reflects the needs of both the population and that of the
objective and validated risk prediction tool and shared individual patient. This updated statement aims to facilitate
decision-making. In most circumstances, surgery should safe, effective and timely care for patients undergoing
proceed unless the risk assessment indicates the risk of surgery. Whilst this document is primarily targeted for
proceeding exceeds the risk of delay. clinician use, we aim to provide recommendations that
8 There is no benefit to delaying surgery beyond 7 weeks could assist policymakers, administrative staff, clinicians
for patients who have fully recovered or have had mild and, most importantly, patients regarding safe timing of
SARS-CoV-2 infection. surgery following SARS-CoV-2 infection.
1148 © 2023 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.
El-Boghdadly et al. | SARS-CoV-2 infection and timing of surgery Anaesthesia 2023, 78, 1147–1152
Prevention of peri-operative mortality rate reported in the study of 0.1%, there remains a
SARS-CoV-2 infection significantly increased relative risk for all patients with pre-
Prevalence of COVID-19 in the UK population remains high, operative SARS-CoV-2 infection. Caution must be exercised
ranging between 1 in 15 and 1 in 50 people at any given when interpreting these population-based data [17]; these
time [21]. It is likely that this will persist, meaning patients still show that peri-operative 30-day mortality risk remains
remain at risk of pre-operative exposure to SARS-CoV-2. increased when patients have surgery within 7 weeks of
Peri-operative infection with SARS-CoV-2 is associated with SARS-CoV-2 infection, though the risks are lower than in the
relative increases in postoperative morbidity and mortality first year of the pandemic. In addition, the variation in
[19, 20, 22, 23], but the absolute increase in risk is mortality may be affected by significant confounders such
determined by pre-existing risk [9, 17]. as case-mix and may not be due to the effects of infection.
Preventing pre-operative infection and nosocomial Since mandatory pre-operative screening for infection was
transmission has safety benefits for patients, staff and not in place throughout this period, it is plausible that cases
others. The most effective intervention to reduce the risk of of infection were missed in the historical infection cohort.
severity of COVID-19 [19], and thus peri-operative risk, is up- The mortality risk quoted in this study appears notably lower
to-date vaccination [24–26]. Therefore, patients not up to than anticipated from similar studies, making interpretation
date with vaccination should be encouraged to receive pre- difficult. However, this finding of reduced population risk in
operative COVID-19 vaccination, ideally arranged in the the Omicron and vaccinated era is also supported by
community at the point of referral for consideration of unpublished data from COVIDSurg 3 [29].
surgery. The most recent vaccination should ideally be at Another epidemiological database study in the USA
least 2 weeks before surgery [27]. assessed peri-operative risks of mortality and major adverse
Prevention of nosocomial transmission to patients, staff cardiovascular and cerebrovascular events (MACE) in
and others has benefits to patient outcomes, workforce patients following SARS-CoV-2 infection [19]. The study
well-being and resilience and population health. Therefore, included data from patients with Omicron SARS-CoV-2
patients with known SARS-CoV-2 infection should be infection and those who were vaccinated. Compared with
managed in dedicated pathways, ideally isolated from patients who did not have pre-operative COVID-19
others who do not have SARS-CoV-2. Institutions should (incidence of MACE 5.9%), surgery within 4 weeks, between
manage environmental ventilation, air filtering, 4 and 8 weeks and beyond 8 weeks was associated with an
decontamination and provision of respiratory protective incidence of MACE of 7.5%, 6.1% and 5.5%, respectively
equipment consistent with best practice. Healthcare (adjusted OR (95%CI) within 4 weeks of infection 1.28
workers should use appropriate high-filtering respiratory (1.17–1.41)). This risk was impacted by disease severity, with
protective equipment in proximity to patients with SARS- mild disease having a minimal temporal impact on
CoV-2 infection [28]. outcomes, whilst moderate (hospitalised) or severe
(admitted to ICU and ventilated) COVID-19 had a
progressively more significant influence. Vaccination was
Timing of elective surgery after SARS-CoV-2 infection also associated with a reduced risk of MACE in patients with
Data before the era of Omicron and widespread vaccination a history of COVID-19 (OR (95%CI) 0.87 (0.76–0.99)), as well
