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ORIGINAL ARTICLE
Year : 2023 | Volume
: 9
| Issue : 1 | Page : 41-45
Coronavirus disease 2019, a popup differential to the postoperative inflammatory state and its impact on outcomes after cardiac surgery – A single-center experience
KS Ram Kiran, Visharad Trivedi, Rajesh S P. Venuthurupalli, Deepika Gehlot, Sunil Ninama
Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Ahmedabad, Gujarat, India
Correspondence Address:
Visharad Trivedi
Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Centre, Civil Hospital Campus, Asarva, Ahmedabad - 380 016, Gujarat
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jpcs.jpcs_47_22
Introduction: Coronavirus disease 2019 (COVID-19) affected care among surgical patients. Considering the underlying comorbidities, physical status, and intricate perioperative course, the cardiac surgery patient represents a vulnerable cohort. This study describes baseline characteristics, laboratory findings, diagnosis, postoperative course, and their correlation with immediate outcomes in patients undergoing cardiac surgery. Methodology: Patients who underwent cardiac surgery at our institute for 1 year were screened for COVID-19 with the reverse transcription-polymerase chain reaction swab test and then were posted for surgery only after corroborating negative reports, except for emergency cases. Dedicated preoperative areas and COVID-appropriate measures were taken. Data from the electronic patient records of those diagnosed with COVID-19 in the immediate postoperative period were reviewed retrospectively. Continuous normal distributed variables are presented as mean ± standard deviation, alternatively as median ± interquartile range, and categorical variables as percentages. Results: A total of 22 patients were infected in the immediate postoperative period in spite of appropriate screening and had a high mortality of 36.36% (vs. non-COVID 6.27%, P < 0.001). Days from index surgery to diagnosis were 6 (±3.75). The median stay in the intensive care unit and hospital stay was 6 (±2.75) and 10 (±3.2) days, respectively. The moderate and high-risk categories of the European System for Cardiac Operative Risk Evaluation II showed mortality of 33.3% (vs. 2.69% in non-COVID, odds ratio of 18.42) and 71.4% (vs. 11.2% in non-COVID, odds ratio of 19.65). Patients with C-reactive protein >100 mg/lit, D dimer >1000 ng/ml, and neutrophil/lymphocyte ratio >3.5 showed very high mortality. Noninvasive and invasive ventilation in 27.27% and 31.8%, respectively. Two patients acquired acute kidney injury that required hemodialysis. Conclusions: Despite requisite measures, COVID infection still remains a momentous differential to postoperative complications affecting early outcomes. Therefore, more robust preoperative protocols, better strategies for the COVID-free environment, and early clinical suspicion and workup are required to mitigate its effect on this cohort.
Keywords: Coronavirus disease 2019, inflammatory markers, SARS-Co-2
The pandemic infection caused by coronavirus disease 2019 (COVID-19) has dramatically affected patient care among those undergoing surgery.[1] Despite resource constraints and the possible increased risk of perioperative complications, some patients with COVID-19 infections will require urgent or emergent surgical interventions.
Given that severe infections related to COVID-19 result in pneumonia and acute respiratory distress syndrome, surgical patients who typically require mechanical ventilation and those who have underlying comorbidities can be at particular risk for increased morbidity and mortality.[2] Furthermore, the outcome of patients undergoing thoracic and major abdominal surgery was known to be poor.[3],[4] Considering underlying comorbidities, physical status, and intricate perioperative course,[5] cardiac surgery patients represent a vulnerable patient population, and this cohort may experience worse outcomes with SARS-CoV-2 infection. However, there are limited data available on the effect of COVID-19 diagnosed in immediate postoperative in patients undergoing cardiac surgery.
The article aims to describe the baseline characteristics, postoperative course, laboratory findings, and immediate outcomes of patients undergoing cardiac surgeries over 1 year, who have COVID-19 diagnosed in the early postoperative period.
MethodologyOur study was an observational study that included patients who underwent elective or urgent cardiac surgery at a tertiary care cardiac institute for 1 year. The study protocol was reviewed and approved by our internal review board, and the requirement of consent from the patients was renounced. All patients were screened for COVID-19 with reverse transcription-polymerase chain reaction (RT-PCR) swab test and were then posted for surgery only after corroborating negative report, except for emergency cases where surgery was commenced without waiting for the test report. All health-care professionals who were in contact with the patient during the preoperative period followed prompt measures to avoid transmission (appropriate hand hygiene and personal protective equipment [PPE]). Frequent inhospital visits by relatives were forbidden to all patients. Dedicated preoperative workup areas were used to isolate them on the basis of their COVID-19 test results.
