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Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 16  |  Issue : 2  |  Page : 268-271  

Incidence and severity of postoperative complications in patients undergoing surgery following COVID-19 infection at a tertiary care center in South India


Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Date of Submission23-Aug-2022
Date of Decision01-Sep-2022
Date of Acceptance12-Sep-2022
Date of Web Publication07-Oct-2022

Correspondence Address:
Dr. Sunil Rajan
Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aer.aer_134_22

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   Abstract 

Background: The occurrence of postoperative pulmonary complications (PPCs) and other sequelae of COVID-19 infections like thromboembolic events in patients coming for surgery following COVID-19 infection in the Indian population had not been adequately studied. Aim of the Study: We evaluated the incidence of PPCs, acute kidney injury, and thromboembolic complications such as pulmonary embolism, deep-vein thrombosis, myocardial infarction, stroke, and 30-day mortality rate in post-COVID-19 patients undergoing surgery compared to those without a history of COVID-19 infection. Settings and Design: It was a retrospective, observational, case–control study conducted in a tertiary care center. Materials and Methods: One hundred and sixty-six post-COVID-19 surgical patients were included. A matched control group (n = 166) was formed by choosing patients with no history of COVID-19 who underwent similar surgical procedures under a similar technique of anesthesia. Their medical records were analyzed for the development of postoperative pulmonary and nonpulmonary complications and 30-day mortality. Statistical Analysis Used: Independent samples t-test and Chi-squared test were used for statistical analysis. Results: The mean age of patients in the control group was significantly higher than those in the post-COVID-19 group. The number of patients who received two doses of vaccine was also significantly higher in the control group. Comparison of the distribution of preexisting medical conditions and postoperative complications, duration of hospital stay, and incidence of 30-day mortality did not show any significant difference in both groups. Conclusion: Incidence of postoperative complications, length of hospital stay, and 30-day mortality in post-COVID-19 patients undergoing surgical procedures were comparable with patients with no history of COVID-19 infection.

Keywords: COVID-19 infection, mortality, postoperative complications, pulmonary


How to cite this article:
Abraham AS, Sasikumar NK, Rajan S, Abubaker R, Manoharan KS, Kumar L. Incidence and severity of postoperative complications in patients undergoing surgery following COVID-19 infection at a tertiary care center in South India. Anesth Essays Res 2022;16:268-71

How to cite this URL:
Abraham AS, Sasikumar NK, Rajan S, Abubaker R, Manoharan KS, Kumar L. Incidence and severity of postoperative complications in patients undergoing surgery following COVID-19 infection at a tertiary care center in South India. Anesth Essays Res [serial online] 2022 [cited 2022 Dec 4];16:268-71. Available from: https://www.aeronline.org/text.asp?2022/16/2/268/358094


   Introduction Top


December 2019 is a landmark year in our lives due to the emergence of the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) which surged in China and later became a global pandemic. The initial infections were predominantly caused by the Delta variant of the virus which was clinically more severe as compared to Omicron infection which emerged in late 2021.[1] Although resource utilization, hospitalization, and intensive care unit (ICU) admission are fairly documented in COVID-19 patients, data on their surgical needs and outcomes remains limited. The impact of SARS-CoV-2 on postoperative recovery needs to be understood to inform clinical decision-making during and after the COVID-19 pandemic.[2]

The occurrence of postoperative pulmonary complications (PPCs) and other known sequelae of COVID-19 infections such as thromboembolic events like myocardial infarction, stroke, nonpulmonary infectious complications, and acute kidney injury (AKI) in patients coming for surgery following COVID-19 infection have not been adequately studied. Furthermore, the safe period between turning negative for COVID and planning for an elective nonemergent procedure is unclear. Postoperative outcomes in SARS-CoV-2-infected patients have been previously reported.[3],[4],[5] These studies were mostly from Europe and the Middle East. The outcomes in post-COVID patients undergoing surgery in the Indian population are less explored.

