Postanesthesia complications in pediatric patients with previous SARS-CoV-2 infection: A cohort study

Postoperative cardiopulmonary complications in children with preoperative Omicron SARS-CoV-2 variants infection: a single-center retrospective cohort study

OBJECTIVE

The purpose of this study was to investigate: (1) the incidence of cardiopulmonary complications within 30 days after surgery in pediatric patients with preoperative Omicron variants infection, (2) the mortality, and (3) their possible risk factors.

METHODS

This retrospective study included a consecutive patient cohort who underwent elective non-cardiac surgery for any indication in the Pediatric Department of our hospital between November 2022 and February 2023. Cardiopulmonary complications and mortality within 30 days after surgery were compared between patients with pre-operative SARS-CoV-2 infection (Omicron variants infected group) and those without infection (the uninfected group) within 90-day before the surgery. The study evaluated the demographic data and related clinical factors of complications by analyzing their clinical records.

RESULTS

Our study included 502 patients, of which 194 (38.65%) had a pre-operative Omicron variants diagnosis. The mean duration between definite Omicron variants infection and surgery was 31.28 ± 10.19 days. In our study, the incidence of pulmonary complications was 1.59% (8/502 patients), no cardiac complication or mortality was found in the 30-day postoperative follow-up. The Omicron variants infected group had a significantly higher incidence of complications (7/194, 3.61%) compared to the uninfected group (1/308, 0.32%) (p = 0.006). After adjusted for other factors, it was found that the Omicron variants infection within 4 weeks before surgery (OR = 17.84, 95% CI: 1.25-255.35, p = 0.034), higher BMI (OR = 1.26, 95% CI: 1.02-1.55, p = 0.034), ASA physical status grade III-V (OR = 17.35, 95% CI: 1.19-253.80, p = 0.037), and abnormal preoperative chest radiograph (OR = 60.07, 95% CI: 1.92-1878.21, p = 0.020) were independent risk factors for postoperative pulmonary complications in patients within 30 days after the surgery.

CONCLUSIONS

Omicron infection may heighten the risk of pulmonary complications in children undergoing elective non-cardiac surgery. It is advisable to schedule elective surgery at least 4 weeks after infection of Omicron variants.

Retrospective Cohort Study of Perioperative Complications in Symptomatic and Asymptomatic Children Testing SARS-CoV-2-Positive Within 21 Days Before Surgery

INTRODUCTION

COVID-19 increases anesthetic risk in children, but understanding of complication differences by symptom presence and severity is limited. We hypothesized that symptomatic COVID-19+ children, especially with lower respiratory symptoms, would have higher perioperative complications than asymptomatic patients and that complications would be higher in all patients diagnosed < 6 days before anesthesia.

METHODS

This single-center, retrospective cohort study reviewed records of children < 18 years old undergoing surgery with general anesthesia from March 1, 2020, to March 1, 2022, who tested COVID-19+. A total of 225 patients who tested positive ≤ 10 days before anesthesia were analyzed for the primary outcome, and an additional 298 patients who tested positive ≤ 21 days before anesthesia were analyzed for secondary outcomes. Data on demographics, comorbidities, vaccination, preoperative and perioperative care, complications, and mortality were collected. Primary outcome analysis used univariate regression; secondary outcome analysis used analysis of variance.

RESULTS

Primary Outcome: Symptomatic patients were more likely to experience postoperative respiratory complications (OR: 3.53, 1.18-10.6, p = 0.024), require postoperative medications (OR: 7.64, 2.29-25.51, p = 0.001), and require postoperative oxygen support (OR: 2.62, 1.19-5.79, p = 0.017) versus asymptomatic patients. Those with upper respiratory symptoms were less likely to require postoperative medications (OR: 0.1, 0.01-0.89, p = 0.039) and oxygen support (OR: 0.08, 0.01-0.45, p = 0.004) versus those with lower respiratory symptoms.

SECONDARY OUTCOME

Patients testing COVID-19+ < 6 days before anesthesia had longer PACU stays (p < 0.001) and more postoperative respiratory complications (p = 0.001), medication use (p = 0.038), and oxygen use (p = 0.002) versus other groups.

DISCUSSION

Preoperative symptoms, especially of the lower respiratory tract, increased the risk for perioperative complications in children diagnosed with COVID-19 within 10 days of surgery.

CONCLUSION

The presence of symptoms, particularly of the lower respiratory tract, should be strongly considered in the shared decision-making process between providers and families when discussing the potential delay of procedures in the setting of COVID-19.

