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Postoperative respiratory complications in SARS-CoV-2 positive pediatric patients across 20 United States hospitals: A Cohort Study

Published:November 03, 2022DOI:https://doi.org/10.1016/j.jpedsurg.2022.10.048

      Highlights

      • SARS-CoV-2 positivity has led to cancelation and delay of elective pediatric surgical procedures.
      • It is not understood how these delays and cancelations affect outcomes.
      • Our study found a low rate of postoperative respiratory complications in asymptomatic SARS-CoV-2 positive patients.
      • Moving forward, hospitals should consider these data when making policies regarding case cancelation and rescheduling.

      Abstract

      Introduction

      Data examining rates of postoperative complications among SARS-CoV-2 positive children are limited. The purpose of this study was to evaluate the impact of symptomatic and asymptomatic SARS-CoV-2 positive status on postoperative respiratory outcomes for children.

      Methods

      This retrospective cohort study included SARS-CoV-2 positive pediatric patients across 20 hospitals who underwent general anesthesia from March to October 2020. The primary outcome was frequency of postoperative respiratory complications, including: high-flow nasal cannula/non invasive ventilation, reintubation, pneumonia, Extracorporeal Membrane Oxygenation (ECMO), and 30-day respiratory-related readmissions or emergency department (ED) visits. Univariate analyses were used to evaluate associations between patient and procedure characteristics and stratified analyses by symptoms were performed examining incidence of complications.

      Results

      Of 266 SARS-CoV-2 positive patients, 163 (61.7%) were male, and the median age was 10 years (interquartile range 4–14). The majority of procedures were emergent or urgent (n = 214, 80.5%). The most common procedures were appendectomies (n = 78, 29.3%) and fracture repairs (n = 40,15.0%). 13 patients (4.9%) had preoperative symptoms including cough or dyspnea. 26 patients (9.8%) had postoperative respiratory complications, including 15 requiring high-flow oxygen, 8 with pneumonia, 4 requiring non invasive ventilation, 3 respiratory ED visits, and 2 respiratory readmissions. Respiratory complications were more common among symptomatic patients than asymptomatic patients (30.8% vs. 8.7%, p = 0.01). Higher ASA class and comorbidities were also associated with postoperative respiratory complications.

      Conclusions

      Postoperative respiratory complications are less common in asymptomatic versus symptomatic SARS-COV-2 positive children. Relaxation of COVID-19-related restrictions for time-sensitive, non urgent procedures in selected asymptomatic patients may be reasonably considered. Additionally, further research is needed to evaluate the costs and benefits of routine testing for asymptomatic patients.

      Level of Evidence

      Iii, Respiratory complications

      Keywords

      Abbreviations:

      ECMO (extracorporeal membrane oxygenation), PEDSRC (pediatric surgical research collaborative), REDCAP (research electronic data capture), HFNC (high flow nasal cannula), PE (pulmonary embolus), ED (emergency department), ASA (American Society of Anesthesia), BMI (body mass inde), US (United States), URI (upper respiratory infections)

      1. Introduction

      Since the start of the COVID-19 pandemic, hospitals have had to determine whether operations on SARS-CoV-2 positive children are safe to perform or should be postponed. Prior reports have noted the development of postoperative hypoxia following orthopedic surgery [
      • Fazolo T.
      • Lima K.
      • Fontoura J.C.
      • et al.
      Pediatric COVID-19 patients in South Brazil show abundant viral mRNA and strong specific anti-viral responses.
      ] and the risk of increased mortality [
      • Pierce C.A.
      • Preston-Hurlburt P.
      • Dai Y.
      • et al.
      Immune responses to SARS-CoV-2 infection in hospitalized pediatric and adult patients.
      ] for previously asymptomatic SARS-CoV-2 positive adults. However, little is known regarding the risk of surgery in SARS-CoV-2 positive children, and children have been found less likely to experience severe COVID-19 symptoms compared to adults [
      • Fazolo T.
      • Lima K.
      • Fontoura J.C.
      • et al.
      Pediatric COVID-19 patients in South Brazil show abundant viral mRNA and strong specific anti-viral responses.
      ,
      • Pierce C.A.
      • Preston-Hurlburt P.
      • Dai Y.
      • et al.
      Immune responses to SARS-CoV-2 infection in hospitalized pediatric and adult patients.
      .
      With access to preoperative testing, many hospitals are performing routine SARS-CoV-2 PCR tests prior to elective surgery [
      • Ingram M.C.E.
      • Raval M.V.
      • Newton C.
      • Lopez M.E.
      • Berman L.
      Characterization of initial North American pediatric surgical response to the COVID-19 pandemic.
      ]. While most surgical practices will postpone elective surgery for SARS-CoV-2 positive patients owing to concerns about postoperative morbidity and staff exposure, variations in managing positive test results in children have been reported [
      • Ingram M.C.E.
      • Mehl S.
      • Rentea R.M.
      • et al.
      Sharing strategies for safe delivery of surgical care for children in the COVID-19 era.
      ,
      • Ludvigsson J.F.
      Systematic review of COVID-19 in children shows milder cases and a better prognosis than adults.
      ,