Our primary objective was to evaluate the PPCs in patients with a history of COVID-19 undergoing surgery. Secondary objectives included evaluation of the occurrence of AKI, thromboembolic complications such as pulmonary embolism (PE), deep-vein thrombosis, myocardial infarction, stroke, and the 30-day mortality rate in these patients.


   Materials and Methods Top


The study was a retrospective, observational, case–control study. All post-COVID-19 patients who underwent surgery were included in the study. The study was conducted after obtaining the institutional ethical committee clearance (IEC-AIMS-2021-ANES-181 dated July 19, 2021). We defined post-COVID-19 patients as those who previously had a positive PCR test and then had two negative antigen tests for SARS-CoV-2 before surgery. The characteristic of COVID-19 infection was noted as asymptomatic, requiring oxygen support minimally through nasal prongs or face masks, and the requirement of noninvasive ventilation (NIV) or mechanical ventilation. Duration of the disease process and the time interval between the last negative testing for COVID to present surgical disease presentation were also noted. A matched control group was formed by choosing patients with no history of COVID-19 but who underwent similar surgical procedures under a similar technique of anesthesia.

Cases and controls were chosen 1 week after the surgical procedure and their medical records were examined. The data collected included age, gender, comorbidities, surgery the patient underwent, status during previous COVID infection (asymptomatic/oxygen requirement/duration of oxygen requirement/need for mechanical ventilation or NIV), immunization status, and number of vaccines taken.

Then, we looked at whether they developed any complications following the present surgery. We defined PPC as the occurrence of two or more symptoms and signs such as respiratory rate, oxygenation (P/F ratio), auscultatory findings, chest radiological diagnosis chest radiograph, fever/cough, and requirement for postoperative ventilation, reintubation, or use of bilevel positive airway pressure. Length of the ICU stay and type of anesthesia for surgery (general or regional anesthesia) were noted. Occurrences of any nonpulmonary complications such as AKI, thromboembolic complications like PE, deep-vein thrombosis, myocardial infarction, and stroke were also looked for. One month after surgery, medical records are rechecked again to evaluate the mortality rates. The study period was from June 2021 to January 2022. Written informed consent was obtained from the patients for the use of medical data for research and educational purposes and the guidelines of the Declaration of Helsinki were followed.

Statistical analysis

Categorical variables were presented as numbers and percentages, and continuous variables as mean with standard deviation. The differences between the observed means in two independent samples were compared using the independent samples t-test and the Chi-squared test was used for comparison of proportions. Statistical analyses were conducted using the SPSS version 20.0 for Windows (IBM Corporation Armonk, NY, USA).


   Results Top


Data from 332 patients were analyzed. It was seen that the mean age of patients in the control group was significantly higher than those in the post-COVID-19 group (P = 0.0001). The distribution of gender was comparable in both groups. The number of patients who received two doses of vaccine was also significantly higher in the control group [P = 0.0004, [Table 1]. [Table 2] delineates the severity of COVID infection in the post-COVID-19 group. Comparison of the distribution of preexisting medical conditions and postoperative complications, mean duration of hospital stay, and incidence of 30-day mortality did not show any significant difference in both groups [Table 3] and [Table 4].
Table 1: Comparison of age, gender, and vaccination details

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Table 2: Severity of COVID infection in the post-COVID-19 group

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Table 3: Comparison of the distribution of comorbidities

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Table 4: Comparison of the distribution of types of anesthesia and postoperative complications

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   Discussion Top


In the present study, we observed that the incidence of postoperative complications, length of hospital stay, and 30-day mortality in post-COVID-19 patients undergoing surgical procedures were comparable with patients with no history of COVID infection. A significant difference in the age of patients observed in both groups could be because in the general population people aged over 60 years were only provided COVID vaccination in the initial period of the pandemic in India. The significant difference in the number of patients who received two doses of vaccine may probably indicate the efficiency of vaccination toward protection against infection.

