Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study
BACKGROUND:The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. METHODS:This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. FINDINGS:This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74Ã‚Â·0%) had emergency surgery and 280 (24Ã‚Â·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26Ã‚Â·1%) patients. 30-day mortality was 23Ã‚Â·8% (268 of 1128). Pulmonary complications occurred in 577 (51Ã‚Â·2%) of 1128 patients; 30-day mortality in these patients was 38Ã‚Â·0% (219 of 577), accounting for 81Ã‚Â·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1Ã‚Â·75 [95% CI 1Ã‚Â·28-2Ã‚Â·40], p<0Ã‚Â·0001), age 70 years or older versus younger than 70 years (2Ã‚Â·30 [1Ã‚Â·65-3Ã‚Â·22], p<0Ã‚Â·0001), American Society of Anesthesiologists grades 3-5 versus grades 1-2 (2Ã‚Â·35 [1Ã‚Â·57-3Ã‚Â·53], p<0Ã‚Â·0001), malignant versus benign or obstetric diagnosis (1Ã‚Â·55 [1Ã‚Â·01-2Ã‚Â·39], p=0Ã‚Â·046), emergency versus elective surgery (1Ã‚Â·67 [1Ã‚Â·06-2Ã‚Â·63], p=0Ã‚Â·026), and major versus minor surgery (1Ã‚Â·52 [1Ã‚Â·01-2Ã‚Â·31], p=0Ã‚Â·047). INTERPRETATION:Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. FUNDING:National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.
Population Coverage of Trauma Systems: What Do Helicopters Add?
Trauma is a time-critical condition. Helicopters are thought to enhance the accessibility to trauma centers, but this benefit is poorly quantified. The aim of this study was to conduct a geographical analysis of the added benefit provided by helicopters, over ground transport. This study uses geospatial analysis. Helicopter bases and Level I and II designated trauma centers were geocoded. 60-minute drive-time and elliptical flight-time isochrones were mapped with ArcGISâ„¢ (Esri, Redlands, CA). Calculations included allowance for mission ground time (MGT). We compared the proportion of the population that could be taken to Level I and II trauma centers, within 60 minutes, by road and by air. Using a 30-minute MGT model, helicopters permit 279,317 additional residents (5.8%) access to a Level I trauma center within 60 minutes. Using the 20-minute MGT model, 1,089,177 more residents (22.8%) would have access to Level I trauma center care. The benefits were marginally greater for access to Level I and II trauma center care. Helicopters enhance access to specialist trauma center care, but the benefit is small and dependent on MGT. Consideration should be given to the siting of helicopters, particularly in relation to trauma patients, MGT, and the timely response of EMS when determining the triage for helicopter transport.