翻譯：張 麗 徐醫2022級麻醉學研究生
審校：趙林林 徐醫附院麻醉科
American Society of Anesthesiologists and Anesthesia Patient Safety Foundation
Joint Statement on Elective Surgery/Procedures and Anesthesia for Patients after
COVID-19 Infection
美國麻醉醫師協會和麻醉患者安全基金會關於COVID-19感染後患者的擇期手術和麻醉的聯合聲明
Since hospitals are able to continue to perform elective surgeries while the COVID-19 pandemic continues, determining the optimal timing of procedures for patients who have recovered from COVID-19 infection and the appropriate level of preoperative evaluation are challenging given the current lack of evidence or precedent. The following guidance is intended to aid hospitals, surgeons, anesthesiologists, and proceduralists in evaluating and scheduling these patients. The updated recommendations detailed in this document are based upon new evidence that has come to light over the past year. The recommendations will be subject to continued evolution as new evidence emerges.
COVID-19大流行仍在繼續，醫院能夠繼續開展擇期手術，鑑於目前缺乏證據或先例，為從COVID-19感染中恢復的患者確定最佳手術時機和適當的術前評估水平具有挑戰性。以下指南旨在幫助醫院、手術醫生、麻醉醫師和外科醫生評估和安排這些患者。本文詳細介紹的更新建議是基於過去一年中發現的新證據。這些建議將隨著新證據的出現而不斷更新。
Elective surgeries should be performed for patients who have recovered from COVID-19 infection only when the anesthesiologist and surgeon or proceduralist agree jointly to proceed.The decision for surgery/procedure is centered on two factors: 1. Is the patient still infectious? and 2. For patients that are no longer infectious what is the appropriate length of time to wait between recovery from COVID and surgery/procedure in terms of risk to the patient.
對於COVID-19感染康復的患者，只有在麻醉醫師和外科醫生都同意的情況下，才應進行擇期手術。手術的兩個決定因素：1、病人是否還有傳染性? 2、對於不再具有傳染性的患者，從COVID恢復到可以手術之間的適當等待時間是多長?
What determines when a patient confirmed to have COVID-19 is no longer infectious?
怎麼判定確診患有COVID-19的患者何時不再具有傳染性?
The Centers for Disease Control and Prevention (CDC) provides guidance for physicians to decide when transmission-based precautions (e.g., isolation, use of personal protective equipment and engineering controls) may be discontinued for hospitalized patients, or home isolation may be discontinued for outpatients.
疾病控制和預防中心(CDC)為醫生提供指導，以決定何時可以停止對住院患者進行基於傳播的預防措施(例如隔離、使用個人防護設備和工程控制)，或停止對門診患者進行居家隔離。
Patients infected with SARS-CoV-2, as confirmed by reverse transcriptase-polymerase chain reaction (RT-PCR) testing of respiratory secretions, may be asymptomatic or symptomatic. The National Institutes of Health has recently updated the categories of SARS-CoV-2 infection into the following phenotypic expressions of COVID severity. (see Appendix I for full description).
對呼吸道分泌物進行逆轉錄-聚合酶鏈反應(RT-PCR)檢測，確診感染SARS-CoV-2的患者可能無症狀，也可能有症狀。美國國立衛生研究院最近將SARS-CoV-2感染的類別更新為以下按COVID嚴重程度的表型表達(詳見附錄一)。
• Asymptomatic or Presymptomatic Infection
• Mild Illness.
• Moderate Illness
• Severe Illness
• Critical Illness
•無症狀或症狀前感染（暫時還沒有出現症狀，但以後會有症狀出現）
•輕微疾病
•中度疾病
•重度疾病
•危重疾病
Severely immunocompromised patients, whether suffering from asymptomatic or symptomatic COVID-19, are considered separately.
