中英双语：美国麻醉医师协会ASA和麻醉患者安全基金会关于COVID-19感染后患者的择期

糖糖不次糖 · 发表于 2023-1-8 21:35:56

以下文章来源于麻醉新超人，作者麻醉新超人

翻译：张丽徐医2022级麻醉学研究生

审校：赵林林徐医附院麻醉科

登录/注册后可看大图

2e0e1662473f37ecaff4c1c68547468b.jpg (317 KB, 下载次数: 11)

下载附件

2023-1-8 21:33 上传

American Society of Anesthesiologistsand Anesthesia Patient Safety Foundation

Joint Statement on Elective Surgery/Proceduresand Anesthesia for Patients after

COVID-19 Infection

美国麻醉医师协会和麻醉患者安全基金会关于COVID-19感染后患者的择期手术和麻醉的联合声明

Since hospitals are able to continue toperform elective surgeries while the COVID-19 pandemic continues, determiningthe optimal timing of procedures for patients who have recovered from COVID-19infection and the appropriate level of preoperative evaluation are challenginggiven the current lack of evidence or precedent. The following guidance isintended to aid hospitals, surgeons, anesthesiologists, and proceduralists inevaluating and scheduling these patients. The updated recommendations detailedin this document are based upon new evidence that has come to light over thepast year. The recommendations will be subject to continued evolution as newevidence emerges.

COVID-19大流行仍在继续，医院能够继续开展择期手术，鉴于目前缺乏证据或先例，为从COVID-19感染中恢复的患者确定最佳手术时机和适当的术前评估水平具有挑战性。以下指南旨在帮助医院、手术医生、麻醉医师和外科医生评估和安排这些患者。本文详细介绍的更新建议是基于过去一年中发现的新证据。这些建议将随着新证据的出现而不断更新。

Elective surgeries should be performed forpatients who have recovered from COVID-19 infection only when theanesthesiologist and surgeon or proceduralist agree jointly to proceed.The decision for surgery/procedure iscentered on two factors: 1. Is the patient still infectious? and 2. Forpatients that are no longer infectious what is the appropriate length of timeto wait between recovery from COVID and surgery/procedure in terms of risk tothe patient.

对于COVID-19感染康复的患者，只有在麻醉医师和外科医生都同意的情况下，才应进行择期手术。手术的两个决定因素：1、病人是否还有传染性? 2、对于不再具有传染性的患者，从COVID恢复到可以手术之间的适当等待时间是多长?

What determines when a patient confirmedto have COVID-19 is no longer infectious?

怎么判定确诊患有COVID-19的患者何时不再具有传染性?

The Centers for Disease Control andPrevention (CDC) provides guidance for physicians to decide whentransmission-based precautions (e.g., isolation, use of personal protectiveequipment and engineering controls) may be discontinued for hospitalizedpatients, or home isolation may be discontinued for outpatients.

疾病控制和预防中心(CDC)为医生提供指导，以决定何时可以停止对住院患者进行基于传播的预防措施(例如隔离、使用个人防护设备和工程控制)，或停止对门诊患者进行居家隔离。

Patients infected with SARS-CoV-2, asconfirmed by reverse transcriptase-polymerase chain reaction (RT-PCR) testingof respiratory secretions, may be asymptomatic or symptomatic. The NationalInstitutes of Health has recently updated the categories of SARS-CoV-2infection into the following phenotypic expressions of COVID severity. (seeAppendix I for full description).

对呼吸道分泌物进行逆转录-聚合酶链反应(RT-PCR)检测，确诊感染SARS-CoV-2的患者可能无症状，也可能有症状。美国国立卫生研究院最近将SARS-CoV-2感染的类别更新为以下按COVID严重程度的表型表达(详见附录一)。

• Asymptomatic or Presymptomatic Infection

• Mild Illness.

• Moderate Illness

• Severe Illness

• Critical Illness

•无症状或症状前感染（暂时还没有出现症状，但以后会有症状出现）

•轻微疾病

•中度疾病

•重度疾病

•危重疾病

Severely immunocompromised patients,whether suffering from asymptomatic or symptomatic COVID-19, are consideredseparately.

免疫功能严重受损的患者，无论是无症状的COVID-19患者还是有症状的COVID-19患者，都被单独考虑。

Current data indicate that, in patientswith mild to moderate COVID-19, repeat RT-PCR testing may detect SARS-CoV-2 RNAfor a prolonged period after symptoms first appear.According to the Centers for Disease Controland Prevention (CDC), it is rare to recover replication-competent virus after10 days from onset of symptoms, except in people who have severe COVID-19 orwho are moderately or severely immunocompromised.

