中英双语：COVID-19与择期手术时机的选择指南

本文由“麻醉新超人"授权转载

翻译：刘郁鋆 徐医2022级麻醉学研究生

蒋蕴儒  徐医2020级麻醉学研究生

审校：赵林林 徐医附院麻醉科

Guideline

SARS-CoV-2 infection, COVID-19 and timing of elective surgery

SARS-CoV-2病毒感染， COVID-19疫情与择期手术时机的选择

A multidisciplinary consensus statement on behalf of the Association of Anaesthetists, the Centre for Peri-operative Care, the Federation of Surgical Specialty Associations,  the Royal College of Anaesthetists and the Royal College of Surgeons of England

由麻醉医师协会、围手术期医学中心、外科专业协会联合会、皇家麻醉学院和英国皇家外科学院为代表发布的多学科共识声明

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

S. McNally,9 N. Mercer,10 S. R. Moonesinghe11 and D. J. Summerton12,13

1 Consultant, 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

6 Fellow, Health Services Research Centre, London, UK

7 Clinical Services Co-ordinator, University of Arkansas for Medical Sciences Library, Little Rock, AR, USA

8 Chair, Patient Lay Group, Royal College of Surgeons of England, London, UK

9 Consultant, Department of Orthopaedic Surgery, Eastbourne Hospital, Eastbourne, UK

10 Consultant, Cleft Unit of the South West of England, Bristol Dental School, Bristol, UK

11 Professor and Head of Centre for Peri-operative Medicine, University College London, London, UK

12 Consultant, Department of Urology, Leicester General Hospital, Leicester, UK

13 Honorary Professor, University of Leicester, Leicester, UK

1、英国伦敦盖伊和圣托马斯医疗服务体系信托基金会麻醉科和围手术期医学部顾问

2、英国伦敦国王学院高级荣誉讲师

3、英国巴斯皇家联合医院NHS基金会信托基金麻醉和重症监护医学系顾问

4、英国布里斯托尔大学名誉教授

5、英国牛津马诺医院整形重建外科顾问

6、英国伦敦卫生服务研究中心研究员

7、美国阿肯色州小石城阿肯色大学医学科学图书馆临床服务协调员

8 、英国伦敦英国皇家外科学院患者组主席

9、英国伊斯特本伊斯特本医院骨科外科顾问

10、英国布里斯托尔牙科学院裂口科顾问

11、伦敦大学学院围手术期医学中心教授兼主任

12、英国莱斯特总医院泌尿科顾问

13、英国莱斯特莱斯特大学名誉教授

Summary

The scale of the COVID-19  pandemic  means that a significant  number of patients who  have  previously been  infected  with  SARS-CoV-2  will  require  surgery.  Given  the  potential  for multisystem   involvement, timing  of surgery  needs to  be  carefully  considered to  plan for safe  surgery. This  consensus statement uses evidence from a systematic  review and expert opinion to  highlight  key  principles  in the timing of surgery. Shared decision-making regarding timing of surgery after SARS-CoV-2 infection must account for severity of the initial infection; ongoing symptoms of COVID-19; comorbid and functional status; clinical priority  and  risk  of  disease  progression;  and  complexity  of  surgery.  For  the  protection  of  staff,  other patients and the public, planned surgery should not be considered during the period that a patient may be infectious. Precautions should be undertaken to prevent pre- and peri-operative infection, especially in higher risk patients. Elective surgery should not be scheduled within 7 weeks of a diagnosis of SARS-CoV-2 infection unless the risks of deferring surgery outweigh the risk of postoperative morbidity or mortality associated with COVID-19. SARS-CoV-2 causes either transient or asymptomatic disease for most patients, who require no additional precautions beyond a 7-week delay, but those who have persistent symptoms or have been hospitalised require special attention. Patients with persistent symptoms of COVID-19 are at increased  risk  of  postoperative  morbidity  and  mortality  even  after  7 weeks.  The  time  before  surgery should  be  used for functional assessment,  prehabilitation and  multidisciplinary optimisation. Vaccination several weeks before surgery will reduce risk to patients and might lessen the risk of nosocomial SARS-CoV-2  infection  of other  patients  and staff.  National vaccine  committees should  consider whether suchpatients can be prioritised for vaccination. As further data emerge, these recommendations may need to be  revised,  but the  principles  presented should  be  considered to ensure safety  of patients, the  public and staff.