免疫功能嚴重受損的患者，無論是無症狀的COVID-19患者還是有症狀的COVID-19患者，都被單獨考慮。
Current data indicate that, in patients with mild to moderate COVID-19, repeat RT-PCR testing may detect SARS-CoV-2 RNA for a prolonged period after symptoms first appear.According to the Centers for Disease Control and Prevention (CDC), it is rare to recover replication-competent virus after 10 days from onset of symptoms, except in people who have severe COVID-19 or who are moderately or severely immunocompromised.
目前的數據表明，在輕度至中度COVID-19患者中，重複RT-PCR檢測可能在症狀首次出現後的很長一段時間內檢測到SARS-CoV-2 RNA。根據美國疾病控制和預防中心(CDC)的數據，除了患有嚴重COVID-19或中重度免疫功能低下的人外，很少在症狀出現10天後恢復有複製能力的病毒。
Considering this information, the CDC recommends that physicians use a time- and symptom-based strategy to decide when patients with COVID-19 are no longer infectious.
考慮到這一信息，美國疾病控制與預防中心建議醫生使用基於時間和症狀的策略來決定COVID-19患者何時不再具有傳染性。
For patients with confirmed COVID-19 infection the CDC recommends discontinuing isolation and other transmission-based precautions per the following：
對於確診的COVID-19感染患者，CDC建議停止隔離和其他基於傳播的預防措施，具體如下:
• Children and adults with mild, symptomatic COVID-19:Isolation can end at least 5 days after symptom onset and after fever ends for 24 hours (without the use of fever-reducing medication) and symptoms are improving, if these people can continue to properly wear a well-fitted mask around others for 5 more days after the 5-day isolation period. Day 0 is the first day of symptoms.
•患有輕微症狀的COVID-19的兒童和成人：如果這些人在5天隔離期後，還能繼續正確地在其他人周圍再戴5天口罩，那麼在症狀出現後至少5天，發燒結束24小時(不使用退燒藥)並且症狀正在改善後，隔離可以結束。第0天是出現症狀的第一天。
• People who are infected but asymptomatic (never develop symptoms): Isolation can end at least 5 days after the first positive test (with day 0 being the date their specimen was collected for the positive test), if these people can continue to wear a properly well-fitted mask around others for 5 more days after the 5-day isolation period. However, if symptoms develop after a positive test, their 5-day isolation period should start over (day 0 changes to the first day of symptoms)*
•無症狀感染者(從未出現症狀)：隔離可在首次陽性檢測後至少5天結束(第0天為收集標本進行陽性檢測的日期)，前提是這些人在5天隔離期後仍能繼續正確佩戴的口罩與他人接觸5天。但是，如果在檢測呈陽性後出現症狀，則應重新開始5天的隔離期(第0天改為出現症狀的第一天)*
• People who have moderate COVID-19 illness:Isolate for 10 days.
•COVID-19中度患者：隔離10天。
• People who are severely ill (i.e., requiring hospitalization, intensive care, or ventilation support): Extending the duration of isolation and precautions to at least 10 days and up to 20 days after symptom onset, and after fever ends (without the use of fever-reducing medication) and symptoms are improving, may be warranted.
•病情嚴重的人(即需要住院、重症監護或通氣支持的人)：可能有必要將隔離和預防措施的持續時間延長至症狀出現後至少10天至20天，並且在發燒結束(不使用退燒藥)和症狀有所改善後。
• People who are moderately or severely immunocompromised might have a longer infectious period:Extend isolation to 20 or more days (day 0 is the first day of symptoms or a positive viral test). Use a test-based strategy and consult with an infectious disease specialist to determine the appropriate duration of isolation and precautions.
•中度或嚴重免疫功能低下的人可能會有更長的感染期：將隔離時間延長至20天或更長時間(第0天是出現症狀或病毒檢測呈陽性的第一天)。使用基於測試的策略，並諮詢傳染病專家，以確定適當的隔離時間和預防措施。
*The additional 5-day isolation period with masking for asymptomatic and mildly symptomatic patients has no practical implication in anesthesia care.Patients in these categories should be considered infectious for anesthesia care purposes for the full 10 days.