highlighted that surgery within 7 weeks of SARS-CoV-2 as reduced postoperative mortality (1.2% vs. 1.8%).
infection was associated with an increased risk of morbidity A prospective observational study of 4928 patients who
and mortality [3, 23]. More recent data have suggested that underwent surgery during the Omicron phase of the
risks associated with surgery within 7 weeks of infection pandemic included 705 patients with pre-operative SARS-
may be more modest than in previous phases of the CoV-2 infection [18]. Infection up to 8 weeks pre-
pandemic [18, 20]. In the Omicron post-vaccination era, a operatively was not associated with increased risks of
population-based data platform analysis in England postoperative pulmonary complications compared with no
showed that surgery 2 weeks, 2–4 weeks, 4–7 weeks and history of infection (3.4% vs. 2.75%; p = 0.83). Only patients
> 7 weeks after SARS-CoV-2 infection was associated with a with pre-operative SARS-CoV-2 infection and ongoing
30-day mortality rate of 1.1%, 0.5%, 0.3% and 0.2%, symptoms had an increased risk of postoperative
respectively [20]. Compared with equivalent data from the pulmonary complications (OR (95%CI) 4.29 (1.02–15.8);
first year of the pandemic (i.e. pre-vaccine) these outcomes p = 0.04). Whilst this study reports temporal and mortality
are more favourable (mortality 4.1%, 2.3%, 1.3% and 0.9%, outcomes, it was underpowered to draw any other
respectively). However, compared with the pre-pandemic conclusions and is somewhat at odds with other data.
Figure 1 Graphic to support decision-making on timing of surgery after SARS-CoV-2 infection.
Overall, the data, including the Omicron wave and outweighed by the risk of deferring surgery. This is
widespread vaccination, do not provide definitive answers particularly important within the first 10 days following
but continue to suggest that SARS-CoV-2 infection SARS-CoV-2 diagnosis as the patient may be infectious,
2 weeks before surgery is associated with increased which is a risk to other patients, staff and surgical
morbidity and mortality for most patient cohorts. When pathways.
surgery is undertaken between 2–4 weeks following Patients who develop symptoms consistent with SARS-
infection, there remain increased risks to patients, but this CoV-2 infection (e.g. fever, cough, sore throat, fatigue [30])
appears to disproportionately affect patients who are within 7 weeks of planned surgery, including on the day of
unvaccinated, have more severe disease and greater surgery, should be screened for SARS-CoV-2 infection.
medical and/or surgical complexity. Beyond 4 weeks, From 2 weeks to 7 weeks after SARS-CoV-2 infection,
these risks reduce further before returning close to surgery can proceed if the patient and surgery are low risk
baseline risk for most patients at 7 weeks and beyond. This (Fig. 1). Where either the patient or surgery is not low risk, a
temporal waning of impact is a change from early reports risk assessment should be performed, considering: patient
in which risk was stably increased throughout a 7-week factors (age, comorbid and functional status); infection
period [2, 3]. factors (severity, ongoing symptoms and vaccination); and
Given the above, elective surgery should be avoided surgical factors (clinical priority, risk of disease progression
for at least 2 weeks after a positive SARS-CoV-2 test or and grade of surgery). This risk assessment should inform
confirmed symptom onset unless the benefit of waiting is shared decision-making between the multidisciplinary team
El-Boghdadly et al. | SARS-CoV-2 infection and timing of surgery Anaesthesia 2023, 78, 1147–1152
and patient, with documentation of risks and benefits of the inconsequential to increased mortality. Thus, these
timing of surgery and the decision-making process. Patients recommendations need to factor in population risk and
with persistent symptoms, moderate-to-severe COVID-19 national health needs, individual risk and the benefits or
or who are immunosuppressed may still have increased harm of delay. Guidance can rarely be compressed into a
risks beyond 7 weeks [18, 19]; these patients may require single sentence, as is the case here.
specialist assessment and individualised, multidisciplinary This guidance document supports more general
peri-operative management with consideration of further clinical guidance on risk assessment prior to surgery:
delay. decision-making should be shared, individualised and
Baseline risk assessment should include the use of a consider the balance of risk associated with proceeding with
validated tool such as the Surgical Outcome Risk Tool v2 surgery as planned, against other options. As is the case with