摘要

COVID-19的大规模流行意味着，大量以前感染过新冠的患者将需要手术。由于新冠感染可能涉及多系统，医生需要仔细考虑手术时机，以确保患者的安全。这一共识声明使用来自系统回顾和专家意见的证据来强调手术时机选择的关键原则。关于新冠病毒感染后手术时机的共同决策必须考虑到初始感染的严重程度；COVID-19的持续症状；基础疾病及身体状况；临床优先级和疾病进展风险以及手术的复杂性。为了保护医务工作者、其他患者和社会群众，在患者疑似感染期间不应考虑实行择期手术。对于这些患者，尤其是高危患者，应采取预防措施，以防止术前和围手术期感染。在诊断为新冠病毒感染后7周内不应安排择期手术，除非推迟手术的风险超过与COVID-19相关的术后发病或死亡的风险。对于大多数患者，新冠病毒表现为一过性或无症状感染，他们在7周后不需要额外的预防措施，但那些有持续症状或已住院的患者需要特别关注。COVID-19症状持续的患者即使在感染7周后，术后发病和死亡的风险也会增加。术前应对患者实施机体功能评估、预适应和多学科优化。在手术前几周接种疫苗将降低患者的感染风险，并可能降低其他患者和医务工作者院内新冠病毒感染的风险。国家疫苗委员会应考虑患者是否可优先接种新冠疫苗。随着更多临床数据的出现，这些建议可能需要修改，但是仍应考虑所提出的原则，以确保患者、公众和医务工作者的安全。

Recommendations

1    Shared decision-making regarding timing of surgery after   SARS-CoV-2   infection   between   patient   and multidisciplinary clinical teams must consider: severity of the initial infection; ongoing symptoms of COVID- 19; comorbid and functional status, both before and after SARS-CoV-2 infection; clinical priority and risk of disease progression; and complexity of surgery.

2    Planned surgery should not be considered during the period  that  a  patient  may  be  infectious:  10 days after  mild/moderate  disease  and  15–20 days  after severe   disease.   For   patients   who   are   severely immunosuppressed  (online  Supporting  Information Appendix  S1),  which  may  include  patients  treated with  dexamethasone  or  monoclonal  antibodies  for severe COVID- 19, specialist advice should be sought. If emergency surgery is required during this period, full    transmission-based    precautions    should    be undertaken for the protection of staff.

3    Surgery  within  7 weeks  of  SARS-CoV-2  infection  is associated  with  increased  morbidity  and  mortality. Elective  surgery  should  not  be  scheduled  within

7 weeks of a diagnosis of SARS-CoV-2 infection, unless outweighed by the risk of deferring surgery such as disease progression or clinical priority.

4    Most patients infected with SARS-CoV-2 have either transient  or  asymptomatic  disease  and  require  no additional  precautions  beyond  a  7-week  delay,  but those who  have  persistent symptoms or  have  been hospitalised require special attention.

5    Patients with persistent symptoms of COVID- 19 are at increased risk of postoperative morbidity and mortality even after 7 weeks. Therefore, delaying surgery beyond this  point  should  be  considered,  balancing this  risk against their  risk  of disease  progression  and  clinical priority.    Specialist    assessment    and    personalised, multidisciplinary peri-operative management is required.

6   The time before surgery should be used for functional assessment,    rehabilitation    from    severe    illness, prehabilitation and multidisciplinary optimisation.

7 Vaccination several weeks before surgery will reduce risk to patients and might lessen the risk of nosocomial SARS-CoV-2 infection of other patients and staff. National vaccine committees should consider whether such patients can be prioritised for vaccination.

8   As  a  result  of the  increased  risk  of  morbidity  and mortality of peri-operative COVID- 19, precautions to prevent  admission  of  patients  who  are  incubating SARS-CoV-2 and infection within the hospital should continue.

建议

1、患者和多学科临床团队之间关于新冠病毒感染后手术时机的共同决策必须考虑：

①初始感染的严重程度;

②COVID-19的持续症状;

③SARS-CoV-2感染前后患者基础疾病和基本身体状况;

④手术的临床优先级和疾病进展风险;

⑤手术的复杂程度。

2 、在患者可能具有传染性的时期:轻、中度感染后10天内，严重感染后15-20天内，不应考虑择期手术。对于严重免疫抑制的患者（包括使用地塞米松或单克隆抗体治疗的重症COVID-19患者），应寻求专家建议。如果在此期间需要进行紧急手术，则应采取全面的防护措施，以保护工作人员。