Multicentre analysis of severe perioperative adverse events in children undergoing surgery who were infected with SARS-CoV-2: a propensity score-adjusted analysis

BACKGROUND

The incidence of severe adverse events in children with SARS-CoV-2 undergoing anaesthesia has not been well established. We examined the relationship between SARS-CoV-2 infection and severe perioperative adverse events in children.

METHODS

This multicentre (21 North American institutions), retrospective cohort study included children <18 years old, with American Society of Anesthesiologists physical status (ASA PS) of 1-4 and non-severe SARS-CoV-2, who underwent general anaesthesia between April 1, 2020, and March 31, 2021. The primary outcome was the incidence of severe perioperative adverse events (admission to the intensive care unit for escalation of respiratory support, acute respiratory distress syndrome, postoperative pneumonia, cardiovascular arrest, extracorporeal life support, and death) within 7 days of the anaesthetic, assessed using multivariable analysis with inverse probability of treatment weighting by the propensity score. A propensity score mixed-effects model included variables selected a priori. Inverse probability of treatment weighting was used to retain all data while balancing exposure groups on measured confounders.

RESULTS

We matched 1138 patients with SARS-CoV-2 positive testing within 10 days of the anaesthetic to 3396 non-infected controls. The cohort included 56.6% (2568/4534) male patients, 69.9% (2839/4060) White patients, and 63.5% (2879/4533) ASA PS 1-2 patients. General surgery cases comprised 38.4% (1739/4534) of the cohort, followed by orthopaedic surgery at 12.6% (573/4534) and ear, nose, and throat surgery at 8.2% (371/4534). In the overall sample of 4534 patients, 52 had a severe adverse event (0.01%). Children with SARS-CoV-2 had a higher risk of at least one severe adverse event (25/1138 [2.20%] vs 27/3396 [0.80%] in those non-infected; adjusted odds ratio 2.34; 95% confidence interval 1.25-4.39). None of the children with SARS-CoV-2 had a cardiac arrest, required extracorporeal life support, or died.

CONCLUSIONS

In the largest cohort to date of paediatric patients undergoing general anaesthesia, SARS-CoV-2 infection was associated with severe perioperative adverse events, but no children in the infected cohort died.

Preoperative Risk Factors and Postoperative Complications of COVID-Positive Children Requiring Urgent or Emergent Surgical Care

BACKGROUND

Preoperative COVID-19 testing protocols were widely implemented for children requiring surgery, leading to increased resource consumption and many delayed or canceled operations or procedures. This study using multi-center data investigated the relationship between preoperative risk factors, COVID-positivity, and postoperative outcomes among children undergoing common urgent and emergent procedures.

METHODS

Children (<18 years) who underwent common urgent and emergent procedures were identified in the 2021 National Surgical Quality Improvement Program Pediatric database. The outcomes of COVID-positive and non-COVID-positive (negative or untested) children were compared using simple and multivariable regression models.

RESULTS

Among 40,628 children undergoing gastrointestinal surgery (appendectomy, cholecystectomy), long bone fracture fixation, cerebrospinal fluid shunt procedures, gonadal procedures (testicular detorsion, ovarian procedures), and pyloromyotomy, 576 (1.4%) were COVID-positive. COVID-positive children had higher American Society of Anesthesiologists scores (p ≤ 0.001) and more frequently had preoperative sepsis (p ≤ 0.016) compared to non-COVID-positive children; however, other preoperative risk factors, including comorbidities, were largely similar. COVID-positive children had a longer length of stay than non-COVID-positive children (median 1.0 [IQR 0.0-2.0] vs. 1.0 [IQR 0.0-1.0], p < 0.001). However, there were no associations between COVID-19 positivity and overall complications, pulmonary complications, infectious complications, or readmissions.

CONCLUSIONS

Despite increased preoperative risk factors, COVID-positive children did not have an increased risk of postoperative complications after common urgent and emergent procedures. However, length of stay was greater for COVID-positive children, likely due to delays in surgery related to COVID-19 protocols. These findings may be applicable to future preoperative testing and surgical timing guidelines related to respiratory viral illnesses in children.

LEVEL OF EVIDENCE

III.

Postoperative outcomes of pediatric patients with perioperative COVID-19 infection: a systematic review and meta-analysis of observational studies

OBJECTIVE

To quantify the risk of adverse postoperative outcomes in pediatric patients with COVID-19 infection.