(SORT-2) [31], which has the best combination of clinical most other risk factors which could be reduced or optimised
utility and accuracy of any pre-operative risk assessment over time, the risks of proceeding without delay will depend
tool internationally [32]. Baseline risk assessment should on the patient’s other risk factors and magnitude and
take place at the time of scheduling surgery so that urgency of the surgery planned. For example, for major
modifiable risk factors can be identified and sufficient cancer procedures which are time-sensitive because of the
time provided for optimisation. Assessing risks of surgery risk of disease progression, decision-making must be
due to current or recent SARS-CoV-2 infection should shared between the patient and their multidisciplinary
include assessment of absolute risk, because any increase team (surgeons, oncologists, anaesthetists and critical
in relative risk impacts most those with the highest pre- care clinicians). Similarly, in a low-risk surgical setting
existing absolute risk [9]. Patients should also be (e.g. eye surgery under local anaesthesia, ambulatory
informed that a positive pre-operative SARS-CoV-2 test gynaecological, general, orthopaedic or urological surgery)
may trigger a review of the risks of proceeding with operations should proceed after 2 weeks unless there is a
surgery. Whilst categorising risk can be challenging, reason not to. Most of the surgery undertaken in the NHS is
examples classifying patients as low risk include ASA of this latter nature, and unnecessary delays to proceeding,
physical status 1–2; aged < 70 y; and being generally fit particularly in the current context of long waiting times, can
and well. Examples of low-risk surgery include most potentially cause disruption and upset to patients, which
outpatient eye surgery; minor body surface or extremity outweigh the potential benefit. For this reason, the use of an
surgery; and surgery with a low risk of death or objective risk assessment tool, such as the SORT-2 or other
complications. In undertaking these risk assessments, a validated approaches, is essential for understanding the risk
risk communication tool can be considered [9], and all to an individual patient of surgery and their relative risk
decision-making should be shared and documented. of proceeding earlier than 7 weeks after SARS-CoV-2
infection.
Discussion For most patients undergoing low-risk surgery or for
Didactic recommendations to defer surgery for 7 weeks patients whose surgery is time sensitive, this guidance
following SARS-CoV-2 infection are not appropriate. supports surgery proceeding 2 weeks after SARS-CoV-2
Indeed, a blanket ban has never been recommended [4, 9], infection, if symptoms have resolved. A minority of patients
but there are some concerns that previous guidance has require risk assessment and shared decision-making due to
been interpreted in this manner. From a population higher risk of morbidity or mortality and include: those who
perspective, recent data indicate that the absolute risk of have ongoing symptoms; had moderate or severe SARS-
surgery soon after SARS-CoV-2 infection might be lower in CoV-2 infection; are significantly comorbid; or require
the UK than previously reported by COVIDSurg [3, 20]. major surgery.
Furthermore, there is a significant backlog of surgery which
mandates every effort to mitigate barriers to surgery. As the Acknowledgements
same data also reconfirm a significantly increased relative KE is an Editor for Anaesthesia. SM is the National Clinical
risk of patient harm and death if surgery is undertaken soon Director for Critical and Peri-operative Care, NHS England.
after SARS-CoV-2 infection, population risk implications SM is supported by the National Institute for Health
must be balanced against the needs of individual patients, Research’s Central London Patient Safety Research
with this increased risk varying from trivial to critical. This, in Collaboration and University College London Hospitals
turn, must be balanced against the consequences for the Biomedical Research Centre. No external funding or other
individual of delaying surgery, which may range from competing interests declared.
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Anaesthesia 2023, 78, 1147–1152 doi:10.1111/anae.

Timing of elective surgery and risk assessment after

K. El-Boghdadly,1,2 T. M. Cook,3,4 T. Goodacre,5 J. Kua,6,7 S. Denmark,8 N. Mercer,9

Accepted: 31 May 2023

Recommendations In the pre-vaccine, wild-type phase of the COVID-19

Figure 1 Graphic to support decision-making on timing of surgery after SARS-CoV-2 infection.

References 18. Garnier M, Constantin J-M, Cinotti R, et al. Association of

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