A year ago, the COVID-19 pandemic altered our world in myriad ways. We sheltered, socially distanced, masked in public. Due to safety and capacity concerns, health systems and providers scaled back non-emergency care, including canceling non-urgent surgeries. While this cautious approach was necessary early in the pandemic, it limited health systems' and providers' ability to fulfill their mission and deliver needed care to patients. We needed to find a safe path forward.
The value of multidisciplinary collaboration to collect and distribute health guidance updates has been a hallmark in the pandemic era. In that spirit, the American Society of Anesthesiologists (ASA) – working with the Anesthesia Patient Safety Foundation, the American College of Surgeons, the Association of periOperative Registered Nurses and the American Hospital Association – immediately began developing to guide safe care. These living documents are revised as new scientific information is established and in accordance with CDC recommendations.
The multispecialty guidance documents factor in whether the surgery is emergent, essential, or elective, and whether the patient has tested positive for or recovered from COVID-19. By following these recommendations, health systems and providers can ensure their patients get the care they need as soon as it is safe to do so. Many of these new practices in surgical care likely will remain in place for the foreseeable future, if not permanently, for the safety of patients – and all of us.
Surgery is Essential, But Safety First
Whatever the procedure, one of the first orders of business before proceeding with surgery or a procedure is to determine the patient's COVID-19 status. All patients should be screened for COVID-19 symptoms and exposure to someone who tested positive in the previous 14 days, as well as undergo within three days of their surgery. Reports suggest that currently infected patients are at higher risk for serious morbidity or mortality related to surgery. If the patient tests positive or has symptoms, the surgeon and physician anesthesiologist together should determine whether the surgery is truly urgent. If they decide it is not, the procedure should be delayed.
It's also important to determine if patients have been previously infected with COVID-19. Even after recovery from the infection, many continue to have multi-system issues that may cause concern during surgery. has shown more than one in four previously infected patients – even those who had minimal symptoms – have post-COVID-19 disease ("long-haulers") and continue to have ongoing health concerns such as decreased mental acuity, decreased pulmonary and cardiac function, tingling, muscle pain, and dizziness as well as issues with smell and taste. Therefore, those who have previously had COVID-19 must be carefully assessed before proceeding with surgery.
In fact, the pandemic has shone a spotlight on the vital importance of thorough preoperative evaluation. As a team, the surgeon and physician anesthesiologist can evaluate the patient's readiness for surgery and optimize care, based on their health and COVID-19 status. That entails developing a surgical and anesthetic plan tailored to each patient. If a patient has had COVID-19, the surgeon and physician anesthesiologist can determine if preparations can be made to safely proceed with surgery. For example, asthma medication may help make surgery safer for patients with compromised lung function after COVID-19 infection.
As part of the preoperative evaluation, the surgical team needs to take time to explain to patients and their loved ones that waiting room protocols have changed for everyone's safety. In many facilities, surgical patients must be dropped off and picked up at a designated entrance. In other cases, particularly for pediatric and special needs patients, one person may be allowed to wait in the waiting room. Providers should also assure families that in the era of COVID-19, patients are being provided extra support and care while hospitalized, to help compensate for the lack of in-person support from loved ones.
Proceed with Emergency Surgery While Taking Precautions
If a patient who needs emergency surgery tests positive for COVID-19 or is symptomatic (or if his or her status is unclear and a test result is not available in time), providers can proceed but extra precautions are needed. That means donning adequate personal protection equipment, including an N95 mask, close-fitting goggles or other eye protection, protective gown and a second layer of protective gloves. Using a negative pressure system or leaving the operating room vacant for sufficient time between surgeries will ensure adequate air exchange before the next patient is treated and reduce spread of the virus.
After the procedure, the patient should be placed in isolation through recovery and the remainder of facility stay, and continue to quarantine after discharge for the remainder of the recommended two-week period.
Wait Until it's Safe to Have Non-Urgent Surgery – and Get Vaccinated
Patients whose procedure is essential, but not an emergency, should follow recommended wait times before having surgery to reduce risks. Hip and knee replacements are among the most common surgeries that have been postponed by the pandemic, but many of these patients are older and are at higher risk for poor outcomes if they become infected with COVID-19.
To reduce those risks, all patients should consider being vaccinated before proceeding with surgery. Vaccination does not interfere with anesthesia and is significantly protective against COVID-19, especially against serious illness and death. Scheduling surgery at least two weeks after the final dose of vaccine ensures the most effective protection. Patients who have not had the vaccine should talk to their surgeon and physician anesthesiologists about the safest way to proceed.
It is recommended that those who have previously had COVID-19 or tested positive for the infection (even if they were asymptomatic or had mild symptoms) recover fully before proceeding with surgery. The ASA and Anesthesia Patient Safety Foundation from the date of COVID-19 diagnosis to surgery:
- Four weeks for an asymptomatic patient or recovery from only mild non-respiratory symptoms
- Six weeks for a symptomatic patient (e.g., cough or dyspnea) who did not require hospitalization
- Eight to 10 weeks for a symptomatic patient who has diabetes or is immunocompromised or was hospitalized
- Twelve weeks for a patient who was admitted to an intensive care unit due to COVID-19 infection
After those requirements are met, the surgeon and physician anesthesiologist must jointly agree when it is safe for the patient to proceed with surgery.
Just as AIDS/HIV changed the way blood is handled and 9/11 altered airport security, it is likely that these COVID-19-era recommendations will remain in place for quite some time, if not permanently. The lessons we've learned and applied will ensure we will be better prepared for the next pandemic or public health crisis. Employing these COVID-19-era procedures and protocols may take extra time, but it is imperative to follow them. Safer surgery clearly is in the patients' and in everyone's best interest.
is president of the American Society of Anesthesiologists as well as founding director of the Day Surgery Unit at Brigham and Women's Hospital and professor of anesthesia at Harvard Medical School in Boston.