3、 新冠病毒感染后7周内进行择期手术可能会增加患者的发病率和死亡率。在诊断为SARS-CoV-2感染后7周内不应安排择期手术，除非疾病进展或临床优先级等因素导致推迟手术的风险超过了择期手术。

4、大多数感染SARS-CoV-2的患者都表现为一过性或者无症状感染，除了手术时间推迟7周外不需要额外的预防措施，但那些有持续症状或已住院的患者需要特别关注。

5、COVID-19症状持续的患者即使在7周后进行择期手术，其术后发病和死亡的风险也会增加。因此，应该考虑更长的手术推迟时间，在新冠感染后的手术风险与疾病进展的风险和临床优先级之间寻找合适的平衡，这需要专家的评估和个性化个体化、多学科参与的围手术期管理。

6、手术前应对患者进行机体功能评估、重症康复、预适应和多学科综合治疗优化。

7、手术前几周接种疫苗将降低患者的风险，并可能降低其他患者和工作人员感染医院内SARS-CoV-2的风险。国家疫苗委员会应考虑是否可以优先为这类患者接种疫苗。

8、由于围手术期患者感染COVID-19的发病率和死亡率风险增加，应继续采取预防措施，防止处于新冠病毒感染潜伏期的患者入院，进而导致院内感染。

These recommendations are based on evidence available at the time of writing and may be subject to future review.

这些建议是基于撰写本文时可获得的证据，可能需要今后进行审查。

Introduction

SARS-CoV-2 infection  has contributed to more than  118 million infections globally and more than 2.6 million deaths from  COVID-19  [1]. The  impact  of COVID-19  has  been particularly significant in the UK, with more than 4.2 million cases and 125,000 people dying within 28 days of a positive SARS-CoV-2 test [2]. The scale of the pandemic has created substantial   pressures   on   healthcare   systems   globally, leading  to  sustained  reductions  in  surgical  activity.  An estimated 28 million operations were cancelled in 12 weeks of the irst pandemic surge [3], with millions of patients still waiting for surgery [4, 5]. To support delivery of surgical services throughout the pandemic, prioritisation of different procedures has been undertaken [6].

One of the challenges of surgery during the COVID- 19 pandemic  is  the  peri-operative  risk  of  morbidity  and mortality  to  patients  with  active  SARS-CoV-2  infection. Evidence  suggests  a  19. 1%  30-day  mortality  in  elective (planned)   and   26.0%   30-day   mortality   in   emergency surgical  patients,  with  around  half  of  patients  having surgery  when  infected  with  SARS-CoV-2  experiencing postoperative  pulmonary  complications  [7].  In addition, given the scale of the pandemic, peri-operative outcomes after  a  previous  SARS-CoV-2  infection  are  an  important concern,  as  a signiicant  number  of  patients  who  have previously been infected (estimated at 15–20% of the UK population     [8]) will require surgery.

Surgery after a previous SARS-CoV-2 infectionshould be timed to ensure the safest delivery of peri-operative care. SARS-CoV-2 infection may cause multisystem disease with both  short  and  long-term  sequelae,  including  chronic pulmonary  dysfunction,  myocardial  inlammatory  states, renal  impairment,  psychological distress, chronic fatigue and  musculoskeletal  deconditioning  [9– 12]. These  short and long-term complications of SARS-CoV-2 infection could have an impact on postoperative recovery, and therefore must be considered in order to plan safe surgery.

This consensus statement aims to use evidence and expert opinion to highlight key principles in the timing of surgery for the growing number of patients who have had a SARS-CoV-2  infection  to  support  safe  surgery  in  those requiring it. The document refers in parts speciically to UK practice,  but  the  underlying  principles  are  likely  to  be relevant internationally.

介绍

SARS-CoV-2感染已导致全球超过1.18亿人感染，超过260万人死于COVID-19[1]。COVID-19在英国的影响尤其显著，感染人数超过420万例，其中12.5万人在新冠病毒检测呈阳性的28天内死亡。新冠病毒大规模流行给全球卫生保健系统带来了巨大压力，导致外科手术的持续减少。在第一次大流行感染人数激增[3]的12周内，大约有2800万例手术被取消，数以百万计的患者仍在等待手术[4,5]。为了在整个大流行期间能为患者提供外科手术的医疗服务支持，已经对不同的手术进行了优先级排序。

