Immuno-Thrombotic Complications of COVID-19: Implications for Timing of Surgery and Anticoagulation

Frontiers in Surgery

article

Laura Gillespie¹  Rashid Z. Khan²  Christiaan N. Mamczak³  Robert March⁵  Rachel Macias³  Brian S. Bull⁷  Mark M. Walsh³  Connor M. Bunch⁹  Ernest E. Moore^1,10  Hunter B. Moore^1,10  Matthew D. Neal^1,11  Anthony V. Thomas³  Nuha Zackariya³  Jonathan Zhao⁸  Sufyan Zackariya⁸  Toby J. Brenner⁸  Margaret Berquist⁸  Hallie Buckner⁸  Grant Wiarda⁸  Daniel Fulkerson³  Wei Huff³  Hau C. Kwaan^1,13  Genevieve Lankowicz⁸  Gert J. Laubscher^1,14  Petrus J. Lourens^1,14  Etheresia Pretorius^1,15  Maritha J. Kotze^1,17  Muhammad S. Moolla^1,18  Sithembiso Sithole^1,18  Tongai G. Maponga^1,19  Douglas B. Kell^1,15  Mark D. Fox³ 

[1] Department of Quality Assurance and Performance Improvement, Saint Joseph Regional Medical Center;Department of Hematology;Indiana University School of Medicine South Bend Campus;Department of Orthopaedic Trauma, Memorial Hospital South Bend;Department of Cardiothoracic Surgery, St. Joseph Regional Medical Center;Department of Plastic and Reconstructive Surgery, St. Joseph Regional Medical Center;Department of Pathology and Human Anatomy, Loma Linda University School of Medicine;Department of Internal Medicine, Saint Joseph Regional Medical Center;Department of Emergency Medicine, Henry Ford Hospital;Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health;Pittsburgh Trauma Research Center, University of Pittsburgh Medical Center;Department of Neurosurgery, Saint Joseph Regional Medical Center;Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine;Mediclinic Stellenbosch;Department of Physiological Sciences, Stellenbosch University;Department of Biochemistry and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool;Division of Chemical Pathology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University and National Health Laboratory Service, Tygerberg Hospital;Division of General Medicine, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital;Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University;The Novo Nordisk Foundation Centre for Biosustainability, Technical University of Denmark

关键词: COVID-19;    elective surgical procedure;    immunothrombosis;    obstetrics;    orthopedic procedures;    venous thromboembolism;    thrombophilia;    fibrinolysis;   

DOI  :  10.3389/fsurg.2022.889999

学科分类：社会科学、人文和艺术（综合）

来源: Frontiers

【 摘 要 】

Early in the coronavirus disease 2019 (COVID-19) pandemic, global governing bodies prioritized transmissibility-based precautions and hospital capacity as the foundation for delay of elective procedures. As elective surgical volumes increased, convalescent COVID-19 patients faced increased postoperative morbidity and mortality and clinicians had limited evidence for stratifying individual risk in this population. Clear evidence now demonstrates that those recovering from COVID-19 have increased postoperative morbidity and mortality. These data—in conjunction with the recent American Society of Anesthesiologists guidelines—offer the evidence necessary to expand the early pandemic guidelines and guide the surgeon’s preoperative risk assessment. Here, we argue elective surgeries should still be delayed on a personalized basis to maximize postoperative outcomes. We outline a framework for stratifying the individual COVID-19 patient’s fitness for surgery based on the symptoms and severity of acute or convalescent COVID-19 illness, coagulopathy assessment, and acuity of the surgical procedure. Although the most common manifestation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is COVID-19 pneumonitis, every system in the body is potentially afflicted by an endotheliitis. This endothelial derangement most often manifests as a hypercoagulable state on admission with associated occult and symptomatic venous and arterial thromboembolisms. The delicate balance between hyper and hypocoagulable states is defined by the local immune-thrombotic crosstalk that results commonly in a hemostatic derangement known as fibrinolytic shutdown. In tandem, the hemostatic derangements that occur during acute COVID-19 infection affect not only the timing of surgical procedures, but also the incidence of postoperative hemostatic complications related to COVID-19-associated coagulopathy (CAC). Traditional methods of thromboprophylaxis and treatment of thromboses after surgery require a tailored approach guided by an understanding of the pathophysiologic underpinnings of the COVID-19 patient. Likewise, a prolonged period of risk for developing hemostatic complications following hospitalization due to COVID-19 has resulted in guidelines from differing societies that recommend varying periods of delay following SARS-CoV-2 infection. In conclusion, we propose the perioperative, personalized assessment of COVID-19 patients’ CAC using viscoelastic hemostatic assays and fluorescent microclot analysis.

【 授权许可】

CC BY