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Achieving safe surgery after COVID‐19 vaccination
23 auth. J. Kovoor, J. Jacobsen, Joanna K. Duncan, A. Addo, D. Tivey, W. Babidge, D. Penn, James Churchill, Trevor G. Collinson, J. Kok, ...
COVID-19 has changed surgery worldwide. As surgical outcomes for patients with COVID-19 are significantly poorer than those without, one of the most important preventative measures for surgical safety has been vaccination, which dramatically reduces…
COVID-19 has changed surgery worldwide. As surgical outcomes for patients with COVID-19 are significantly poorer than those without, one of the most important preventative measures for surgical safety has been vaccination, which dramatically reduces transmission and disease severity. Predicated largely on favourable phase II/III clinical trials, several vaccines have been rolled out internationally with phase IV outcomes meeting expectations. Despite evidence supporting the safety and efficacy, it has been challenging to develop evidence-based guidelines for safely providing vaccination and surgical care worldwide. Consideration of risks is necessary at the individual patient level. This perspective piece aimed to explore factors relating to available COVID-19 and provide recommendations for undertaking surgery in those who have been recently vaccinated. For each clinical statement made, a level of evidence, according to the evidence hierarchy outlined by Merlin et al., is provided. The levels of evidence provided represent the body of literature retrieved in a report undertaken by the Royal Australasian College of Surgeons that incorporated a formal search strategy. This article represents a major collaborative effort, and all listed authors contributed to the manuscript’s conception, analysis and interpretation of data, revised the article critically for important intellectual content, and provided final approval of the version to be published. Reactogenicity refers to the expected, transient reactions occurring after vaccination and is common after COVID-19 vaccinations. The typical influenza-like symptoms (e.g. pain, fatigue, headache, chills and myalgia), are generally mild and self-limiting, lasting one to 3 days with few events observed after seven. It disproportionally burdens adults under 65, females, those with past COVID-19, or obesity. Reactogenicity following COVID-19 vaccinations is important for perioperative management, as symptoms may prevent accurate assessment of surgical risk preoperatively, and may mimic symptoms of infection postoperatively. Staff should be vigilant if a patient has been recently vaccinated, and any symptoms investigated to ascertain whether they stem from expected reactogenicity or surgical pathology (level II evidence). Adverse events of special interest (AESI) are adverse events associated with COVID-19 vaccines or specific vaccine platforms. A range of AESI have been reported following vaccination, however for most it is unclear whether their incidence surpasses backgrounds rates, whether they have been clinically verified, or whether they are causally associated with COVID-19 vaccines. Presently, reported AESI with causal or suspected causal links to COVID-19 vaccines include Guillain-Barre syndrome (GBS), myocarditis and pericarditis, and thrombosis with thrombocytopenia syndrome (TTS). These generally occur within 2 weeks post vaccination. TTS has occurred more frequently after first doses of the Oxford-AstraZeneca vaccine, whereas myocarditis and pericarditis have occurred more frequently following second doses of the Moderna and Pfizer-BioNTech. Younger adults appear to be disproportionally affected, but risk factors remain to be fully elucidated. Current evidence suggests these events may be serious, but are extremely rare. If a surgical patient experiences adverse events related to COVID-19 vaccination, operative delay until resolution should be considered given potential alteration of cardiovascular and clotting functions (level II evidence). Staff should familiarize themselves with current guidelines relating to TTS, GBS and myocarditis and pericarditis, so that required management can be optimized. Of note, thrombosis may be worsened in the presence of heparin due to enhanced platelet activation in TTS, hence heparins should be avoided and direct anticoagulants used instead (level II evidence). Data from large clinical trials suggest that immunity against SARS-CoV-2 is generally reached between 7 days (Pfizer-BioNTech) to 14 days (Oxford-AstraZeneca, Gamaleya, Janssen, Moderna, Novavax, Sinovac and Sinopharm) following final vaccine dose. Allowing at least 14 days after vaccination enables development of optimal immune responses, minimizing risk of nosocomial acquisition or transmission (level II evidence). Patients with immunological deficiencies or haematological malignancy may not develop protective immune responses following vaccination. Regardless, rates of COVID-19 are dramatically higher for unvaccinated versus vaccinated persons, and vaccination should always be advised. Surgery and anaesthesia may dysregulate the immune system, an effect potentially persisting for some weeks. This may in turn affect COVID-19 vaccine efficacy. Booster vaccine doses may also be necessary at a population level as data suggest that vaccine-induced immunity wanes. On average, vaccine efficacy or effectiveness against SARS-CoV-2 infection decreases from 1–6 months after full vaccination by over 20% across people of all ages. This should be evidence-based and prioritized according to patient risk. Crucial to safe clinical decision-making is patient stratification by operative urgency, level of morbidity and co-morbidities (level III-2 to IV evidence). Case-by-case evaluation should incorporate: age; comorbidities associated with COVID-19-related risk such as hypertension, diabetes, cardiovascular or pulmonary disease, and immunocompromise; severity of surgical pathology; individual wishes; and likelihood of active SARS-CoV-2 infection (level III-2 to IV evidence). As vaccination against COVID-19 significantly
Published in
ANZ journal of surgery
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