COVID-19大流行期间手术面临的挑战之一是活动性SARS-CoV-2感染患者的围手术期发病和死亡风险。有证据表明，择期手术患者的30天死亡率为19.1%，急诊手术患者的30天死亡率为26.0%，约一半的患者在感染SARS-CoV-2后接受手术术后肺部并发症[7]。此外，考虑到大流行的规模，以前感染过SARS-CoV-2的患者的围手术期结局是一个重要的问题，因为大量既往感染患者(估计占英国人口[8]的15-20%)将需要手术。

既往感染过SARS-CoV-2的患者应选择合适的手术时间，以确保医务工作者能提供最安全的围手术期护理。新型冠状病毒感染可引起多系统疾病，并伴有短期和长期后遗症，包括慢性肺功能障碍、心肌炎、肾功能损害、心理压力、慢性疲劳和肌肉骨骼的退化等[9-12]。这些新冠病毒感染的短期和长期并发症可能会影响术后恢复，因此在计划手术时，为了确保患者的安全，必须考虑到这些因素。

这一共识声明旨在利用证据和专家意见，通过强调手术时机选择的重要原则为强调越来越多的SARS-CoV-2感染患者提供安全的手术。该文件在某些部分特别提到了英国的做法，但其基本原则具有国际适用性。

Prevention of peri-operative SARS-CoV-2 infection

Peri-operative   SARS-CoV-2  infection   (de novo or  re- infection  [Hall  et  al.,  pre-print,  https://doi.org/10.1101/ 2021.01.13.21249642]) is associated with a more than 10- fold  increase  in  short-term  mortality  [7,  Abbot  et  al., pre-print,   https://doi.org/10.1101/2021.02.17.21251928]. Therefore, it is essential to  minimise the  risk of patients either arriving in hospital whilst incubating SARS-CoV-2 or acquiring  it  in  hospital. This  is  particularly  important  in patients who are at high risk of severe disease and mortality from COVID- 19, such as older people, men, Black, Asian and  minority ethnic groups and comorbid  patients. The principal actions to achieve this for all patients are:

1 .  SARS-CoV-2  vaccination  of  patients  several  weeks before hospital admission, where appropriate and as prioritised by national vaccination strategies;

2  .  Self-isolation for a period that exceeds the incubation period  of  SARS-CoV-2  illness  [13]  combined  with polymerase   chain   reaction   (PCR)   testing   before admission;

3  . Adherence   to   practices   that   reduce   the   risk   of community-acquired  SARS-CoV-2  infection,  such  as hand hygiene, wearing masks and social distancing, as well as shielding advice where indicated;

4  .  Screening  of  hospital  staff  to  prevent  contact  with infectious staff [14];

5   . Maintaining dedicated pathways that separate screened and PCR-negative patients from contact with patients with suspected or conirmed SARS-CoV-2 infection and the staff and locations involved in their treatment [15];

6  .  Minimising time spent within healthcare environments.

围手术期SARSCoV-2感染的预防

围手术期新冠病毒感染(新发或再感染)与短期死亡率增加10倍以上相关。

因此，必须尽量减少患者处于新冠病毒感染潜伏期或者发生院内感染的风险。这对于罹患严重疾病和COVID-19死亡风险较高的患者尤其重要，如老年人、男性、黑人、亚裔和少数民族以及具有基础病的患者。实现这一目标的主要措施是：

1、根据国家疫苗接种战略的优先顺序，在患者入院前几周对其进行新冠病毒疫苗接种;

2、入院前自我隔离超过新冠病毒感染的潜伏期[13]并进行PCR检测;

3、坚持降低社区获得性新冠病毒感染风险的做法，如注意手部卫生、戴口罩和保持社交距离，以及在必要时根据指示进行隔离；

4、对医院工作人员进行筛查，防止与受感染的工作人员接触;