      Pediatric Surgical Research Collaborative. Published 2022. https://www.pedsrc.org/.

      ]. There are some preliminary data to suggest that SARS-CoV-2 positive pediatric patients do not carry the same risk of increased postoperative morbidity and mortality as adult patients [
      • Ingram M.C.E.
      • Raval M.V.
      • Newton C.
      • Lopez M.E.
      • Berman L.
      Characterization of initial North American pediatric surgical response to the COVID-19 pandemic.
      ,
      • Ingram M.C.E.
      • Mehl S.
      • Rentea R.M.
      • et al.
      Sharing strategies for safe delivery of surgical care for children in the COVID-19 era.
      ,
      • Ludvigsson J.F.
      Systematic review of COVID-19 in children shows milder cases and a better prognosis than adults.
      ]. In some cases, delay of operation may confer additional risk to patients. For example, there could be an increased risk of incarceration owing to delay in hernia repair or recurrent pilonidal abscess while waiting for definitive treatment. A more complete understanding of the impact of SARS-CoV-2 positive status on postoperative outcomes for pediatric patients may inform policymaking around the scheduling of semi elective, non urgent procedures. The aim of this study is to describe the rate of unanticipated respiratory complications among symptomatic and asymptomatic SARS-CoV-2 positive pediatric patients undergoing general anesthesia.

      2. Methods

      2.1 Patient selection

      We conducted a multi-center retrospective cohort study of SARS-CoV-2 positive children who underwent general anesthesia in 20 hospitals across the United States. We included patients 18 years of age or younger undergoing general anesthesia from March 13, 2020 to October 31, 2020, who had a positive SARS-CoV-2 test within the 10 days before their general anesthesia exposure. Patients undergoing Extracorporeal Membrane Oxygenation (ECMO) cannulation for COVID-related respiratory failure as their primary operation were excluded.
      Sites were recruited through the Pediatric Surgical Research Collaborative (PedSRC) [

      Pediatric Surgical Research Collaborative. Published 2022. https://www.pedsrc.org/.

      ], the American Pediatric Surgical Association Quality and Safety Committee, and through email correspondences with individual providers who had previously contributed to an online open-access data-sharing document [
      • Ingram M.C.E.
      • Raval M.V.
      • Newton C.
      • Lopez M.E.
      • Berman L.
      Characterization of initial North American pediatric surgical response to the COVID-19 pandemic.
      ,
      • Ingram M.C.E.
      • Mehl S.
      • Rentea R.M.
      • et al.
      Sharing strategies for safe delivery of surgical care for children in the COVID-19 era.
      .
      Eligible patients were identified locally at each institution through one or more of the following mechanisms: electronic medical record queries, utilization of hospital data resource centers to identify encounters that met inclusion criteria, and/or review of operating room logs during the study period to identify cases with a positive SARS-CoV-2 test result associated with the encounter (within 10 days before).

