Factors Associated With Surgical Mortality and Complications Among Patients With and Without Coronavirus Disease 2019 (COVID-19) in Italy
Factors Associated With Surgical Mortality and Complications Among Patients With and Without Coronavirus Disease 2019 (COVID-19) in Italy
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DOI：
10.1001/jamasurg.2020.2713
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发表时间：
2020-08-01
期刊：
影响因子：
16.9
通讯作者：
Fontanella, Marco Maria
中科院分区：
文献类型：
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作者：
Doglietto, Francesco;Vezzoli, Marika;Fontanella, Marco Maria
问题 2019 年冠状病毒病 (COVID-19) 与早期手术死亡率和并发症相关吗？结果 在这项队列研究中，41 名患有 COVID-19 的手术患者和 82 名紧密匹配的未患 COVID-19 的对照患者进行了队列研究，结果显示早期死亡率和并发症发生率存在显着差异，肺炎和血栓并发症与 COVID-19 显着相关，并且不同的模型将 COVID-19 确定为与手术并发症相关的第一个变量。意味着只要有可能，COVID-19 患者的手术就应该推迟，因为它是一个比传统手术风险因素更重要的额外手术风险因素。这项队列研究比较了意大利不同亚专科中患有和不患有 COVID-19 的患者的早期手术结果。重要性 关于接受手术的 2019 年冠状病毒病 (COVID-19) 患者的死亡率和并发症率的数据有限。目的评价不同亚专科COVID-19患者的早期手术结局。设计、设置和参与者 这项匹配队列研究在 Spedali Civili 医院（意大利布雷西亚）的普通科、血管和胸外科、骨科和神经外科科室进行，纳入的患者在 2020 年 2 月 23 日至 4 月 1 日接受手术治疗，并且在术前或术后 1 周内 COVID-19 检测结果呈阳性。妇科和小型外科手术被排除在外。将患有 COVID-19 的患者与未患 COVID-19 的患者进行匹配，性别、年龄组、美国麻醉医师协会评分以及美国外科医生学会国家手术质量改进计划的手术风险计算器中记录的合并症的比例为 1:2。 65 岁以上的患者也匹配了临床衰弱量表评分。暴露 COVID-19 呈阳性且接受手术的患者与未感染的匹配手术患者相比。通过鼻咽拭子、胸部放射线摄影和/或计算机断层扫描中的逆转录酶-聚合酶链反应测定来进行 COVID-19 筛查。 COVID-19 的诊断基于其中至少一项调查的阳性结果。主要结局和措施 主要终点是 COVID-19 患者的早期手术死亡率和并发症；次要终点是并发症模型，以确定与其他手术危险因素相比，COVID-19 的重要性。结果 41 例（同期接受手术的 333 例）主要接受紧急手术的患者中，33 例（80.5%）术前 COVID-19 检测结果呈阳性，8 例（19.5%）在术后 5 天内检测结果呈阳性。在合并队列的 123 名患者中（78 名女性 [63.4%]；平均 [SD] 年龄，76.6 [14.4] 岁），与未患 COVID-19 的对照患者相比，患有 COVID-19 的患者的 30 天死亡率显着较高（比值比 [OR]，9.5；95% CI，1.77-96.53）。并发症也明显较高（OR，4.98；95% CI，1.81-16.07）；肺部并发症是最常见的（OR，35.62；95% CI，9.34-205.55），但血栓并发症也与 COVID-19 显着相关（OR，13.2；95% CI，1.48-无穷大）。不同的模型（累积链接模型和分类树）将 COVID-19 确定为与并发症相关的主要变量。结论和相关性 在这项匹配队列研究中，与未患 COVID-19 的患者相比，患有 COVID-19 的患者的手术死亡率和并发症更高。这些数据表明，只要有可能，就应推迟 COVID-19 患者的手术。
Question Is coronavirus disease 2019 (COVID-19) associated with early surgical mortality and complications? Findings In this cohort study of 41 surgical patients with COVID-19 and 82 tightly matched control patients without COVID-19, significant differences were documented regarding rates of early mortality and complications, pneumonia and thrombotic complications were significantly associated with COVID-19, and different models identified COVID-19 as the first variable associated with surgical complications. Meaning Whenever possible, surgery should be postponed in patients with COVID-19 because it is an additional surgical risk factor that overweighs traditional ones.This cohort study compares early surgical outcomes of patients in Italy with and without COVID-19 in different subspecialties.Importance There are limited data on mortality and complications rates in patients with coronavirus disease 2019 (COVID-19) who undergo surgery. Objective To evaluate early surgical outcomes of patients with COVID-19 in different subspecialties. Design, Setting, and Participants This matched cohort study conducted in the general, vascular and thoracic surgery, orthopedic, and neurosurgery units of Spedali Civili Hospital (Brescia, Italy) included patients who underwent surgical treatment from February 23 to April 1, 2020, and had positive test results for COVID-19 either before or within 1 week after surgery. Gynecological and minor surgical procedures were excluded. Patients with COVID-19 were matched with patients without COVID-19 with a 1:2 ratio for sex, age group, American Society of Anesthesiologists score, and comorbidities recorded in the surgical risk calculator of the American College of Surgeons National Surgical Quality Improvement Program. Patients older than 65 years were also matched for the Clinical Frailty Scale score. Exposures Patients with positive results for COVID-19 and undergoing surgery vs matched surgical patients without infection. Screening for COVID-19 was performed with reverse transcriptase-polymerase chain reaction assay in nasopharyngeal swabs, chest radiography, and/or computed tomography. Diagnosis of COVID-19 was based on positivity of at least 1 of these investigations. Main Outcomes and Measures The primary end point was early surgical mortality and complications in patients with COVID-19; secondary end points were the modeling of complications to determine the importance of COVID-19 compared with other surgical risk factors. Results Of 41 patients (of 333 who underwent operation during the same period) who underwent mainly urgent surgery, 33 (80.5%) had positive results for COVID-19 preoperatively and 8 (19.5%) had positive results within 5 days from surgery. Of the 123 patients of the combined cohorts (78 women [63.4%]; mean [SD] age, 76.6 [14.4] years), 30-day mortality was significantly higher for those with COVID-19 compared with control patients without COVID-19 (odds ratio [OR], 9.5; 95% CI, 1.77-96.53). Complications were also significantly higher (OR, 4.98; 95% CI, 1.81-16.07); pulmonary complications were the most common (OR, 35.62; 95% CI, 9.34-205.55), but thrombotic complications were also significantly associated with COVID-19 (OR, 13.2; 95% CI, 1.48-infinity). Different models (cumulative link model and classification tree) identified COVID-19 as the main variable associated with complications. Conclusions and Relevance In this matched cohort study, surgical mortality and complications were higher in patients with COVID-19 compared with patients without COVID-19. These data suggest that, whenever possible, surgery should be postponed in patients with COVID-19.