5、对筛查及核酸阴性的患者使用专用通道，远离疑似或确诊的新冠病毒感染者以及治疗此类患者的医务工作者和医疗环境，做好院内分区。

6、尽量减少在医疗环境中滞留的时间。

Protection of others

Elective surgery after SARS-CoV-2 infection must be safe for staff, other patients and the public [16– 19]. Therefore, adherence   to   self-isolation   guidelines is imperative. Symptoms   of   COVID-19   present 4–5 days following infection with SARS-CoV-2, and it is most contagious  in the  2 days  before  and the 5 days after the onset of symptoms [20]. In asymptomatic and mild to moderately symptomatic patients, it is rare for the virus to be cultured beyond 10 days  after  symptom  onset,  which  underlies both UK and World Health Organization recommendations for self-isolation of 10 days following a positive SARS-CoV-2 PCR test [13,21–23]. In the severely ill or severely  immunocompromised  patients,  infectivity may continue for longer [20,24]. In the severely ill, the risk of  replication-competent  virus  is  approximately  5%  at 15 days  after  symptom  onset  and  extremely   rare  at 20 days [25,26]. Therefore, to protect staff, other patients and members of the public, patients should self-isolate for 10 days  with  mild  to  moderate  disease,  or  15–20 days with  severe  illness.  This  applies  to  any  attendance  for hospital services. Those who are severely immunocompromised   (online   Supporting    Information Appendix S1) may need specialist advice on duration of self-isolation.  Of  note,  PCR  positivity  does  not  correlate with secretion of live virus, so  is of little or  no value  in assessing  the  risk  of  infectivity  in  the  3 months  after conirmed SARS-CoV-2 infection.

Planned surgery should not be considered during the period  that  a   patient   may   be   infectious,   and  when emergency  surgery  is  required  during  this  period,  full transmission-based   precautions  should   be   undertaken [27,28].

防护措施

新冠病毒感染后的择期手术必须确保医务工作者、其他患者和公众安全[16-19]。因此，必须遵守自我隔离的原则。COVID-19在感染后4-5天出现症状，发病前2天和发病后5天传染性最强[20]。在无症状和轻至中度症状的患者中，出现症状10天后实验室体液培养检测出病毒的情况很少，这也是英国和世界卫生组织建议民众在新冠病毒PCR检测阳性后10天内自我隔离的证据基础[13,21 - 23]。重症或严重免疫功能低下的患者感染后病毒传染性可能会持续更长时间[20,24]。重症患者在症状出现后第15天体内仍存在具有复制能力的病毒的风险约为5%，在症状出现后20天体内存在具有复制能力的病毒的风险极为罕见[25,26]。因此，为保护医务工作者、其他患者和公众，轻至中度患者应自我隔离10天，重症患者应自我隔离15-20天。这适用于任何医院的公共卫生服务。免疫系统严重受损的患者，在自我隔离的时间上，可能需要有关的专家建议。值得注意的是，PCR阳性与活病毒分泌无关，因此，在确诊新冠病毒感染后3个月内,PCR对评估病毒传染性风险几乎没有价值。

在患者可能具有传染性期间，不应考虑择期手术，在此期间如果需要进行急诊手术，则应采取全面的预防病毒传播的防护措施[27,28]。

Timing of elective surgery after SARS- CoV-2 infection

Following  infection  with  SARS-CoV-2,  timing  of  surgery must account for severity and ongoing symptoms of COVID- 19,  the  patient/s  comorbid  status  and  the  priority  and complexity of surgery. Detailed methodology and results of the systematic  review are  reported in online Supporting Information Appendix S2.

新型冠状病毒感染后择期手术时机

感染新型冠状病毒后，手术时机必须考虑到COVID-19的严重程度和持续症状、患者的基础疾病、基本身体状况以及手术的优先级和复杂性。系统评价的详细方法和结果在在线支持信息附录S2中报告。 

Symptoms and severity of disease

The  phases  of  COVID- 19  [29]  and  the  scale  of  clinical severity [30] are both important factors in planning surgery and are summarised in Tables 1 and 2.

It is important to note that for the majority of patients infected  with  SARS-CoV-2,  it  is  either  a  transient  or asymptomatic  disease followed  by full  recovery (Fig. 1). Approximately  15% of infected patients are hospitalised, 5% require advanced oxygen therapies and around 1% of all cases require critical care admission (Fig. 1). Following SARS-CoV-2 infection, nearly 5% of all patients still have residual  symptoms  at  8 weeks  [Sudre  et  al.,  pre-print, https://doi.org / 10.1101 /2020.10.19.20214494]. This rate is higher in patients who have been hospitalised with COVID- 19. In a cohort study of 1655 hospitalised patients in China followed up at 6 months [10] and another of 143 patients inItaly followed up at 9 weeks [11], 76% and 87% of patients reported at least one persisting symptom, respectively. In the former study, more severe COVID- 19 was associated with progression to post-COVID- 19 syndromes including functional  and  physiological  restrictions,  [10]  but  in the latter study persisting symptoms correlated poorly with the severity of acute symptoms [11].