      2.2 Variable development, data entry, and outcomes observed

      Independent retrospective chart reviews were conducted at each institution, with data abstraction into a common Research Electronic Data Capture (REDCap) database through the University of Texas Health Science at Houston. Data collection instruments were created in REDCap, based from the existing literature on COVID-19 positivity and complications after anesthesia [
      • Davenport M.
      • Pakarinen M.P.
      • Tam P.
      • Laje P.
      • Holcomb III, G.W.
      From the editors: the COVID-19 crisis and its implications for pediatric surgeons.
      ,
      • Gruskay G.A.
      • Dvorzhinskiy A.
      • Konnaris M.A.
      • et al.
      Universal testing for COVID-19 in essential orthopaedic surgery reveals a high percentage of asymptomatic infections.
      ,
      • Nahshon C.
      • Bitterman A.
      • Haddad AS.
      • Hazzan D.
      • Lavie O
      Hazardous postoperative outcomes of unexpected COVID-19 infected patients: a call for global consideration of sampling all asymptomatic patients before surgical treatment.
      ,
      • Mehl S.C.
      • Loera J.M.
      • Shah S.R.
      • et al.
      Favorable postoperative outcomes for children with COVID-19 infection undergoing surgical intervention: experience at a free-standing children's hospital.
      ,
      • Nepogodiev D.
      • Bhangu A.
      • Glasbey J.C.
      • et al.
      Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study.
      ]. The final set of variables and their definitions were adjudicated by discussions within the PedSRC. Variables captured included patient demographics, comorbidities, absence or presence of preoperative COVID-19 symptoms, procedure-related details, and postoperative respiratory complications within 30 days of the procedure. A specified data dictionary and details on data collection processes were provided to each site. A copy of the data dictionary is provided in Supplemental File 1. Cases were categorized as emergent (to occur within one hour of case request), urgent (to occur within 2 to 24 h), or elective (non urgent, non emergent). All center identifiers were encrypted with unique four-digit pin IDs. The final de identified cohort of all participating sites was evaluated in aggregate. All data collection forms and processes were overseen and approved by local IRBs at each participating site.

      2.3 Statistical analysis

      We performed descriptive analyses to evaluate the characteristics of patients undergoing surgery while SARS-CoV-2 positive and what types of procedures were being performed. We tested associations between patient characteristics, including COVID-19 symptoms and the likelihood of experiencing postoperative respiratory complications within 30 days (defined as the need for high flow nasal cannula (HFNC), non invasive ventilation, reintubation, pneumonia, ECMO, pulmonary embolus (PE), thromboembolic complications, death, or 30-day readmission or emergency department (ED) revisit for a respiratory-related complaint). Covariates that were evaluated include case status (emergent, urgent, elective), patient comorbidities (obesity, asthma, cancer, immunosuppressive disease, prior pulmonary comorbidities/oxygen dependence), ASA (American Society of Anesthesia) class (I, II, III, IV) and age.
      Missing data were included in flowcharts and descriptive analyses, allowing denominators to remain consistent in calculations. Estimates of medians with interquartile ranges were presented where appropriate. Chi-square tests, Fisher's Exact, and Wilcoxon Rank-Sum with a significant p-value set at p<0.05 were conducted where appropriate to test associations between patient and procedure characteristics and the presence of respiratory complications after surgery. Stratified analyses were performed for symptomatic and asymptomatic patients, and Fisher's Exact test was used to compare differences between groups. All analyses were conducted using Stata version 17.0 (College Station, TX).