Patients diagnosed with COVID-19 infection in the immediate postoperative period through positive throat swab taken due to clinical suspicion were reviewed and presented. All positive patients were transferred to the dedicated cardiac intensive care unit (ICU) or wards within our hospital (supervised by cardiac anesthetists of the same department), further evaluation and management were based on institution protocol and the condition of the patients. Data from the electronic patient records were collected, reviewed retrospectively, and presented. Preoperative data included demographic data, comorbidities, the European System for Cardiac Operative Risk Evaluation (EUROSCORE) II,[6] echocardiographic parameters, and any positive history in preoperative assessment charts. Intraoperative data included were the type of surgery, cardiopulmonary bypass (CPB) time, and any adverse surgical complications. Postoperative data were time from index surgery to diagnosis of COVID-19, presentation at the time of diagnosis, inflammatory markers on diagnosis (neutrophil/lymphocyte [N/L] ratio, C-reactive protein (CRP) and D dimer levels, need for noninvasive and invasive ventilation, acute kidney injury (AKI) requiring hemodialysis, length of COVID ICU, and hospital stay and mortality.
The continuous normal distributed variables are presented as mean (standard deviation) or median (interquartile range) for the continuous variables and groups are compared using the Mann–Whitney U test. The categorical data are presented as n (%) and compared using the Chi-squared or Fisher's exact tests. For laboratory results, we also assessed whether measurements were outside the normal range. All statistical analyses were performed using the SPSS software Version 20.0. (IBM Corp., Armonk, NY). A two-tailed value of P < 0.05 was considered statistically significant.
ResultsDuring the study period of 1 year, a total of 1284 adult cardiac surgical procedures were performed. Of these, 22 patients were diagnosed with COVID-19 in the immediate postoperative period despite adequate screening in the preoperative period. Among them, all underwent urgent or elective basis.
The baseline characteristics of the COVID-19 patients, EUROSCORE II, and the type of surgery they underwent are described in [Table 1]. Time from index surgery to diagnosis varied in the postoperative period (from day 1 to 17) with the median of 6 (±3.75) days. The diagnosis on day 1 was for the patient who had Bentall surgery, where surgery was started without waiting for the test report. None of them had surgery-related complications and only one patient required reexploration for bleeding. Two patients required readmission. The patient had different presentations at the time of diagnosis, as mentioned in [Figure 1].
Table 1: Baseline characteristics, European System for Cardiac Operative Risk Evaluation II and surgical procedures of COVID-19-positive patients
Figure 1: Presentation at the time of diagnosis of COVID-19. COVID-19: Coronavirus disease 2019Mortality was observed in 8 (36.36%) patients, who were diagnosed with COVID-19 in the immediate postoperative period. It was significantly high (P < 0.001) when compared to 6.27% mortality in COVID-19-negative patients. Mortality was correlated with the EUROSCORE II classification, where patients with moderate risk (score 2–5) and high-risk category (score >5) of EUROSCORE II had mortality of 33.33% (vs. 2.69% in non-COVID-19) with odd's ratio of 18.42 (P < 0.001), and 71.4% (vs. 11.2% in non-COVID-19) with odd's ratio of 19.65 (P = 0.005), respectively. Detailed variables in patients with mortality are described in [Table 2].
Inflammatory markers such as the N/L ratio, CRP, and Dimer D performed at the time of diagnosis of COVID-19 were noted, categorized, and were then correlated with mortality, as shown in [Figure 2] and [Figure 3]. It was observed that mortality directly correlated with the level of markers (mortality with CRP >100 mg/l was 2.8 times more, with D dimer >1000 ng/dl was 3.3 times more and with N/L ratio of >3.5 was 1.6 times higher than values below).