*對無症狀和輕度症狀患者額外的5天口罩隔離期在麻醉照護中沒有實際意義。在麻醉照護的10天內，這些類別的患者應該被認為是有傳染性的。
Consultation with infection control experts is strongly advised prior to discontinuing precautions for patients with severe to critical illness or who are severely immunocompromised. Clinical judgment ultimately prevails when deciding whether a patient remains infectious. Maintaining transmission-based precautions and repeat RT-PCR testing may be appropriate if clinical suspicion of ongoing infection exists.
對於重症、危重症患者或免疫功能嚴重受損的患者，在停止預防措施之前，強烈建議諮詢感染控制專家。在決定病人是否仍然具有傳染性時，臨床判斷最終占上風。如果臨床懷疑存在持續感染，保持基於傳播的預防措施和重複RT-PCR檢測可能是合適的。
If a patient suspected of having SARS-CoV-2 infection is never tested, the decision to discontinue transmission-based precautions can be made using the symptom-based strategy described above.
如果懷疑患有SARS-CoV-2感染的患者從未進行過檢測，則可以使用上述基於症狀的策略來決定避免傳播的預防措施。
Other factors, such as advanced age, diabetes mellitus, or end-stage renal disease, may pose a much lower degree of immunocompromise; their effect upon the duration of infectivity for a given patient is not known.
其他因素，如高齡、糖尿病或終末期腎病，可能造成較低程度的免疫損害；它們對特定患者的傳染性持續時間的影響尚不清楚。
Ultimately, the degree of immunocompromise for the patient is determined by the treating provider, and preventive actions are tailored to each individual and situation.
最終，患者的免疫損害程度由治療提供者決定，預防措施針對每個人及其情況而定。
What is the appropriate length of time between recovery from COVID-19 and surgery/procedure with respect to minimizing postoperative complications?
為了儘量減少術後併發症，從COVID-19恢復到可以手術之間的合適時間是多長?
Currently there is a backlog of surgical procedures that have been delayed but are necessary to improve the health and quality of life of our patients.Although there is increasing information to address the timing of surgery after COVID-19 infection, studies continue to lag behind the emerging variants and the likelihood that vaccinated patients have a lower a risk of postoperative complications as compared to unvaccinated patients. Almost all available data come from study periods with zero to low prevalence of vaccination.
目前，推遲的外科手術已經出現積壓，但對於改善我們患者的健康和生活質量是必要的。雖然關於COVID-19感染後手術時機的信息越來越多，但研究仍然落後於新出現的變異，以及與未接種疫苗的患者相比，接種疫苗的患者術後併發症風險較低。幾乎所有可用數據都來自疫苗接種率低的研究時期。
The preoperative preparation of a surgical patient who is recovering from COVID-19 involves evaluation and optimization of the patient’s medical conditions and physiologic status. Since COVID-19 can impact virtually all major organ systems, the timing of surgery after a COVID-19 diagnosis is important when considering the risk of postoperative complications.Heretofore, protocols have been based on limited data specific to SARS-CoV-2, expert opinion, and previous data from other post-viral syndromes.
COVID-19恢復期外科患者的術前準備包括評估和優化患者的醫療條件和生理狀態。由於COVID-19幾乎可以影響所有主要器官系統，在考慮到術後併發症的風險時，COVID-19診斷後的手術時機非常重要。迄今為止，方案一直基於SARS-CoV-2特有的有限數據、專家意見以及以前來自其他病毒後綜合徵的數據。
An early limited study of 122 patients found a significantly higher risk of pulmonary complications within the first four weeks after SARS-CoV-2 diagnosis. A Brazilian study of 49 patients who underwent surgery with a median delay of 25 days after asymptomatic COVID-19 did not have increased complications when compared to a cohort of patients with a negative SARS-CoV-2 test.