      3. Results

      During the specified time frame, 281 patients underwent general anesthesia and were SARS-CoV-2 positive within 10 days before their procedure. Fifteen patients were missing data on respiratory complications and were excluded from the analysis, leaving 266 patients in total (Fig. 1). The majority of patients were male (163 patients, 61.7%), and the median age was 10 years (interquartile range 4–14) (Table 1). SARS-CoV-2 positivity was determined either the day before or the day of the procedure in the vast majority of patients (Fig. 2). Patient and procedure characteristics of children with and without respiratory complications are shown in Table 1. Most cases were emergent (13.6%) or urgent (67.2%), but there were 51 patients (19.3%) who had elective surgery while SARS-CoV-2 positive. The majority of procedures were performed by general pediatric or orthopedic surgeons, with several other subspecialties represented (Table 1). Notable patient and procedure characteristics associated with respiratory complications included urgent surgery, higher ASA class, and preoperative dyspnea or need for HFNC or ventilator support (Table 1). The two most common procedures were appendectomies (29.3%) and fracture repairs (15.0%). Other procedures included vascular access, gastrostomy, hernia repair, craniotomy, and sternotomy, in addition to diagnostic studies such as MRI (Supplemental Tables 1 and 2).
      Fig 1
      Fig. 1Data flow to demonstrate sources of missing data.
      Table 1Rate of postoperative respiratory complications by patient/procedure characteristics, univariate analysis.
      Patient/Procedure CharacteristicRespiratory Complications
      NoYesP-value
      N%N%
      Surgery Type
       Emergent2877.8822.20.007
       Urgent16793.8116.2
       Elective4486.3713.7
      Surgical Approach
       Open9587.21412.80.009
       Laparoscopic8995.744.3
       Laparoscopic assist360240
       Endoscopic2110000
       Other3083.3616.7
      Surgical Specialty
       Neurosurgery139217.10.001
       General Surgery11592.797.3
       Trauma150150
       Cardiac150150
       ENT1785315
       Urology1010000
       Plastic450450
       Orthopedic4795.924.1
       Other3186.1513.9
      Comorbidities Present
      Comorbidities include cancer, being immunocompromised, presence of asthma, cancer, obesity; ASA=American Society of Anesthesia.
       No16594.3105.70.003
       Yes7483.21516.9
      Body Mass Index
       Underweight1493.316.70.81
       Healthy8290.199.9
       Overweight3093.826.3
       Obese4387.8612.2
      ASA Class
       15610000<0.001
       212692.7107.4
       35179.71320.3
       4562.5337.5
       5110000
      Age (median, Interquartile Range)9.44–1412.75–140.415
      Race0.333
       White15891.9148.1
       Black2978.4821.6
       Asian410000
       Mixed610000
       Other2291.728.3
       Unknown1789.5210.5
      Sex
       Female9089.11110.90.654
       Male14890.8159.2
      Preop Symptoms
      Loss of Smell/Taste
       No23890.2269.90.64
       Yes210000
      Abdominal Pain
       No18988.72411.30.1
       Yes5196.223.8
      Fevers
       No21190.2239.80.935
       Yes2990.639.4
      Cough
       No23190.6249.40.338
       Yes981.8218.2
      Dyspnea
       No24090.9249.1<0.001
       Yes002100
      Respiratory Requirement Preop
      None
       No1773.9626.10.006
       Yes22391.8208.2
      Nasal Cannula
       No23590.7249.30.09
       Yes571.4228.6
      Non-invasive Ventilation
       No23690.8249.20.049