目前的数据表明，在轻度至中度COVID-19患者中，重复RT-PCR检测可能在症状首次出现后的很长一段时间内检测到SARS-CoV-2 RNA。根据美国疾病控制和预防中心(CDC)的数据，除了患有严重COVID-19或中重度免疫功能低下的人外，很少在症状出现10天后恢复有复制能力的病毒。

Considering this information, the CDCrecommends that physicians use a time- and symptom-based strategy to decidewhen patients with COVID-19 are no longer infectious.

考虑到这一信息，美国疾病控制与预防中心建议医生使用基于时间和症状的策略来决定COVID-19患者何时不再具有传染性。

For patients with confirmed COVID-19infection the CDC recommends discontinuing isolation and othertransmission-based precautions per the following：

对于确诊的COVID-19感染患者，CDC建议停止隔离和其他基于传播的预防措施，具体如下:

• Children and adults with mild,symptomatic COVID-19: Isolation can end at least 5days after symptom onset and after fever ends for 24 hours (without the use offever-reducing medication) and symptoms are improving, if these people cancontinue to properly wear a well-fitted mask around others for 5 more daysafter the 5-day isolation period. Day 0 is the first day of symptoms.

•患有轻微症状的COVID-19的儿童和成人：如果这些人在5天隔离期后，还能继续正确地在其他人周围再戴5天口罩，那么在症状出现后至少5天，发烧结束24小时(不使用退烧药)并且症状正在改善后，隔离可以结束。第0天是出现症状的第一天。

• People who are infected butasymptomatic (never develop symptoms): Isolationcan end at least 5 days after the first positive test (with day 0 being thedate their specimen was collected for the positive test), if these people cancontinue to wear a properly well-fitted mask around others for 5 more daysafter the 5-day isolation period. However, if symptoms develop after a positivetest, their 5-day isolation period should start over (day 0 changes to thefirst day of symptoms)*

•无症状感染者(从未出现症状)：隔离可在首次阳性检测后至少5天结束(第0天为收集标本进行阳性检测的日期)，前提是这些人在5天隔离期后仍能继续正确佩戴的口罩与他人接触5天。但是，如果在检测呈阳性后出现症状，则应重新开始5天的隔离期(第0天改为出现症状的第一天)*

• People who have moderate COVID-19illness: Isolate for 10 days.

•COVID-19中度患者：隔离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 10days and up to 20 days after symptom onset, and after fever ends (without theuse of fever-reducing medication) and symptoms are improving, may be warranted.

•病情严重的人(即需要住院、重症监护或通气支持的人)：可能有必要将隔离和预防措施的持续时间延长至症状出现后至少10天至20天，并且在发烧结束(不使用退烧药)和症状有所改善后。

• People who are moderately or severelyimmunocompromised might have a longer infectious period: Extend isolation to 20 or more days (day 0 is the first day ofsymptoms or a positive viral test). Use a test-based strategy and consult withan infectious disease specialist to determine the appropriate duration ofisolation and precautions.

•中度或严重免疫功能低下的人可能会有更长的感染期：将隔离时间延长至20天或更长时间(第0天是出现症状或病毒检测呈阳性的第一天)。使用基于测试的策略，并咨询传染病专家，以确定适当的隔离时间和预防措施。

*The additional 5-day isolation period withmasking for asymptomatic and mildly symptomatic patients has no practicalimplication in anesthesia care.Patientsin these categories should be considered infectious for anesthesia carepurposes for the full 10 days.

*对无症状和轻度症状患者额外的5天口罩隔离期在麻醉照护中没有实际意义。在麻醉照护的10天内，这些类别的患者应该被认为是有传染性的。

Consultation with infection control expertsis strongly advised prior to discontinuing precautions for patients with severeto critical illness or who are severely immunocompromised. Clinical judgmentultimately prevails when deciding whether a patient remains infectious.Maintaining transmission-based precautions and repeat RT-PCR testing may be appropriateif clinical suspicion of ongoing infection exists.

对于重症、危重症患者或免疫功能严重受损的患者，在停止预防措施之前，强烈建议咨询感染控制专家。在决定病人是否仍然具有传染性时，临床判断最终占上风。如果临床怀疑存在持续感染，保持基于传播的预防措施和重复RT-PCR检测可能是合适的。

If a patient suspected of having SARS-CoV-2infection is never tested, the decision to discontinue transmission-basedprecautions can be made using the symptom-based strategy described above.

