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 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). 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

Recruitment of the Serratus Anterior as an Accessory Muscle of Ventilation During Graded Exercise

The role of the serratus anterior (SA) as an accessory muscle of ventilation and its physiologic significance under exercising conditions remains unclear. Recent investigations have utilized the measurement of SA as an analog for respiratory muscle oxygenation. The purpose of this investigation was to examine the action of the serratus anterior via surface electromyography (EMG) and near infrared spectroscopy (NIRS) during exercise while controlling for muscular effort not related to ventilation. Nine healthy volunteers (age = 24.4 ± 0.5 years, VO2max= 3.416 ± 0.35 l min−1; VEpeak = 127.5 ± 13.1 l min−1; TVpeak = 2.844 ± 0.226 l) completed a graded exercise test to volitional exhaustion on a cycle ergometer. The subjects’ arms were folded and relaxed at the abdomen to minimize muscular effort resulting from scapular stabilization during pushing/forward flexion of the arms associated with cycle ergometry. VO2 and VE were monitored breath-by-breath throughout exercise. EMG was recorded over the right SA, and a near infrared probe was placed over the left SA. No significant differences were observed throughout the graded exercise test for tissue oxygenation (StO2) (n = 6, F[1.532, 7.661] = 0.895, P \u3e 0.05, η2 = 0.15) or EMG (n = 9, F[1.594, 12.75] = 3.067, P \u3e 0.05, η2 = 0.27). Although the recruitment of the SA has been postulated to aid in ventilation in various postures and disease states, it is concluded that it shows little muscular effort in healthy subjects during upright cycling. Additional research is needed to conclude the pertinence of utilizing StO2 of the SA as an analog for respiratory muscle oxygenation