Risk of Acquiring Perioperative COVID-19 During the Initial Pandemic Peak

A Retrospective Cohort Study

Lucas G. Axiotakis Jr., BS; Brett E. Youngerman, MD, MS; Randy K. Casals, MD; Tyler S. Cooke, MD; Graham M. Winston, MD; Cory L. Chang, AB; Deborah M. Boyett, MD, MS; Anil K. Lalwani, MD; Guy M. McKhann, MD


Annals of Surgery. 2021;273(1):41-48. 

In This Article

Abstract and Introduction


Objective: To determine the risk of acquiring perioperative COVID-19 infection in previously COVID-19 negative patients.

Summary of Background Data: During the initial peak of the COVID-19 pandemic, there was significant concern of hospital acquired COVID-19 infections. Medical centers rapidly implemented systems to minimize perioperative transmission, including routine preoperative testing, patient isolation, and enhanced cleaning.

Methods: In this retrospective cohort study, medical records of all adult patients who underwent surgery at our quaternary, acute care hospital between March 15 and May 15, 2020 were reviewed. The risk of preoperatively negative patients developing symptomatic COVID-19 within 2–14 days postoperatively was determined. Surgical characteristics, outcomes, and complications were compared between those with and without acquired perioperative COVID-19 infection.

Results: Among 501 negative patients undergoing index surgeries, 9 (1.8%) developed symptomatic COVID-19 in the postoperative period; all occurred before implementation of routine preoperative testing [9/243, 3.7% vs 0/258, 0%, odds ratio (OR): 0.048, P = 0.036]. No patient who was polymerase-chain-reaction negative on the day of surgery (n = 170) developed postoperative infection. Perioperative infection was associated with preoperative diabetes (OR: 3.70, P = 0.042), cardiovascular disease (OR: 3.69, P = 0.043), angiotensin receptor blocker use (OR: 6.58, P = 0.004), and transplant surgery (OR: 11.00, P = 0.002), and multiple complications, readmission (OR: 5.50, P = 0.029) and death (OR: 12.81, P = 0.001).

Conclusions: During the initial peak of the COVID-19 pandemic, there was minimal risk of acquiring symptomatic perioperative COVID-19 infection, especially after the implementation of routine preoperative testing. However, perioperative COVID-19 infection was associated with poor postoperative outcome.


The coronavirus disease 2019 (COVID-19) pandemic is an unprecedented global crisis with significant ramifications for the healthcare system. Ominously, surge modeling forecasted inadequate medical equipment, supplies, and staffing to address the expected needs of seriously ill, ventilator dependent, COVID-19 infected patients. Without drastic reduction in surgical services, life-threatening shortages of personal protective equipment, ventilators, and hospital beds were expected.[1–3] Furthermore, early reports suggested that patients with perioperative COVID-19 infection undergoing surgery had significantly worse outcomes.[4,5] For the elective surgical patient, there was concern that uninfected patients undergoing surgery might contract the SARS-CoV-2 virus perioperatively. In the face of logistical challenges, resource limitations, and uncertain risk-benefit relationships, governments, hospitals, and surgical specialty societies urged the delay of elective cases.[6]

As the virus reached the United States, New York City became the epicenter of the COVID-19 pandemic. New York hospitals rapidly implemented systems, based on limited empirical evidence, to enhance safety and minimize surgical risks. At Columbia University, all elective surgeries were canceled. In addition to reducing case volume and performing only urgent and emergent operations, hospitals isolated patients based on COVID-19 status, reorganized dedicated perioperative areas, made the operating room a negative pressure environment, and increased infection prevention and control practices, including COVID-specific operating room and equipment cleaning.[1–3,7] As faster and more reliable testing became more widely available, many centers implemented various forms of routine preoperative testing to delay cases in positive patients, when feasible, or isolate them and take special precautions when surgery could not be delayed.[8–10] However, the actual risk of patients becoming newly infected in the perioperative period and the efficacy of these measures aimed at reducing transmission remain unknown.

In this study, we investigate the risk of acquiring symptomatic perioperative COVID-19 infection during the initial peak of the pandemic and the impact of routine preoperative COVID-19 testing on this risk. In the cohort of patients with perioperative COVID-19 infection, we assess the association of patient and surgical risk factors in developing the infection, and the impact on postoperative outcomes and adverse events.