Perioperative Morbidity and Mortality of Patients With COVID-19 Who Undergo Urgent and Emergent Surgical Procedures

Anne Knisely, MD; Zhen Ni Zhou, MD, PhD; Jenny Wu, BS; Yongmei Huang, MD, MPH; Kevin Holcomb, MD; Alexander Melamed, MD, MPH; Arnold P. Advincula, MD; Anil Lalwani, MD; Fady Khoury-Collado, MD; Ana I. Tergas, MD, MPH; Caryn M. St. Clair, MD; June Y. Hou, MD; Dawn L. Hershman, MD; Mary E. D'Alton, MD; Yolanda Ya-Chin Huang, MD, PhD; Jason D. Wright, MD


Annals of Surgery. 2021;273(1):34-40. 

In This Article

Abstract and Introduction


Objective: To evaluate the perioperative morbidity and mortality of patients with COVID-19 who undergo urgent and emergent surgery.

Summary Background Data: Although COVID-19 infection is usually associated with mild disease, it can lead to severe respiratory complications. Little is known about the perioperative outcomes of patients with COVID-19.

Methods: We examined patients who underwent urgent and emergent surgery at 2 hospitals in New York City from March 17 to April 15, 2020. Elective surgical procedures were cancelled throughout and routine, laboratory based COVID-19 screening was instituted on April 1. Mortality, complications, and admission to the intensive care unit were compared between patients with COVID-19 detected perioperatively and controls.

Results: Among 468 subjects, 36 (7.7%) had confirmed COVID-19. Among those with COVID-19, 55.6% were detected preoperatively and 44.4% postoperatively. Before the routine preoperative COVID-19 laboratory screening, 7.7% of cases were diagnosed preoperatively compared to 65.2% after institution of screening (P = 0.0008). The perioperative mortality rate was 16.7% in those with COVID-19 compared to 1.4% in COVID-19 negative subjects [aRR = 9.29; 95% confidence interval (CI), 5.68–15.21]. Serious complications were identified in 58.3% of COVID-19 subjects versus 6.0% of controls (aRR = 7.02; 95%CI, 4.96–9.92). Cardiac arrest, sepsis/shock, respiratory failure, pneumonia, acute respiratory distress syndrome, and acute kidney injury were more common in those with COVID-19. The intensive care unit admission rate was 36.1% in those with COVID-19 compared to 16.4% of controls (aRR = 1.34; 95%CI, 0.86–2.09).

Conclusions: COVID-19 is associated with an increased risk for serious perioperative morbidity and mortality. A substantial number of patients with COVID-19 are not identified until after surgery.


Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), now known as coronavirus disease 2019 (COVID-19), is a novel coronavirus that was first recognized in the Hubei province of China in late 2019.[1–3] COVID-19 typically results in mild respiratory disease but may lead to respiratory failure and critical illness in approximately 5% of patients.[2] COVID-19 has spread rapidly across the world and was declared a pandemic by the World Health Organization (WHO) on March 11, 2020.[4]

The spread of COVID-19 has had a significant impact on surgical services worldwide and posed a number of challenges. First, the emergence of COVID-19 has placed a significant strain on hospital systems due to the largescale increase in hospitalizations for coronavirus-associated disease.[2] The need to reallocate resources has limited the availability of operating room facilities and staff. These resource constraints, along with efforts to promote social distancing, have led to recommendations to postpone elective surgical procedures when feasible.[5,6]

Second, patients with either symptomatic or occult COVID-19 infections who undergo surgery may be at increased risk for adverse outcomes.[7] Given that severe COVID-19 related infections result in pneumonia and acute respiratory distress syndrome, surgical patients who typically require mechanical ventilation, are immunosuppressed perioperatively, and who often have underlying comorbidities may be at particular risk for increased morbidity.[8] To date, there are limited data describing the perioperative outcomes of patients with COVID-19.[7,9]

Despite resource constraints and the possible increased risk of perioperative complications, some patients with COVID-19 infections will require urgent or emergent surgical interventions. Further, as many patients with COVID-19 infections are asymptomatic or demonstrate only mild symptomatology, there is a significant risk that patients with occult or unrecognized COVID-19 infections may undergo surgery in areas where community spread of the virus is widespread.[10] We performed a cohort study to determine the outcomes of patients with recognized or occult COVID-19 infection who underwent surgery at 2 urban hospital system in New York City during a widespread outbreak of COVID-19 in the region.