Figure 2: Inflammatory markers at time of diagnosis of COVID-19. COVID-19: Coronavirus disease 2019The duration of stay in the ICU and the stay in the ward of COVID were 6 (±2.75) and 10 (±3.2) days, respectively. Other requirements after the diagnosis of COVID-19 are described in Figure. A total of 13 (59.09%) patients developed acute lung injury that required ventilation (invasive ventilation - 31.8% and noninvasive - 27.27%). Two (9.1%) patients developed AKI that required hemodialysis.
DiscussionIn spite of meticulous screening protocol in our institute, we found that 22 patients were acquired COVID-19 in the postoperative period. They could have contracted the virus during preoperative workup either before admission or while in hospital. Days from index surgery to diagnosis of COVID-19 also varied. The sensitivity of the RT-PCR test, the asymptomatic incubation period, and the wide variety of presentation at the time of diagnosis could be the factors preventing the early detection of this disease.[7] Above that, a few symptoms of COVID-19 and those of cardiac disease could be analogous, leading to missing out on early diagnosis.
In our study, we observed a very high mortality of 36.36% (vs. 6.27% in patients without COVID-19). It was similar to that observed in various other studies, where perioperative mortality was as high as 52%.[8],[9] Such high mortality in our cohort can be attributed to associated comorbid conditions, poor physical status, complexity of surgery, use of CPB, and prolonged postoperative course compared to other general surgeries. This was quite evident in our study as the grade of EUROSCORE was directly correlating to mortality. The moderate risk score and high-risk score groups had a mortality of 33.3% (odds ratio of 18.42) and 71.4% (odds ratio of 19.65), respectively.
Cardiac arrest, sepsis/shock, respiratory failure, pneumonia, acute respiratory distress syndrome, and AKI were more common in those with COVID-19, which perplexed postoperative outcomes in terms of mortality and prolonged hospital stay.[5],[10] In our study, we also had similar observation with prolonged stay in the ICU and hospital stay of 6 (±2.75) and 10 (±3) days, respectively, which was an additional burden stating that the activation of COVID-19 could complicate and prolong postoperative course. A total of 59.09% of the patients required ventilatory support and 9% acquired AKI that required hemodialysis. Similar findings were observed by Hoste et al. and Marin and Gattinoni. in their study.[5],[11] Myocardial damage from infection, combined with the physiological and inflammatory stresses associated with surgery, need for mechanical ventilation, and ischemia reperfusion, all of which could contribute to accelerated multiorgan dysfunction in these patients.
The increase in inflammatory markers (N/L ratio, CRP, and D dimer) could be confounding in our cohort. Cardiac disease, surgical stress, and the use of CPB could also contribute to the inflammatory state in the immediate postoperative period.[12],[13] However, we observed that most of them had exorbitant marker levels at the time of diagnosis. Therefore, we classified them according to the severity levels and then observed their correlation with mortality. Hence, our findings were similar to the observations of Ullah et al., where high marker levels at diagnosis were correlated with the outcomes in terms of mortality.[14] This could be explained by the fact that complexity of cardiac surgery may accelerate the progression of COVID-19 through an altered immune response.
Limitations
We included a single RT-PCR swab test for screening, which due to its false negativity may be a reason for missing out on asymptomatic patients during the incubation period. Since our data included patients over 1 year, protocols and management plans were for the initial set could be different compared to the latter part where experience and better management protocols evolved. We included a single value of inflammatory markers at diagnosis and their correlation with mortality. Correlating a trend of inflammatory markers with outcomes could provide better validation. Ours is a single-center experience over 1 year; a large database from multiple centers can give a better idea about the burden of this pandemic on cardiac surgical outcomes.
ConclusionsDespite requisite preoperative measures, COVID-19 still remained a momentous differential to postoperative complications significantly affecting early outcomes. Considering ongoing course of the pandemic more robust presurgery protocols, better strategies to maintain COVID-19-free environment, early clinical suspicion, and workup are required mitigate its effect on this cohort.
Current implementations: we began to implement better strategies to prevent COVID-19 in the perioperative period. We now perform a rapid antigen test along with the RT-PCR test all patients admitted to our preoperative centers, dedicated preoperative hubs based on the stage of testing and test results, more active screening in the preoperative period (CRP and D dimer levels as part of the surgical profile), strict PPE by medical and paramedics staff in contact, early suspicion, and workup in the postoperative period.
Ethics clearance
This is a observational study and reviewed by the Internal Ethics Committee and waived off the ethical clearance.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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