Peri-operative  risks  are  increased  in  patients  with persistent  symptoms  of COVID-19  compared with those who have been asymptomatic or those in whom symptoms have fully resolved at the time of surgery [31]. Pulmonary function  may  remain  disturbed for  several  months  after moderate or severe COVID-19, affecting up to a quarter of patients    at    3 months    [12],    resembling    long-term respiratory sequelae following SARS-CoV- 1 infection [32– 34].  Recent evidence suggests that  risks associated with operating on patients who still have symptoms following SARS-CoV-2   infection   decrease   in   a   time-dependent manner [35]. Compared with  patients who did  not  have previous SARS-CoV-2 infection, the odds ratio (95%CI) of 30-day mortality when operating at 0–2 weeks, 3–4 weeks, 5–6 weeks were 3.22 (2.55–4.07), 3.03 (2.03-4.52) and 2.78 (1.64–4.71),  respectively.  However,  at ≥ 7 weeks  after  a SARS-CoV-2 infection diagnosis, the risk of mortality was similar to those who had never had SARS-CoV-2 infection(1.02 (0.66– 1.56)). The timings of these mortality risks are also consistent in elective surgery, and when stratiied by patient demographics, complexity of surgery and urgency of surgery. A similar trajectory is also seen in postoperative pulmonary complications, with risks being greater for the irst 6 weeks after SARS-CoV-2 infection when compared with no  infection, but  returning  to  comparable rates beyond  7 weeks.  Similar  time-dependent  indings  have also been reported in smaller patient cohorts [36].

Notably, symptomatic patients are at greater risk of 30-day mortality than patients whose symptoms have resolved or those who have asymptomatic infection, even beyond a 7-week delay. Moreover, patients with resolved symptoms are also at greater risk of 30-day mortality than those who had asymptomatic infection [36,37]. Thus, both the previous and current clinical condition of patients appear to inluence postoperative outcomes.

Timing of surgery in patients who have been in critical care requires special consideration. In addition to residual pathophysiological sequelae, many will be deconditioned and require physical rehabilitation. Many will also have had dexamethasone 6 mg (equivalent to 40 mg prednisolone) for  10 days and/or anti-inlammatory monoclonal antibodies (e.g. tocilizumab or sarilumab) as part of their COVID- 19 treatment. These  patients are on the cusp of meeting the deinition of severe immunosuppression, and in  the  absence  of  explicit  national  guidance  warrant discussion with specialists, including immunologists, within the multidisciplinary team before planning surgery.

Some data suggest that  peri-operative outcomes of children   with   SARS-CoV-2    infection   are   favourable compared with adults [38], but there remains a dearth of evidence regarding timing of surgery after infection in this

group.  Detailed  consideration  of  timing  of  surgery  in children is outside the scope of this document.

疾病症状和严重程度

COVID-19[29]分期和临床严重程度[30]量表都是决定手术时机的重要因素，在表1和表2中总结。

值得注意的是，对于大多数患者来说，新冠病毒感染是一种短暂性或者无症状疾病，在短期内完全康复(图1)。约15%的感染患者需要住院，5%需要氧疗辅助呼吸，约1%的病例需要重症监护(图1)。在SARS-CoV-2感染后，近5%的患者在8周后仍有残留症状[Sudre等人，预印本，https://doi.org/10.1101/ 2020.10.19.  20214494]。在因COVID-19住院的患者中，这一比例更高。在一项对1655名中国住院患者进行6个月[10]随访和另一项对143名意大利患者进行9周[11]随访的队列研究中，分别有76%和87%的患者报告显示至少有一种持续性症状。在前一项研究中，更严重的COVID-19症状与COVID-19后综合征(包括功能和生理限制)的进展相关，但在后一项研究中，持续症状与急性症状的严重程度相关性较低。

与无症状或手术时症状完全缓解的患者相比，有持续COVID-19症状的患者围手术期风险增加[31]。在中度或重度COVID-19后，肺功能可能会持续紊乱数月，在3个月[12]时仍有多达四分之一的患者受到影响，这种表现类似于SARS-CoV-1感染后的长期呼吸道后遗症[32 - 34]。最近的证据表明，对SARS-CoV-2感染后仍有症状的患者进行手术，其手术风险的降低程度具有时间依赖性[35]。对比之前没有感染过SARS-CoV-2的患者，患者在感染后0 ~ 2周、3 ~ 4周、5 ~ 6周进行手术后30天死亡率的比值比(95%可信区间)分别为3.22(2.55 ~ 4.07)、3.03(2.03 ~ 4.52)、2.78(1.64 ~ 4.71)。然而，在SARS-CoV-2感染诊断后≥7周，死亡风险与从未感染过SARS-CoV-2的患者相似(1.02(0.66-1.56))。这些死亡风险的发生时间在择期手术中也是一致的，在按患者人口统计学、手术复杂性和手术紧急程度分层时也是一致的。术后肺部并发症也出现了类似的轨迹，与未感染相比，SARS-CoV-2感染后前6周的风险更大，但在7周后恢复到类似的风险。在较小的患者队列[36]中也报道了类似的时间依赖性结果。