一項對122名患者的早期有限研究發現，在SARS-CoV-2診斷後的前四周內，肺部併發症的風險明顯更高。巴西的一項研究對49名無症狀COVID-19患者進行了手術，與一組SARS-CoV-2檢測陰性的患者相比，這些患者的併發症沒有增加。
Subsequently, a multi-country (116 countries), multi-center (1674 hospitals) study, in a mixture of high income and low/middle income countries, followed more than 140,000 patients with 3,127 having COVID-19 infections before surgery.Data were collected from surgery in October 2020, meaning that none of these patients had received even one vaccination. They reported increased risks of mortality and morbidity—especially with pulmonary complications--up to 7 weeks post COVID diagnosis, although the confidence interval for patients in the 5-6 week cohort suggests that there may not be a true difference in this group. This data found increased risks to be present at 5-6 weeks regardless of being asymptomatic or symptomatic, older or younger than 70, having major or minor surgery, or undergoing elective or emergency surgery. Mortality data is summarized in the table below. Finally, patients with ongoing symptoms at ≥7 weeks were at increased risk for complications versus patients without symptoms.
隨後，一項多國(116個國家)、多中心(1674家醫院)的研究，在高收入和中低收入國家進行，隨訪了14萬多名患者，其中3127人在手術前感染了covid - 19。數據是從2020年10月的手術中收集的，這意味著這些患者都沒有接種過疫苗。儘管5-6周隊列患者的置信區間表明該組可能沒有真正的差異，但是他們報告了COVID診斷後長達7周的死亡和發病率風險增加，特別是肺部併發症。該數據發現，無論無症狀或有症狀，年齡大於或小於70歲，接受大手術或小手術，或接受擇期或急診手術，5-6周時風險均增加。死亡率數據摘要載於下表。最後，與無症狀患者相比，持續症狀≥7周的患者發生併發症的風險增加。
A second U.S. study covering a timeline of patients with a COVID-19 diagnosis and surgery up to May 31, 2021 reviewed 5479 surgical patients following COVID-19 infection.Immunization status was not given but the study period ranged from a time of zero vaccination until a period when about 30% of the US adult population had received at least one vaccination. The results corroborate the above findings and report higher postop complications of pneumonia and respiratory failure at 0-4 weeks and continued higher postoperative pneumonia complications 4-8 weeks post PCR diagnosis.
美國的第二項研究涵蓋了截至2021年5月31日的COVID-19診斷和手術患者的時間表，研究了5479名COVID-19感染後的手術患者。研究人員沒有給出免疫狀況，但研究期間從零疫苗接種到約30%的美國成年人至少接種了一次疫苗。結果證實了上述發現，並報導了在PCR診斷後0-4周肺炎和呼吸衰竭的術後併發症較高，4-8周後持續較高的術後肺炎併發症。
Of note, a consensus-based statement from the United Kingdom recommends 「delaying surgery, whenever feasible for a minimum of 7 weeks after known SARS-CoV-2 infection.「
值得注意的是，來自英國的一份基於共識的聲明建議「在已知的SARS-CoV-2感染後，儘可能推遲手術至少7周」。
To date, there are no robust data on patients recovering from more recent Delta and Omicron variants. According to the CDC, the Omicron variant causes less severe disease, and is more likely to reside in the oro- and nasopharynx without infiltration and damage to the lungs.It should also be noted that severity likely varies by vaccination status. Some have extrapolated these facts to a conclusion that risk in patients who are vaccinated and are recovering from Omicron should be less. However plausible, such a conclusion remains unproven. SARS-CoV-2 affects other organ systems beyond the pulmonary system (e.g., thromboembolic events including stroke, myocarditis, renal failure).
迄今為止，還沒有關於患者從最近的Delta和Omicron變異中恢復的可靠數據。根據美國疾病控制與預防中心的說法，Omicron變異導致的疾病不那麼嚴重，而且更有可能存在於口咽部和鼻咽部，不會浸潤和損害肺部。還應注意的是，嚴重程度可能因接種疫苗情況而異。有人根據這些事實推斷出這樣一個結論：接種了疫苗並正在從Omicron中恢復的患者的風險應該更小。無論這一結論多麼可信，它仍未得到證實。SARS-CoV-2影響肺部系統以外的其他器官系統(例如血栓栓塞事件，包括中風、心肌炎、腎衰竭)。
Residual symptoms such as fatigue, shortness of breath, and chest pain are common in patients who have had COVID-19 (10,11). These symptoms can be present more than 60 days after diagnosis (11). In addition, COVID-19 may have long term deleterious effects on myocardial anatomy and function (12). A more thorough preoperative evaluation, scheduled further in advance of surgery with special attention given to the cardiopulmonary systems, should be considered in patients who have recovered from COVID-19 and especially those with residual symptoms.