METHODS

We searched PubMed, Embase, Cochrane Library from December 2019 to 21 April 2023. Observational cohort studies that reported postoperative early mortality and pulmonary complications of pediatric patients with confirmed COVID-19-positive compared with COVID-19-negative were eligible for inclusion. We excluded pediatric patients underwent organ transplantation or cardiac surgery. Reviews, case reports, letters, and editorials were also excluded. We used the Newcastle-Ottawa Scale to assess the methodological quality and risk of bias for each included study. The primary outcome was postoperative early mortality, defined as mortality within 30 days after surgery or during hospitalization. The random-effects model was performed to assess the pooled estimates, which were expressed as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI).

RESULTS

9 studies involving 23,031 pediatric patients were included, and all studies were rated as high quality. Compared with pediatric patients without COVID-19, pediatric patients with COVID-19 showed a significantly increased risk of postoperative pulmonary complications (PPCs) (RR = 4.24; 95% CI 2.08-8.64). No clear evidence was found for differences in postoperative early mortality (RR = 0.84; 95% CI 0.34-2.06), postoperative intensive care unit (ICU) admission (RR = 0.80; 95% CI 0.39-1.68), and length of hospital stay (MD = 0.35, 95% CI -1.81-2.51) between pediatric patients with and without COVID-19.

CONCLUSION

Perioperative COVID-19 infection was strongly associated with increased risk of PPCs, but it did not increase the risk of postoperative early mortality, the rate of postoperative ICU admission, and the length of hospital stay in pediatric patients. Our preplanned sensitivity analyses confirmed the robustness of our study findings.

Timing of general anesthesia for pediatric patients recovering from COVID-19: a prospective cohort study

OBJECTIVE

To explore the timing of general anesthesia for pediatric patients who have recovered from novel coronavirus infection and summarize anesthesia-related complications.

METHODS

We summarized the perioperative management of children under 14 years of age who underwent general anesthesia in our hospital according to national epidemic prevention and control requirements. We compared the incidence of postoperative pulmonary complications within 2 weeks (Group A), 3-4 weeks (Group B), and 5-6 weeks (Group C) after COVID-19 recovery.

RESULTS

There were differences among the three groups in terms of decreased blood oxygen saturation (< 94%), secretions, and coughing during the PACU period. The risk of low blood oxygen saturation during PACU decreased as the time of COVID-19 recovery extended in the three groups. Compared to Group A, the risk of low blood oxygen saturation was lower in Group B. The presence of respiratory symptoms and a body temperature above 40℃ increased the risk of decreased blood oxygen saturation. The proportion of children aged 11-14 years and children with high fever experiencing decreased blood oxygen saturation during PACU was higher in Groups A and B. Among the three groups, children with respiratory symptoms and longer illness duration had a higher proportion of decreased blood oxygen saturation during PACU.

CONCLUSION

Pediatric patients who have recovered from COVID-19 for more than 2 weeks have a lower risk of postoperative complications after general anesthesia. For children with respiratory system symptoms or high fever, there is a higher risk of transient blood oxygen saturation decrease during PACU. For older children, those with high fever, respiratory system symptoms, or longer illness duration, it is recommended to appropriately extend the time from COVID-19 recovery to surgery.

Anaesthesia in SARS-CoV-2 infected children - single-centre experience. A case-control study

INTRODUCTION

Although manifestation of SARS-CoV-2 infection in children is gene-rally mild or asymptomatic, anaesthetic implications of the infection in children are still a matter of concern. Single reports suggest that patients with SARS-CoV-2 infection are at higher risk of anaesthetic complications.

MATERIAL AND METHODS

We performed a retrospective, case control study analysing the risk of general anaesthesia in SARS-CoV-2 infected children admitted to a tertiary paediatric university hospital for the purpose of urgent procedures requiring anaesthesia  between April 1st and September 30 th , 2021. The control group consisted of  SARS-CoV-2 negative children consecutively anaesthetised for the same reasons during the first month of observation. Our hypothesis was: general anaesthesia can be safely performed in SARS-CoV-2 infected children. Study endpoints: primary - anaesthetic respiratory complications (bronchospasm, laryngospasm, intraoperative desaturation below 94%, desaturation below 94% after awakening, unplanned postoperative mechanical ventilation); secondary - hospital length of stay, thrombotic, cardiac, haemorrhagic events, ICU admission, deaths during hospitalisation.

RESULTS

The examined group consisted of 58 SARS-CoV-2 infected children, the matched control group of 198 patients. The rate of complications in both groups was very low, with no significant difference between the groups. The only differences observed were a higher frequency of desaturations in the awakening period and longer time of hospitalisation in SARS-CoV-2 infected patients. Multivariate logistic regression analysis showed that physical status of the patient and duration of the procedure were the main factors influencing the risk of complications.

CONCLUSIONS

In our experience anaesthesia of SARS-CoV-2 infected children can be safely performed.