值得注意的是，即使手术推迟到新冠病毒感染的7周后，有症状的患者比症状消失的患者或无症状感染的患者30天死亡的风险更大。此外，症状缓解的患者30天死亡风险也高于无症状感染的患者[36,37]。因此，患者既往和当前的临床状况似乎都影响术后结果。

一直处于重症监护的患者需要谨慎考虑手术时机。除了感染后残留的病理生理后遗症，许多患者的健康状态恶化，需要较长的身体康复时间。许多患者还将服用6毫克地塞米松(相当于40毫克泼尼松龙)10天和/或抗炎单克隆抗体(如托珠单抗或沙利鲁单抗)作为COVID-19治疗的一部分。这些患者即将达到定义上的严重免疫抑制，在缺乏明确的国内指南的情况下，在计划手术前，需要包括免疫学家在内的多学科团队内的专家进行讨论。

一些数据表明，与[38]成人相比，感染SARS-CoV-2的儿童围手术期预后良好，但关于该组感染后手术时机的证据仍然缺乏。关于儿童手术时机的详细考虑不在本文讨论范围之内。

Figure 1  Estimated population distribution of SARS-CoV-2 presentation. NIV, non-invasive ventilation; HFNO, high-low nasal oxygen.

图1 SARS-CoV-2表现的估计人群分布。NIV,无创通气;HFNO，高流量鼻导管吸氧。

Comorbid and functional status

The patient/s comorbid and functional status, both before SARS-CoV-2 infection and after it, should be considered in planning,  in the  same  manner  as for  any  interventional procedure.  Comorbidity   may   inluence  the  timing  of surgery   if   deferring  the   procedure   may   provide   an opportunity for improvement or resolution of post-COVID-19 pathophysiology; the additional time can be used for prehabilitation,    particularly    when    there    has    been deconditioning, or for rehabilitation of patients recovering from  a  critical  care  admission.   Further  discussion  of functional  assessment and  prehabilitation  is  beyond the remit of this document.

基础疾病和功能状态

在规划手术时，要考虑SARS-CoV-2感染前和感染后患者的基础疾病和功能状态，这和所有外科手术的常规流程一样。推迟手术可能能够改善或解决COVID-19 感染后患者的病理生理学后遗症。基础疾病可能会影响手术时机;推迟手术带来的额外的时间可用于患者的预适应，特别是在健康状况恶化的情况下，或者用于转出重症监护室的患者的康复。关于功能评估和预适应的进一步探索超出了本文讨论的范围。

Priority and complexity of surgery

To  support  the  organisation  and  delivery  of  surgical services during the COVID- 19 pandemic, prioritisation of surgical urgency for patients based on clinical conditions has   been   implemented   [6].  This   process   categorises surgical   procedures   into   priority   groups   based   on immediate and longer-term risks to patient health and well- being, including the risks of pain, adverse sequelae and disease progression, and a /recovery prioritisation matrix/ enables prioritisation of cases within each group [39]. This prioritisation  is  under  constant  review  and  subject  to change; the most recent version is presented in Box 1.

The complexity and the nature of surgery is a further consideration,  as  more  complex  surgery  is  consistently associated  with  increased  postoperative  morbidity  and mortality, including in patients with COVID- 19 [7]. Validated risk prediction tools account for complexity and urgency of surgery, and can be used to aid decision-making regarding timing of surgery after SARS-CoV-2 infection [41].

