Postoperative Evolution of Asymptomatic Covid-19 Patients Not Recognized Preoperatively: A Case Report of 12 Patients

Case Series

Ann Surg Perioper Care. 2024 ; 9(1) : 1064.

Postoperative Evolution of Asymptomatic Covid-19 Patients Not Recognized Preoperatively: A Case Report of 12 Patients

Benakrout A¹*; Doghmi N¹; Jaafari A¹; Bensghir N¹; Balkhi H¹; Abouelalaa K²

¹Department of Anesthesiology and Intensive Care, Military Hospital Mohammed V, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco

²Department of Anesthesiology And Intensive Care, Head of The Operating Theatre Department of The Mohamed 5 Military Training Hospital, Faculty of Medicine And Pharmacy of Rabat, Mohammed V University, Rabat, Morocco

*Corresponding author: Aziz Benakrout Department of Anesthesiology and Intensive Care, Military Hospital Mohammed V, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco. Email: azizbenakrout@gmail.com

Received: December 12, 2023 Accepted: January 17, 2024 Published: January 22, 2024

Abstract

Background: In order to ensure better management of patients with coronavirus disease 2019 and to reduce disease transmission, all scheduled surgeries were postponed. However, with the flattening of the epidemiological curve, surgical activity was gradually resumed which was responsible for increasing the rate of postoperative complications and mortality for undiagnosed asymptomatic patients operated on during the incubation period. The aim of our study was to evaluate the postoperative evolution of asymptomatic undiagnosed patients who developed COVID-19 after scheduled surgery.

Materials and Methods: This is a retrospective monocentric observational study of 12 initially asymptomatic patients who were operated on during their COVID-19 incubation period in the operating theatres of Mohamed V military training hospital of rabat during the period from April 1 to September 30, 2020.

Results: 4638 patients were operated on. Only 12 patients developed COVID-19 infection after confirmation by a reverse transcriptase Polymerase Chain Reaction test postoperatively. The most common symptom was fever (91.6%). The postoperative course was marked by the development of several complications such as secondary superinfection (66.6%), acute respiratory distress syndrome (58.3%), and shock (50%). Seven of the 12 (58.3%) patients were admitted to intensive care and 5/12 (41.6%) required invasive ventilation and subsequently died. Acute respiratory distress syndrome was the main complication in all patients who died.

Conclusion: Many challenges are encountered when performing surgical activity during the pandemic period. Nevertheless, knowledge of the patient’s COVID-19 status prior to any surgical procedure should be considered in order to reduce and control the risk of postoperative morbidity and mortality.

Keywords: COVID-19; Asymptomatic; Postoperative; Surgery

Abbreviations: COVID-19: Coronavirus Disease 2019; MVMTH: Mohamed V Military Training Hospital; RT-PCR: Reverse Transcriptase Polymerase Chain Reaction; ARDS: Acute Respiratory Distress Syndrome; SARS-CoV-2: Severe Acute Respiratory Syndrome Coronavirus 2; ICU: Intensive Care Unit; VHA: Veterans Health Administration

Introduction

As part of the management of the health problems caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and to better manage patients with coronavirus disease 2019 (COVID-19), the majority of elective surgeries were postponed to restrict access to the operating theatre and a specific COVID-19 care pathway was generated, divided into medical wards and the emergency ward for possible emergency surgery; This has consequently affected surgical activity worldwide and led to blockages in the management of other health problems. Nevertheless, as the epidemiological curve flattened, surgeons and anesthetists began to gradually resume scheduled surgeries on a case-by-case basis for non-COVID-19 related conditions in or der not to further delay surgery, especially carcinological surgeries, which posed new challenges for patients on the one hand and health care staff on the other and resulted in unexpected postoperative complications. Patients with COVID-19 may be asymptomatic carriers or they may develop symptoms ranging from mild to respiratory failure and multivisceral failure. [1,2]

Asymptomatic carriers account for 17.9-33.3% of those infected with SARS-CoV-2 [3] and have a longer and variable incubation period between individuals of up to 19 days, resulting in more rapid and uncontrollable transmission of the virus [1,4] and more difficult identification of the disease.

Few reports have been published on the post-operative outcome of patients diagnosed as COVID-19 positive and even fewer on the post-operative outcome of patients with asymptomatic, pre-operatively undiagnosed virus. The impact of unintentionally scheduled surgery during the incubation phase of asymptomatic preoperative patients on the postoperative course has not been sufficiently studied, but these existing data should not be overlooked as a means of reducing morbidity and mortality. Indeed, surgery leads to an immediate alteration of the cell-mediated immunity which represents the main mechanism of the fight against viral infections, which explains the unfavourable evolution of the patients in question [5].

However, recent data suggest an increase in perioperative respiratory complications and a perioperative mortality rate of 19% in people with concurrent COVID-19 infection undergoing scheduled or urgent surgery [6].

Objectives

To assess the postoperative course of asymptomatic patients who underwent scheduled surgeries and were ultimately found to be infected with COVID-19 but not diagnosed preoperatively. To highlight through a review of the literature the question of whether all asymptomatic surgical candidates of COVID-19 status should be tested preoperatively and the new surgical recommendations.

Materials and Methods

We conducted a retrospective monocentric observational study of patients scheduled for surgery or who underwent urgent surgery in the operating rooms of the Mohamed V Military Training Hospital (MVMTH) of Rabat between April 1 and September 30, 2020. The start date of the study corresponds to the date of resumption of surgical activity in most hospitals after the suspension of this activity due to the COVID-19 pandemic. Since the resumption of surgical activity and following the hospital protocols and recommendations of the Ministry of Health and learned societies Moroccan Society of Anesthesia, Analgesia and Resuscitation and Moroccan Society of Emergency Medicine in Morocco, in particular, did not include mandatory screening for COVID-19 in asymptomatic patients considered to be at low risk when screening before scheduled surgery. We retrospectively analyzed the clinical data of 12 asymptomatic patients who developed symptoms after surgery and were diagnosed as COVID-19 positive after laboratory confirmation of SARS-CoV-2 by RT-PCR testing of nasopharyngeal specimens; these patients had undergone scheduled and urgent surgeries during the incubation period of COVID-19.

Study Site: The Operating Theatre Department of MVMTH Rabat - Services and Intensive Care Unit (ICU) COVID-19.

We retrospectively analysed the clinical data of patients who underwent elective surgery during the incubation period of COVID-19 MVMTH in Rabat during the study period. We examined epidemiological, clinical, biological, and radiological characteristics as well as treatment and outcome data. The information included demographics, contact with a suspected or confirmed COVID-19 subject that was discovered postoperatively, comorbidities, type of surgery, surgical time, signs and symptoms, time of surgery until first symptoms of COVID-19 onset, admission to intensive care and resuscitation if any, treatments and complications. All missing or uncertain records were eliminated.

Definitions: The time of onset of COVID-19 was defined as the date when the first sign or symptom was detected. Acute Respiratory Distress Syndrome (ARDS) was defined according to the Berlin definition [13]. Patients were admitted and transferred to the ICU based on the progression of organ failure or the need for mechanical ventilation.

Overall Results

Number of patients operated on

During the study period, we recorded 4638 patients operated on. These were scheduled and emergency surgeries performed in the four operating theatres of the Mohammed V Military Training Hospital in Rabat (Table 1).