       Yes466.7233.3
      Vent Support
       No233912390.003
       Yes770330
      low asterisk Comorbidities include cancer, being immunocompromised, presence of asthma, cancer, obesity; ASA=American Society of Anesthesia.
      Fig 2
      Fig. 2Number of days between positive SARS-CoV-2 test and procedure among children undergoing general anesthesia.
      There were 13 (4.9%) patients who had preoperative respiratory symptoms, most commonly cough or dyspnea, thought to be related to COVID-19 infection. Preoperative respiratory symptoms were seen in 1 (0.4%) patient who underwent emergent surgery, 10 (3.8%) patients who underwent urgent surgery, and 2 (0.8%) patients who underwent elective surgery. Additional documented preoperative “possible COVID-related symptoms” included abdominal pain (n = 53, 19.9%) and fever (n = 32, 12.0%).
      Postoperative respiratory complications were seen in 26 (9.8%) patients. Patients with preoperative respiratory symptoms attributable to SARS-CoV-2 had significantly higher postoperative respiratory complication rates compared with asymptomatic patients (overall 30.8% vs. 8.7%, p = 0.01). Patient and procedure characteristics of children with and without respiratory complications are shown in Table 1. Notable procedure-related risk factors for respiratory complications included urgent surgery, open surgery, and orthopedic surgery. Patients with comorbidities, higher ASA class, and preoperative dyspnea or need for HFNC or ventilator support were also more likely to have respiratory complications (Table 1).
      Of the 26 patients who had postoperative respiratory complications, 15 (5.6%) patients required HFNC, 8 (3.0%) had pneumonia, 4 (1.5%) required non invasive ventilation, 3 (1.1%) visited the emergency department for respiratory symptoms, and 2 (0.8%) were readmitted for respiratory symptoms. In the asymptomatic group, 22 patients had postoperative respiratory complications, 14 (5.5%) patients required HFNC, 6 (2.4%) had pneumonia, 3 (1.2%) required non invasive ventilation, 2 (0.8%) visited the emergency department for respiratory symptoms, and 2 (0.8%) were readmitted for respiratory symptoms. There was no reintubation, mortality, or progression to ECMO in our cohort.
      Stratified analyses in symptomatic versus asymptomatic patients were performed to test associations between comorbidities, preoperative oxygen requirement, symptoms, ASA class, and body mass index (BMI) percentile in symptomatic versus asymptomatic patients (Table 2). Higher ASA class and comorbidities were also associated with postoperative respiratory complications in asymptomatic but not symptomatic patients. Being overweight or obese was not associated with respiratory complications in either symptomatic or asymptomatic patients.
      Table 2Incidence of postoperative respiratory complications in symptomatic vs asymptomatic SARS-CoV-2 positive Patients.
      Patient and Procedure CharacteristicsRespiratory Complications
      Symptomatic (n = 13)p-valueAsymptomatic (n = 253)p-value
      Case class
       Elective0 (0%)0.467 (14.3%)0.11
       Emergent/Urgent4 (36.4%)15 (7.4%)
      Comorbidity status
       No Comorbidities1 (16.7%)0.349 (5.3%)0.01
       Comorbidities3 (42.9%)12 (14.6%)
      ASA Class
       ASA 1–21 (16.7%)0.349 (4.8%)<0.01
       ASA 3–53 (42.9%)13 (19.7%)
      BMI
       Underweight/Healthy BMI3 (37.5%)0.4915 (8.5%)0.53
       Overweight/Obese BMI1 (20.0%)7 (9.1%)
      Age (median, Interquartile Range)14 (5–17)0.1411.9 (5–14)0.64