Earlier publications which reported high postoperative mortality and postoperative complications might have been conducted in patients infected with the Delta variant. It is observed that in patients with COVID-19 who underwent surgery PPCs occur in half of the patients and are associated with high mortality. These pulmonary complications and mortality rates are greater than those reported for even the highest-risk patients before the pandemic. Recently published data suggest an overall postoperative 30-day mortality between 19% and 24%, with more than half of the patients having PPCs.[1],[3],[5] Our study was conducted when the Omicron variant was prevalent which may explain less postoperative complications and mortality.

In India, the pandemic of COVID-19 began in March 2020 and extended to January 2021 and the infection was predominantly due to the Delta variant of coronavirus. A nationwide lockdown was imposed and on lifting them there was a dramatic resurgence of Delta variant by late March 2021. This wave lasted till June 2021.[6] The worldwide dominance of the Omicron variant of SARS-CoV-2 began in South Africa in November 2021. Published data have shown that infection caused by the Omicron variant is less severe as compared to the Delta variant in terms of admission to hospital.[7] Delta variant showed a 12.1% hospital admission as compared to Omicron which showed a 5.3% admission rate. Supplemental oxygen requirement in the form of noninvasive ventilation or oxygen supplementation through nasal prongs or face mask was also significantly higher in the Delta group (8.4%) as compared to Omicron infection (3%). Similar results were seen in comparing the incidence of invasive mechanical ventilation. The WHO COVID-19 Clinical Progression Scale showed less severity for Omicron infections as compared to Delta infections.[8],[9] Our study was conducted from June 2021 to January 2022 during which the predominant strain may be assumed to be the Omicron variant of SARS-CoV-2.

A retrospective review which assessed the incidence of PE during computed tomography pulmonary angiography examinations performed during dominant periods of the ancestral, Delta, and Omicron variants of COVID-19 had shown that COVID-19 vaccination reduced the risk of associated PE. Patients infected with the Delta and Omicron COVID-19 variants were associated with a lower incidence of PE compared with ancestral variants.[10] Unvaccinated patients had an increased risk of COVID-associated PE during the Delta and Omicron periods compared to vaccinated or recovered patients.[10] We have also made a similar observation regarding the efficacy of vaccination in our study.

COVID-19 predominantly affects the respiratory system. Prothrombic coagulation abnormalities, leading to thromboembolism are the main reason for PE seen with COVID-19 infection. This has been attributed to direct viral toxicity, endothelial cell damage, and dysregulation of the immune system.[11],[12] PE in these patients represents pulmonary thrombosis instead of embolism[11] and is associated with a higher risk of morbidity and mortality.[13] Elderly male patients of COVID-19 with coronary artery disease having multiple comorbidities are at a high risk of mortality.[14] In the absence of comorbidities, the mortality was <5% until the age of 80 years.[15]

The limitation of our study was that no genome sequencing was done and hence we are not sure which type of COVID variant was prevalent in our study subjects. We are not sure whether control group patients had asymptomatic COVID-19 infection earlier which went undetected. Only a negative history was elicited from them to be included in the control group. We matched cases with patients undergoing similar procedures under similar techniques of anesthesia as our study was mainly on postoperative complications which depend mainly on the type of surgery and anesthesia. However, group comparison showed a similar distribution of existing medical conditions in both groups. At the time of conduct of the study, age matching was not possible due to earlier mentioned reasons.