手术的优先级和复杂性

为了在COVID-19大流行期间支持医疗机构和提供手术服务，已根据临床情况对患者实施手术优先级排序[6]。这一过程根据对患者健康和幸福感的近期和长期风险，包括疼痛风险、不良后遗症和疾病进展的风险，将外科手术分类为优先组，并且“恢复优先排序矩阵”能够在每个组中对病例进行优先排序[39]。这种优先次序不断受到审查，并可能发生变化;最新的版本在第1栏中。

手术的复杂性和性质是进一步考虑的因素，因为更复杂的手术始终与术后发病率和死亡率增加有关，包括COVID-19[7]患者。经过验证的风险预测工具可考虑手术的复杂性和紧迫性，并可用于辅助SARS-CoV-2感染[41]后的手术时机的决策。

Anaesthetic technique

There  is  currently  no  strong  evidence  that  anaesthetic technique is associated with an alteration in postoperative outcome in patients who have had peri-operative SARS- CoV-2 infection [7]. In patients with persistent respiratory pathophysiological  changes  after  severe  COVID- 19,  the beneits of avoiding general anaesthesia are likely to be the same as in other respiratory disease. The use of local or  regional  anaesthetic  techniques  may  have  outcome and resource-utilisation beneits, but this is not speciic to patients with previous or current SARS-CoV-2 infection.

目前尚无强有力的证据表明麻醉技术与SARSCoV-2围手术期感染[7]患者术后结局的改变有关。在严重COVID-19后出现持续呼吸道病理生理变化的患者中，避免全身麻醉的好处可能与其他呼吸道疾病相同。局部或区域麻醉技术的使用可能有疗效和资源利用方面的益处，但这并不是既往或当前感染过SARS-CoV-2的患者所特有的。

Discussion

As the population of patients requiring surgery following SARS-CoV-2  infection grows, so will the  need to ensure safe peri-operative care for this cohort. The same general principles of safe and effective peri-operative care as for patients  with  no  history  of  SARS-CoV-2  infection  apply. However, timing of surgery must also be sensitive to the impact  of  SARS-CoV-2  on  both  patients  and  others.  In particular, the variable presentation and disease course of SARS-CoV-2      infection      means     that      personalised assessments are required, and rigid timelines unsuitable. This   is   often   complex,   and   must   account   for   the multifactorial implications  of  patient, surgery  and  SARS-CoV-2 status. Current data suggest that after SARS-CoV-2 infection,  the  majority  of  patients  who  have  had  no symptoms or whose symptoms have resolved should have surgery scheduled at least 7 weeks after diagnosis, unless clinical urgency and risk of disease progression outweigh the   risks   of   delayed   procedures.   For   patients   with persisting symptoms or who have more severe COVID-19, waiting    beyond    7 weeks    may    be    benificial    and personalised  multidisciplinary  peri-operative  care  plans are recommended. Peri-operative SARS-CoV-2 infection is associated   with   significantly   increased   morbidity   and mortality.  Current   measures  to   prevent   peri-operative SARS-CoV-2 infection,  before and during admission and after  discharge,  need  to  continue  while  this  remains  a significant    risk.    As    further    data    emerge,    these recommendations may need to be revised.

讨论

随着SARS-CoV-2感染后需要手术的患者人数的增加，确保该人群围手术期安全护理的需求也将增加。对于无SARS-CoV-2感染史的患者，同样适用安全有效的围手术期护理的一般原则。然而，手术时机也必须敏感地考虑SARS-CoV-2对患者和他人的影响。特别是，SARS-CoV-2感染的表现和病程不同，这意味着需要进行个体化评估而非套用病情进程表。评估通常很复杂，必须考虑到患者、手术和SARSCoV-2状态的多因素影响。目前的数据表明，在SARS-CoV-2感染后，大多数没有症状或症状已消退的患者应在诊断后至少7周安排手术，除非临床紧迫性和疾病进展的风险超过了延迟手术的风险。对于症状持续或COVID-19症状更严重的患者，等待7周以上可能是有益的，建议制定个性化的多学科围手术期护理计划。围手术期SARS-CoV-2感染与发病率和死亡率显著增加相关。目前用于预防围手术期SARS-CoV-2感染的措施（包括入院前、入院期间和出院后）需要继续实施，但这些流程仍存在重大风险。随着更多临床数据的出现，这些建议可能需要修改。

Acknowledgements

KE is an Editor for Anaesthesia. RM is the National Clinical Director for critical and peri-operative care, NHS England and  NHS  Improvement.  No  other  competing  interests declared.

致谢

KE是麻醉学杂志的编辑。RM是危重症和围手术期护理临床主任。英国国家医疗服务体系及其财政监管机构，没有其他竞争性利益。

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Supporting Information

Additional supporting information may be found online via the journal website.

Appendix S1. Severe immunosuppression as deined by Public Health England in regard to stepdown of infection control precautions in COVID- 19 patients.

Appendix   S2.   Methodology   and   results   of   the systematic review.