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


Between March 15 and May 15, there were 610 procedures performed on 569 patients; 22 (3.9%) had confirmed preoperative COVID-19 more than 3 days before their index surgery and were excluded (Figure 2). Among the remaining 547 patients who were eligible for preoperative PCR test within 3 days of surgery, 29 (5.3%) tested or were suspected positive preoperatively and were thus excluded from further analysis. 17 patients (3.1%) lacked adequate postoperative follow-up for determination of COVID status and were also excluded. Patient and surgical characteristics, and outcomes and adverse events, for the 501 preoperative presumed or test negative patients are presented in Table 1. Common comorbidities included hypertension (52.5%), diabetes mellitus (25.4%), immunocompromised state (20.2%), heart failure, arrhythmia or valvular disease (20.0%), and cardiovascular disease (18.6%). Of the 14 surgical services represented, general surgery accounted for a plurality of cases (31.5%), followed by vascular surgery (10.7%), obstetrics/gynecology (9.4%), orthopedic surgery (8.8%), and neurological surgery (8.8%). Approximately one-quarter of cases (25.7%) were emergent. Median postoperative LOS was 2 days (IQR: 0–5 days); 107 patients (21.4%) required a postoperative intensive care unit stay.

Rates of testing and new perioperative infection are presented in Table 2. Among 501 preoperative negative patients, 9 (1.8%) developed symptomatic COVID-19 postoperatively. All suspected cases were ultimately confirmed by PCR. During the period of ad hoc preoperative testing before April 6th, only 24 patients (9.3%) had testing within 3 days of surgery, whereas after routine preoperative testing was implemented, 97.8% were tested. With ad hoc testing, 3.5% had testing on the day of surgery, whereas with routine testing 62.3% were tested on the day of surgery. All new cases occurred in patients who had surgery before routine preoperative testing (9/243, 3.7%) while none occurred after routine testing was implemented [0/258, 0%, odds ratio (OR): 0.048, 95% confidence interval (CI): 0.003–0.825, P = 0.036]. No patient who was PCR negative on the day of surgery (n = 170) acquired perioperative COVID-19. Of note, 6 of the 9 new perioperative cases occurred after surgery performed very early in the study period (between March 15th and 23rd).

The hospital courses, and clinical and surgical details, of the 9 patients with perioperative COVID-19 are presented in Figure 3 and Table 3. Of note, 5 of 9 patients had symptom onset by postoperative day 2. Six patients had hypertension, 5 diabetes, and 4 cardiovascular disease. Four patients were taking angiotensin-receptor-blockers (ARBs). Postoperatively, the median LOS was 6 days with a range of 0–20 days. Three patients required intensive care, 2 developed pneumonia, 2 required mechanical ventilation, 2 developed sepsis requiring vasopressors, and 2 expired. NSQIP surgical risk predictions[12] were available for 8 of the 9 procedures. Median postoperative LOS was 4.5 days (IQR: 0.25–7.5) versus median expected LOS of 2.75 days (IQR: 1.25–3.875). One of these 8 patients (12.5%) died as compared to a cumulative expected mortality risk of 2.8%.

Figure 3.

Swimmer plot for patients acquiring symptomatic perioperative COVID-19 infection. Expected length of stay is calculated from the ACS NSQIP Surgical Risk Calculator. ACS NSQIP indicates American College of Surgeons National Surgical Quality Improvement Project; COVID-19, coronavirus disease 2019.

In univariate analysis, several preoperative characteristics were associated with perioperative COVID-19 infection (Table 4) including transplant surgery (OR: 11.00, 95% CI: 2.40–50.48, P = 0.002), use of ARBs (OR: 6.58, 95% CI: 1.84–23.61, P = 0.004), diabetes mellitus (OR: 3.67, 95% CI: 1.05–13.06, P = 0.042), and cardiovascular disease (OR: 3.69, 95% CI: 1.04–13.09, P = 0.043). After correction for multiple comparisons, only transplant surgery remained significant. Perioperative COVID-19 infection was also associated with multiple postoperative outcomes (Table 4) including readmission (OR: 5.50, 95% CI: 1.19–25.46, P = 0.029) and mortality (OR: 12.81, 95% CI: 2.75–59.62, P = 0.001), and numerous adverse events including pneumonia, sepsis, renal failure, cardiac complication, renal failure, and urinary tract infection. After correction for multiple comparisons, only pneumonia and mortality remained significant.