   Conclusion Top


Incidence of postoperative complications, length of hospital stay, and 30-day mortality in patients with a history of COVID-19 who underwent surgical procedures were comparable with patients with no history of COVID-19 infection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
COVID Surg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: An international cohort study. Lancet 2020;396:27-38.  Back to cited text no. 1
    
2.
WHO. WHO Announces COVID-19 Outbreak a Pandemic; March 12, 2020. Available from: http://www.euro.who.int/en/health-topics/healthemergencies/coronavirus-covid-19/news/news/2020/3/whoannounces-covid-19-outbreak-a-pandemic. [Last accessed on 2020 Apr 19].  Back to cited text no. 2
    
3.
Doglietto F, Vezzoli M, Gheza F, Lussardi GL, Domenicucci M, Vecchiarelli L, et al. Factors associated with surgical mortality and complications among patients with and without coronavirus disease 2019 (COVID-19) in Italy. JAMA Surg 2020;155:691-702.  Back to cited text no. 3
    
4.
Lei S, Jiang F, Su W, Chen C, Chen J, Mei W, et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection. EClinicalMedicine 2020;21:100331.  Back to cited text no. 4
    
5.
Carrier FM, Amzallag É, Lecluyse V, Côté G, Couture ÉJ, D'Aragon F, et al. Postoperative outcomes in surgical COVID-19 patients: A multicenter cohort study. BMC Anesthesiol 2021;21:15.  Back to cited text no. 5
    
6.
Yang W, Shaman J. COVID-19 pandemic dynamics in India, the SARS-CoV-2 delta variant and implications for vaccination. J R Soc Interface 2022;19:20210900.  Back to cited text no. 6
    
7.
Lewnard JA, Hong VX, Patel MM, Kahn R, Lipsitch M, Tartof SY. Clinical outcomes among patients infected with Omicron (B. 1.1.529) SARS-CoV-2 variant in southern California. medRxiv 2022.01.11.22269045; Available from: https://doi.org/10.1101/2022.01.11.22269045. [Last accessed on 2022 Aug 20].  Back to cited text no. 7
    
8.
Wrenn JO, Pakala SB, Vestal G, Shilts MH, Brown HM, Bowen SM, et al. COVID-19 severity from omicron and delta SARS-CoV-2 variants. Influenza Other Respir Viruses 2022;16:832-6.  Back to cited text no. 8
    
9.
Wolter N, Jassat W, Walaza S, Welch R, Moultrie H, Groome M, et al. Early assessment of the clinical severity of the SARS-CoV-2 omicron variant in South Africa: A data linkage study. Lancet 2022;399:437-46.  Back to cited text no. 9
    
10.
Law N, Chan J, Kelly C, Auffermann WF, Dunn DP. Incidence of pulmonary embolism in COVID-19 infection in the ED: Ancestral, Delta, omicron variants and vaccines. Emerg Radiol 2022;29:625-9.  Back to cited text no. 10
    
11.
Suh YJ, Hong H, Ohana M, Bompard F, Revel MP, Valle C, et al. Pulmonary embolism and deep vein thrombosis in COVID-19: A systematic review and meta-analysis. Radiology 2021;298:E70-80.  Back to cited text no. 11
    
12.
Ackermann M, Verleden SE, Kuehnel M, Haverich A, Welte T, Laenger F, et al. Pulmonary vascular endothelialitis, thrombosis, and angiogenesis in Covid-19. N Engl J Med 2020;383:120-8.  Back to cited text no. 12
    
13.
Liao SC, Shao SC, Chen YT, Chen YC, Hung MJ. Incidence and mortality of pulmonary embolism in COVID-19: A systematic review and meta-analysis. Crit Care 2020;24:464.  Back to cited text no. 13
    
14.
Ray A, Chaudhry R, Rai S, Mitra S, Pradhan S, Sunder A, et al. Prolonged oxygen therapy post COVID-19 infection: Factors leading to the risk of poor outcome. Cureus 2021;13:e13357.  Back to cited text no. 14
    
15.
Reilev M, Kristensen KB, Pottegård A, Lund LC, Hallas J, Ernst MT, et al. Characteristics and predictors of hospitalization and death in the first 11 122 cases with a positive RT-PCR test for SARS-CoV-2 in Denmark: A nationwide cohort. Int J Epidemiol 2020;49:1468-81.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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