疲勞、呼吸短促和胸痛等殘留症狀在COVID-19患者中很常見。這些症狀可在診斷後60天以上出現。此外，COVID-19可能對心肌解剖和功能有長期的有害影響。對於從COVID-19中恢復的患者，特別是那些有殘留症狀的患者，應考慮在手術前進一步安排更徹底的術前評估，並特別注意心肺系統。
Is repeat SARS-CoV-2 testing needed?
是否需要重複SARS-CoV-2檢測?
At present, the CDC does not recommend re-testing for COVID-19 within 90 days of symptom onset (13). Repeat PCR testing in asymptomatic patients is strongly discouraged since persistent or recurrent positive PCR tests are common after recovery. However, if a patient presents within 90 days and has recurrence of symptoms, re-testing and consultation with an infectious disease expert should be considered.Once the 90-day recovery period has ended, the patient should undergo one pre-operative nasopharyngeal PCR test ideally ≤ three days prior to the procedure.
目前，美國疾病控制與預防中心不建議在症狀出現後90天內重新檢測COVID-19。在無症狀患者中，強烈不鼓勵重複PCR檢測，因為持續或復發的PCR檢測陽性在康復後很常見。但是，如果患者在90天內出現症狀並復發，則應考慮重新檢測並諮詢傳染病專家。90天恢復期結束後，患者應在術前≤3天進行一次鼻咽PCR檢測。
These recommendations are under continuous review and will be updated as additional evidence becomes available.
這些建議正在不斷審查中，並將在獲得更多證據時予以更新。
Appendix I
• Asymptomatic or Presymptomatic Infection: Individuals who test positive for SARS-CoV-2 using a virologic test (i.e., a nucleic acid amplification test [NAAT] or an antigen test) but who have no symptoms that are consistent with COVID-19.
• Mild Illness: Individuals who have any of the various signs and symptoms of COVID-19 (e.g., fever, cough, sore throat, malaise, headache, muscle pain, nausea, vomiting, diarrhea, loss of taste and smell) but who do not have shortness of breath, dyspnea, or abnormal chest imaging.
• Moderate Illness: Individuals who show evidence of lower respiratory disease during clinical assessment or imaging and who have an oxygen saturation (SpO2) ≥94% on room air at sea level.
• Severe Illness: Individuals who have SpO2 <94% on room air at sea level, a ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300 mm Hg, a respiratory rate >30 breaths/min, or lung infiltrates >50%.
• Critical Illness: Individuals who have respiratory failure, septic shock, and/or multiple organ
dysfunction.
•無症狀或症狀前感染：通過病毒學檢測(即核酸擴增檢測[NAAT]或抗原檢測)檢測出SARS-CoV-2陽性，但沒有與COVID-19一致的症狀。
•輕度疾病：有任何COVID-19的體徵和症狀(例如，發燒、咳嗽、喉嚨痛、不適、頭痛、肌肉疼痛、噁心、嘔吐、腹瀉、味覺和嗅覺喪失)，但沒有呼吸短促、呼吸困難或胸部影像學異常。
•中度疾病：在臨床評估或成像中顯示下呼吸道疾病證據，並且氧飽和度(SpO2)≥94%。
•嚴重疾病：SpO2 <94%，動脈氧分壓與吸入氧分數之比(PaO2/FiO2) <300毫米汞柱，呼吸頻率>30次/分鐘，或肺浸潤>50%。
•危重疾病：有呼吸衰竭、感染性休克、多器官功能障礙。
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