Prevention, susceptibility, and clinical features of coronavirus disease 2019 in postoperative patients

Abstract

To the editor, The coronavirus disease 2019 (COVID-19) has rapidly spread worldwide and is now a global pandemic. Surgeries were curtailed in many hospitals during the pandemic, and the recommendation to delay all elective surgeries was issued in account of the increased mortality rate in peri-operative patients with COVID-19. 1 , 2 Before Tongji Hospital of Tongji Medical College, in Wuhan, China was designated to treat patients with COVID-19 and canceled all elective surgeries, few procedural measures were adopted to prevent the spread of SARS-CoV-2 infection form December 15, 2019, to February 15, 2020 in our center. We reviewed 37,783 inpatients with accessible medical documents. The incidence of COVID-19 was 0.028% (7/25,135 patients) among non-surgical patients and 0.158% (20/12,648 patients) among postoperative patients, with a relative risk of 5.685 (P < 0.001; 95% confidence interval, 2.403–13.449) when compared to the non-surgical inpatient counterparts. Anatomically, patients who underwent thoracic operation showed the highest incidence of the infection, with 9 out of 575 patients (1.56%) diagnosed with COVID-19 during the post-surgical periods. And we found a significant increase in neutrophils (P < 0.001), decreased lymphocytes (P < 0.001), and dramatically greater neutrophil to lymphocyte ratio (NLR) (P = 0.001) in the day one after surgery, which demonstrated an immunological change indicating a higher incidence of infection and poor outcomes for COVID-19 patients. And in our analysis, 40% (8/20) of post-surgical patients with COVID-19 developed severe pneumonia, in particular, 66.7% (6/9) of patients who had thoracic surgery progressed to severe pneumonia after COVID-19 diagnosis and three finally died from COVID-19. The laboratory results showed statistical differences in lymphocyte count, prothrombin time, D-dimer, and interleukin-2R between patients with severe pneumonia and mild pneumonia (Table 1 ). Table 1 Clinical characteristics of postoperative patients with COVID-19. Table 1 No. (%) P-valueb Total patients (n = 20)a Severe patients (n = 8) Mild patients (n = 12)a Symptom Fever 0.315 >39 °C 9 (52.9) 6 (75.0) 3 (33.3) ≤39 °C 7 (41.2) 2 (25.0) 5 (55.5) Cough 9 (52.9) 6 (75.0) 3 (33.3) 0.153 Chest distress 5 (29.4) 4 (50.0) 1 (11.1) 0.131 Dyspnea 5 (29.4) 5 (62.5) 0 0.009 Chest pain 2 (11.8) 1 (12.5) 1 (11.1) 1.000 Weak 5 (29.4) 5 (62.5) 0 0.009 Muscular soreness 4 (23.5) 4 (50.0) 0 0.029 Diarrhoea 2 (11.8) 1 (12.5) 1 (11.1) 1.000 Blood routine Neutrophils (×109/L) 6.48 ± 4.21 6.58 ± 5.09 6.39 ± 3.59 0.929 Lymphocytes (×109/L) 0.92 ± 0.34 0.72 ± 0.21 1.09 ± 0.35 0.021 Neutrophil to lymphocyte ratio 8.33 ± 7.90 10.32 ± 10.64 6.55 ± 4.25 0.342 Coagulation function Activated partial thromboplastin time (s) 42.16 ± 7.63 43.51 ± 7.33 40.81 ± 8.19 0.498 Prothrombin time (s) 13.68 ± 1.45 14.45 ± 1.25 12.90 ± 1.25 0.012 D-dimer (μg/L) 4.20 ± 3.93 6.40 ± 4.50 2.00 ± 1.37 0.019 Blood biochemistry Albumin (g/L) 34.89 ± 4.74 36.04 ± 4.34 33.59 ± 5.16 0.335 Alanine aminotransferase (U/L) 34.40 ± 31.86 44.25 ± 40.05 23.14 ± 14.84 0.199 Aspartate aminotransferase (U/L) 39.53 ± 46.34 53.50 ± 60.65 23.57 ± 12.71 0.093 Lactate dehydrogenase (U/L) 229.60 ± 135.44 262.63 ± 170.95 191.86 ± 74.75 0.083 Inflammation profile Procalcitonin (ng/mL) 0.09 ± 0.10 0.13 ± 0.12 0.07 ± 0.06 0.066 Erythrocyte sedimentation rate (mm/h) 45.27 ± 27.27 49.25 ± 30.50 40.71 ± 24.59 0.565 Serum ferritin (ug/L) 603.89 ± 610.10 875.78 ± 724.27 332.00 ± 341.92 0.140 C-reactive protein (mg/L) 63.74 ± 63.76 98.43 ± 75.55 36.76 ± 38.32 0.082 Cytokines Interleukin-1β (pg/mL) 0.462 Increased 2 (15.4) 2 (28.6) 0 Within normal range 11 (84.6) 5 (71.4) 6 (100.0) Interleukin-2R (U/mL) 781.46 ± 469.84 984.29 ± 557.02 544.83 ± 180.78 0.046 Increased 8 (61.5) 6 (85.7) 2 (33.3) Within normal range 5 (38.5) 1 (14.3) 4 (66.7) Interleukin-6 (pg/mL) 31.13 ± 34.78 46.92 ± 41.41 12.70 ± 9.38 0.073 Increased 10 (76.9) 6 (85.7) 4 (66.7) Within normal range 3 (23.1) 1 (14.3) 2 (33.3) Interleukin-8 (pg/mL) 17.85 ± 10.32 21.49 ± 12.11 12.76 ± 4.20 0.157 Increased 0 0 0 Within normal range 13 (100.0) 7 (100.0) 6 (100.0) Interleukin-10 (pg/mL) 0.070 Increased 4 (30.8) 4 (57.1) 0 Within normal range 9 (69.2) 3 (42.9) 6 (100.0) Tumor necrosis factor-α (pg/mL) 7.50 ± 2.22 7.91 ± 2.59 7.02 ± 1.80 0.491 Increased 5 (38.5) 3 (42.9) 2 (33.3) Within normal range 8 (61.5) 4 (57.1) 4 (66.7) Chest image Scope 0.073 Bilateral 10 (58.8) 7 (87.5) 3 (33.3) Unilateral 6 (35.3) 1 (12.5) 5 (55.5) Without signs 1 (5.88) 0 1 (11.1) Ground glass opacity 16 (94.1) 8 (100.0) 8 (88.8) 1.000 Consolidation 10 (58.8) 8 (100.0) 2 (22.2) 0.002 Pleural effusion 6 (35.3) 4 (50.0) 2 (22.2) 0.335 Clinical course, day From surgery to symptom 11.5 ± 11.8 9.1 ± 8.2 13.0 ± 13.8 0.670 From symptom to severe type 6.8 ± 4.9 Complication Acute Respiratory Distress Syndrome 2 (10.0) 2 (25.0) 0 0.147 Abnormal liver function 7 (35.0) 5 (62.5) 2 (16.7) 0.062 Septic 1 (5.0) 1 (12.5) 0 0.400 Others 0 0 0 Co-infection Other virus 5 (29.4) 0 5 (55.5) 0.026 Bacteria 2 (11.8) 1 (12.5) 1 (11.1) 1.000 Fungus 0 0 0 Others 2 (11.8) 1 (12.5) 1 (11.1) 1.000 Treatment Oxygen uptake 14 (70.0) 8 (100.0) 6 (50.0) 0.042 Mechanical ventilation 2 (10.0) 2 (25.0) 0 0.400 Antibiotic therapy 18 (90.0) 8 (100.0) 10 (83.3) 0.495 Antiviral therapy 18 (90.0) 8 (100.0) 10 (83.3) 0.495 Glucocorticoid 6 (30.0) 5 (62.5) 1 (8.3) 0.018 Outcome Destination 0.049 Recovery 17 (85.0) 5 (62.5) 12 (100.0) Died 3 (15.0) 3 (37.5) 0 Measurement data was presented as mean ± standard deviation. a Three mild patients were followed up in out-patient department and symptoms, lab tests and chest images of COVID-19 among these three patients were missing. b P values indicate differences between severe patients and mild patients. P < 0.05 was considered statistically significant. With the fallen curve in a district, it was not appropriate to postpone the elective surgeries indefinitely. Our center resumed elective surgeries from April 1st, 2020. Several managements strategies were adopted to protect surgical patients because of the susceptibility and vulnerability to SARS-CoV-2 infection (Fig. 1 ). These are as follows: 1. Ward transformation: The two zones and passages were arranged in general wards: two-zones include the clean area and the semi-contaminated area; two-passages include the passage for medical staff and the passage for patients. The semi-contaminated area acts as a transition to hold new inpatients and monitor the respiratory symptoms while under medical treatment and care for a period of observation (3–7 days). 2. Pre-admission screening: Radiological and microbiological tests were conducted among patients and their companions before administrated in the semi-contaminated area of the general ward. 3. Enclosed managements: Adopting enclosed managements further eliminated the infection and transmission in the hospital. 4. Post-operative monitoring: Monitor the symptoms and laboratory results after receiving surgery according to our previous experience, especially the decreasing lymphocyte count, prolonged prothrombin time, and higher D-dimer. Fig. 1 Prevention managements and the data comparison. The incidence of COVID-19 in surgical patients before and after taking prevention managements. Fig. 1 In conclusion, this study presents the clinical characteristics and severity of COVID-19 of perioperative case series. The learning experiences from managing these patients, some strategies adopted. And we provided practices to prevent COVID-19 among perioperative patients in hospital after resuming surgery. Declaration of competing interest The authors declare no conflict of interest.