      4. Discussion

      In this multicenter retrospective review of a large pediatric cohort evaluating the association between SARS-CoV-2 positive status and postoperative outcomes, we found that the overall rate of postoperative respiratory complications in SARS-CoV-2 positive children undergoing anesthesia/surgery is lower than expected. Symptomatic patients were more likely to experience respiratory complications than asymptomatic patients. The most common complications were the use of HFNC and pneumonia. Patients who did experience respiratory complications were more likely to have higher ASA class and/or other comorbidities that would increase baseline risk.
      Proceeding with elective surgery and anesthesia in asymptomatic patients may benefit both patients/families as well the healthcare system. Delays in surgical procedures owing to COVID-19 have been cited for causing increased emotional distress for patients awaiting previously scheduled orthopedic procedures and/or oncologic procedures [
      • Wilson J.M.
      • Schwartz A.M.
      • Grissom H.E.
      • et al.
      Patient Perceptions of COVID-19-related surgical delay: an analysis of patients awaiting total hip and knee arthroplasty.
      ,
      • Sokas C.
      • Kelly M.
      • Sheu C.
      • et al.
      Cancer in the shadow of COVID: early-stage breast and prostate cancer patient perspectives on surgical delays due to COVID-19.
      . Additionally, the financial impact of delaying procedures on the United States (US) healthcare system has been significant. The estimated net income from elective surgical procedures to the US hospital system is $48-$65 billion per year. Cancelation of elective surgical procedures owing to COVID-19 leads to estimated losses of $4-$5.4 billion per month in net income to US hospitals during the time they were not being performed [
      • Best M.J.
      • McFarland E.G.
      • Anderson G.F.
      • Srikumaran U.
      The likely economic impact of fewer elective surgical procedures on US hospitals during the COVID-19 pandemic.
      ]. Further, the backlog created by the deferred cases dramatically decreased access in many systems where access was already limited.
      It is known that obesity is associated with more severe disease and poor outcomes in adult patients with COVID-19 [
      • Malik P.
      • Patel U.
      • Patel K.
      • et al.
      Obesity a predictor of outcomes of COVID-19 hospitalized patients – a systematic review and meta-analysis.
      ]. It has also been shown that adolescents aged 13–20 years have an increased risk of severe disease relative to children aged 0–12 years [
      • Guzman B.V.
      • Elbel B.
      • Jay M.
      • Messito M.J.
      • Curado S.
      Age-dependent association of obesity with COVID-19 severity in paediatric patients.
      ]. Our study had 83 (30.4%) patients classified as overweight or obese but did not find an association with postoperative respiratory complications for the obese/overweight patients. Similarly, we did not find that older patients were more likely to experience respiratory complications.
      Similar findings to our study were recently published in a retrospective pediatric series of 66 SARS-CoV-2 positive patients who had undergone surgery (elective and urgent) [
      • Mehl S.C.
      • Loera J.M.
      • Shah S.R.
      • et al.
      Favorable postoperative outcomes for children with COVID-19 infection undergoing surgical intervention: experience at a free-standing children's hospital.
      ]. They also found no incidence of mortality or progression to ECMO. In their cohort, 8% of patients required postoperative oxygen support ranging from nasal cannula to intubation [
      • Mehl S.C.
      • Loera J.M.
      • Shah S.R.
      • et al.
      Favorable postoperative outcomes for children with COVID-19 infection undergoing surgical intervention: experience at a free-standing children's hospital.
      ]. A second retrospective matched cohort study of 51 SARS-CoV-2 positive pediatric patients undergoing general anesthesia reported that having a non severe (asymptomatic) SARS-CoV-2 infection was associated with an 11.8% risk of respiratory complication, but this group also did not observe any incidence of acute respiratory distress syndrome, pneumonia, or perioperative mortality [
      • Saynhalath R.
      • Alex G.
      • Efune P.N.
      • Szmuk P.
      • Zhu H.
      • Sanford E.L
      Anesthetic complications associated with severe acute respiratory syndrome coronavirus 2 in pediatric patients.
      ]. The risk of perioperative respiratory events in the general pediatric population has been cited to be around 0.1–3% for serious events such as aspiration, reintubation, respiratory failure, apnea, or laryngospasm and up to 10% for milder events such as transient desaturation [
      • Egbuta C.
      • Mason K.P.
      Recognizing risks and optimizing perioperative care to reduce respiratory complications in the pediatric patient.
      ]. These event rates are comparable to those experienced by our asymptomatic patients, as the 8.7% who had respiratory complications was largely driven by HFNC requirement in 5.5%.
      Postoperative respiratory complications in children who are symptomatic with upper respiratory infections (URI) other than SARS-CoV-2 appear to be more common, ranging from 24 to 30% [
      • Regli A.
      • Becke K.
      • von Ungern-Sternberg B.S.
      An update on the perioperative management of children with upper respiratory tract infections.
      ,
      • Lee L.K.
      • Bernardo M.K.L.
      • Grogan T.R.
      • Elashoff D.A.
      • Ren W.H.P.
      Perioperative respiratory adverse event risk assessment in children with upper respiratory tract infection: validation of the COLDS score.
      ,
      • Hii J.
      • Templeton T.W.
      • Sommerfield D.
      • Sommerfield A.
      • Matava C.T.
      • von Ungern-Sternberg B.S.
      Risk assessment and optimization strategies to reduce perioperative respiratory adverse events in pediatric anesthesia – part 1 patient and surgical factors.
      ,
      • Zhang S.
      • Ding S.
      • Cai M.
      • et al.
      Impact of upper respiratory tract infections on perioperative outcomes of children undergoing therapeutic cardiac catheterisation.
      ]. As COVID-19 is now an endemic problem, moving forward it may be prudent to develop policies where symptomatic patients are treated the same as symptomatic patients with other URIs. Pediatric patients who develop URI symptoms prior to a scheduled procedure are not routinely tested with a respiratory viral panel, but their case may be delayed until they recover from their URI. In the future, we might consider allowing the presence or absence of symptoms to determine whether surgery should be delayed, so the risks and benefits of delaying surgery versus proceeding with surgery can be considered. It may not be necessary to test every patient prior to a procedure as is currently the standard in many hospitals. Urgent or emergent procedures in patients who are symptomatic and test positive for SARS-CoV-2 should not be delayed, but it should be understood there is a higher risk of respiratory complications in this population. Elective procedures in symptomatic SARS-CoV-2 positive patients should be rescheduled to decrease the risks of postoperative respiratory complications. It may be reasonable to consider relaxation of COVID-19-related restrictions for time-sensitive, non urgent procedures in asymptomatic patients who are at risk of morbidity if surgery is delayed.
      In addition to the operative risks patients face when undergoing surgery while for SARS-CoV-2, the risks to the clinicians taking care of these patients must be considered. COVID-19 infection is transmitted by respiratory droplets, so aerosol-generating procedures pose a higher risk of transmission to healthcare providers [

      CDC. How COVID-19 spreads. Centers for Disease Control and Prevention. Published 2021. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html.

