The continued rise in new COVID-19 infections has led to an increasing number of reports detailing a post-acute COVID-19 syndrome (PACS). Patients with this syndrome, who are also known as COVID-19 long-haulers, have an array of nonspecific symptoms that vary in degree of severity.¹ These symptoms also mean that COVID-19 long-haulers undergoing surgery may require specific care in the perioperative period.

While there are no universally established criteria for PACS, many scientific publications agree on a basic principle: the persistence of mental and physical health consequences after an initial COVID-19 infection has passed. ² Common symptoms present in COVID-19 long-haulers are fatigue, labored breathing, smell and taste disturbances, depression, and cognitive impairment. Given these symptoms and the scientific uncertainty related to PACS, COVID-19 long-haulers should be treated with a practical perioperative approach that is rooted in previously established standards of care. ³

A COVID-19 long-hauler’s symptoms should be treated in a multidisciplinary manner. Ideally, medical centers should create an evaluation and risk-assessment protocol for COVID-19 long-haulers, which can inform both surgical and non-surgical care. ³ These evaluations should be thorough and include analyses of neuropsychiatric, cardiovascular, pulmonary, hematologic, renal, gastrointestinal, and endocrine conditions.

In the preoperative setting, the patient’s initial evaluation should include a focused history and physical assessment that records neurological baseline deficits, palsies, and asymmetries.¹ If this evaluation reveals a history of strokes, immobility, or denervated muscles, which can occur during critical illness such as severe COVID-19, neuromuscular blocking strategies during the surgery become especially important. ⁴ Also, patients with a history of anxiety and depression can and should usually continue taking prescribed medications for those conditions. However, since it is associated with a greater risk of postoperative delirium and cognitive dysfunction, benzodiazepine use should be discouraged. ⁵ Generally, it is necessary to do a thorough review of the patient’s medications to ensure that no therapies will interfere with pertinent perioperative protocols.

Additionally, anesthesiologists should be cognizant of chest pain, palpitations, and other cardiovascular issues experienced by many COVID-19 survivors. Due to these cardiac problems, perioperative cardiovascular challenges should be expected when treating COVID-19 long-haulers. There may be underlying cardiac damage in COVID-19 long-haulers, so chest pain should not be minimized and heart failure, coronary artery disease, and arrhythmias should all be investigated. ⁶ Potential avenues for exploration include obtaining an electrocardiogram, measuring thyroid-stimulating hormone level, and performing a transthoracic echocardiogram. Intraoperatively, patients with pronounced cardiac abnormalities will need invasive monitoring and cardiac-related medications. ⁶

COVID-19 long-haulers also commonly report shortness of breath and other respiratory conditions as health issues. While COVID-19 long-haulers are at a higher risk of having postoperative respiratory failure, this risk significantly decreases seven weeks after recovering from the acute COVID-19 infection. ⁷ Regardless, a multidisciplinary preoperative assessment is still important for this population. Some patients may require a chest CT scan, pulmonary function testing, or echocardiography. ¹ During a COVID-19 long-hauler’s surgical operation, airway manipulation could be difficult in individuals who were previously tracheostomized or intubated during their COVID-19 hospitalizations. ¹ Each individual case should be assessed, and the most appropriate airway device should be used to fit the patient’s physical needs.

Overall, medical professionals who work in perioperative settings should consider a wide variety of factors when treating a COVID-19 survivor. COVID-19 long-haulers are at a greater risk for postoperative respiratory complications and perioperative mortality for up to seven weeks after initial illness. For these patients, symptoms should not be disregarded, and these individuals should receive a thorough preoperative work-up that assesses all organ systems, issues, and medications. The scientific understanding of COVID-19 long-haulers is constantly evolving, so it is essential to use the latest research findings to determine perioperative procedures for this population.

References 

1. Kopanczyk, Rafal, et al. “Post-Acute Covid-19 Syndrome for Anesthesiologists: A Narrative Review and a Pragmatic Approach to Clinical Care.” Journal of Cardiothoracic and Vascular Anesthesia, 2021, https://doi.org/10.1053/j.jvca.2021.09.051.  

2. Baig, Abdul Mannan. “Chronic Covid Syndrome: Need for an Appropriate Medical Terminology for Long‐Covid and Covid Long‐Haulers.” Journal of Medical Virology, vol. 93, no. 5, 2021, pp. 2555–2556., https://doi.org/10.1002/jmv.26624.  

3. Bui, Naomi, et al. “Preparing Previously COVID-19-Positive Patients for Elective Surgery: A Framework for Preoperative Evaluation.” Perioperative Medicine, vol. 10, no. 1, 2021, https://doi.org/10.1186/s13741-020-00172-2.  

4. Price, David R., et al. “Neuromuscular Blocking Agents and Neuromuscular Dysfunction Acquired in Critical Illness.” Critical Care Medicine, vol. 44, no. 11, 2016, pp. 2070–2078., https://doi.org/10.1097/ccm.0000000000001839.  

5. Gray, Shelly L, et al. “Benzodiazepine Use and Risk of Incident Dementia or Cognitive Decline: Prospective Population Based Study.” BMJ, 2016, p. i90., https://doi.org/10.1136/bmj.i90.  

6. Thompson, A, and J R Balser. “Perioperative cardiac arrhythmias.” British Journal of Anaesthesia vol. 93,1 (2004): 86-94. https://doi.org/10.1093/bja/aeh166.

7. COVIDSurg Collaborative. and GlobalSurg Collaborative. “Timing of surgery following SARS-CoV-2 infection: an international prospective cohort study.” Anaesthesia vol. 76,6 (2021): 748-758. https://doi.org/10.1111/anae.15458.