      ]. Transmission is a concern particularly when it comes to the need for intubation to provide general anesthesia. Existing policies to protect healthcare workers perioperatively have included adding isolation protocols or necessitating use of negative pressure rooms for intubation; however, data proving significant benefit of this in reducing transmission rates is limited, particularly in the asymptomatic patient. While the risk of COVID-19 transmission to healthcare workers is real, reported transmissions from index cases through studies on contact tracing and mass surveillance have been low [
      • Saynhalath R.
      • Alex G.
      • Efune P.N.
      • Szmuk P.
      • Zhu H.
      • Sanford E.L
      Anesthetic complications associated with severe acute respiratory syndrome coronavirus 2 in pediatric patients.
      ,
      • Sommerstein R.
      • Fux C.A.
      • Vuichard-Gysin D.
      • et al.
      Risk of SARS-CoV-2 transmission by aerosols, the rational use of masks, and protection of healthcare workers from COVID-19.
      , and are likely to be even lower with widespread vaccine mandates among healthcare workers [
      • Wilson J.M.
      • Schwartz A.M.
      • Grissom H.E.
      • et al.
      Patient Perceptions of COVID-19-related surgical delay: an analysis of patients awaiting total hip and knee arthroplasty.
      ,
      • Sokas C.
      • Kelly M.
      • Sheu C.
      • et al.
      Cancer in the shadow of COVID: early-stage breast and prostate cancer patient perspectives on surgical delays due to COVID-19.
      . Additionally, properly donned personal protective equipment further decreases the risk of SARS-Co-V-2 transmission [
      • Sommerstein R.
      • Fux C.A.
      • Vuichard-Gysin D.
      • et al.
      Risk of SARS-CoV-2 transmission by aerosols, the rational use of masks, and protection of healthcare workers from COVID-19.
      ]. These protective measures, along with existing data on lower than expected transmission from patient to provider, and findings from this study may support relaxing COVID restrictions in operative planning for children.
      There are some limitations to this study that are important to mention. First, this is a retrospective cohort study with data collection occurring at 20 different centers, and since all data were not collected by the same person, this makes the study design more vulnerable to data collection errors. To reduce information bias owing to data collection errors, there was a standardized REDCap database and data dictionary. Second, we did not include a comparison group of children who tested negative for COVID-19 as a control. Without a control group, we cannot definitively conclude that the observed respiratory complications were owing to SARS-CoV-2 positive status. Third, there was no standardized protocol for laboratory testing for SARS-CoV-2 across all 20 centers. To decrease variability and selection bias without a standardized protocol, we only included patients who had a positive SARS-CoV-2 PCR test. The limitations of laboratory testing mean that there were likely some patients excluded from this study based on false-negative results. Future studies should be performed to make recommendations on standardized preoperative testing protocols, especially now in the setting of vaccine availability. Fourth, while our cohort of patients is relatively large for pediatric patients who underwent general anesthesia while SARS-CoV-2 positive, we recognize that it is underpowered for detecting a statistically significant increased risk of death or severe morbidity. Additionally, the number of patients who were symptomatic from their COVID-19 infection were small, which limits the stratified analysis we performed for the asymptomatic and symptomatic populations. Fifth, this study was performed prior to the Delta and Omicron variants of COVID-19. This may have led to an increase in the number of children with COVID-19, but there was no apparent increase in disease severity in children with the Delta variant [
      • Molteni E.
      • Sudre C.H.
      • Canas L.S.
      • et al.
      Illness characteristics of COVID-19 in children infected with the SARS-CoV-2 Delta variant.
      ,

      COVID-19 Vaccines for Children and Teens | CDC. Accessed November 15, 2021. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/children-teens.html.

      . Finally, this study was conducted prior to widespread vaccine availability. Now that the Pfizer vaccine has been approved for children 5 years and older [

      COVID-19 Vaccines for Children and Teens | CDC. Accessed November 15, 2021. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/children-teens.html.

      ], more studies will need to be performed to inform policies regarding whether there is any role for preoperative SARS-CoV-2 testing in vaccinated children.

      5. Conclusions

      Post procedural respiratory complications in asymptomatic SARS-CoV-2 positive children undergoing general anesthesia occurred in 8.7% of cases in this cohort. Moving forward, hospitals should consider these data when making policies regarding case cancelation and rescheduling. Before proceeding with anesthetic exposure and surgical procedures, providers should also consider risks of delaying the procedure for a time-sensitive but non urgent problem, the COVID vaccination status of the patient, exposure risks for hospital staff and other patients, and features of the prevailing COVID variant.

      Financial support statement

      No authors have received direct or indirect funding support for activities related to this project

      Conflict of Interest/Disclosure

      The authors have no related conflicts of interest to declare

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