如果怀疑患有SARS-CoV-2感染的患者从未进行过检测，则可以使用上述基于症状的策略来决定避免传播的预防措施。

Other factors, such as advanced age,diabetes mellitus, or end-stage renal disease, may pose a much lower degree ofimmunocompromise; their effect upon the duration of infectivity for a givenpatient is not known.

其他因素，如高龄、糖尿病或终末期肾病，可能造成较低程度的免疫损害；它们对特定患者的传染性持续时间的影响尚不清楚。

Ultimately, the degree of immunocompromisefor the patient is determined by the treating provider, and preventive actionsare tailored to each individual and situation.

最终，患者的免疫损害程度由治疗提供者决定，预防措施针对每个人及其情况而定。

What is the appropriate length of timebetween recovery from COVID-19 and surgery/procedure with respect to minimizingpostoperative complications?

为了尽量减少术后并发症，从COVID-19恢复到可以手术之间的合适时间是多长?

Currently there is a backlog of surgicalprocedures that have been delayed but are necessary to improve the health andquality of life of our patients.Although there is increasing information to address the timing ofsurgery after COVID-19 infection, studies continue to lag behind the emergingvariants and the likelihood that vaccinated patients have a lower a risk ofpostoperative complications as compared to unvaccinated patients. Almost allavailable data come from study periods with zero to low prevalence ofvaccination.

目前，推迟的外科手术已经出现积压，但对于改善我们患者的健康和生活质量是必要的。虽然关于COVID-19感染后手术时机的信息越来越多，但研究仍然落后于新出现的变异，以及与未接种疫苗的患者相比，接种疫苗的患者术后并发症风险较低。几乎所有可用数据都来自疫苗接种率低的研究时期。

The preoperative preparation of a surgicalpatient who is recovering from COVID-19 involves evaluation and optimization ofthe patient’s medical conditions and physiologic status. Since COVID-19 canimpact virtually all major organ systems, the timing of surgery after aCOVID-19 diagnosis is important when considering the risk of postoperativecomplications.Heretofore, protocolshave been based on limited data specific to SARS-CoV-2, expert opinion, andprevious data from other post-viral syndromes.

COVID-19恢复期外科患者的术前准备包括评估和优化患者的医疗条件和生理状态。由于COVID-19几乎可以影响所有主要器官系统，在考虑到术后并发症的风险时，COVID-19诊断后的手术时机非常重要。迄今为止，方案一直基于SARS-CoV-2特有的有限数据、专家意见以及以前来自其他病毒后综合征的数据。

An early limited study of 122 patientsfound a significantly higher risk of pulmonary complications within the firstfour weeks after SARS-CoV-2 diagnosis. A Brazilian study of 49 patients whounderwent surgery with a median delay of 25 days after asymptomatic COVID-19did not have increased complications when compared to a cohort of patients witha negative SARS-CoV-2 test.

一项对122名患者的早期有限研究发现，在SARS-CoV-2诊断后的前四周内，肺部并发症的风险明显更高。巴西的一项研究对49名无症状COVID-19患者进行了手术，与一组SARS-CoV-2检测阴性的患者相比，这些患者的并发症没有增加。

Subsequently, a multi-country (116countries), multi-center (1674 hospitals) study, in a mixture of high incomeand low/middle income countries, followed more than 140,000 patients with 3,127having COVID-19 infections before surgery.Data were collected from surgery in October 2020, meaning that none ofthese patients had received even one vaccination. They reported increased risks of mortalityand morbidity—especially with pulmonary complications--up to 7 weeks post COVIDdiagnosis, although the confidence interval for patients in the 5-6 week cohortsuggests that there may not be a true difference in this group. This data foundincreased risks to be present at 5-6 weeks regardless of being asymptomatic orsymptomatic, older or younger than 70, having major or minor surgery, orundergoing elective or emergency surgery. Mortality data is summarized in the table below. Finally, patients with ongoing symptoms at ≥7weeks were at increased risk for complications versus patients withoutsymptoms.

随后，一项多国(116个国家)、多中心(1674家医院)的研究，在高收入和中低收入国家进行，随访了14万多名患者，其中3127人在手术前感染了covid - 19。数据是从2020年10月的手术中收集的，这意味着这些患者都没有接种过疫苗。尽管5-6周队列患者的置信区间表明该组可能没有真正的差异，但是他们报告了COVID诊断后长达7周的死亡和发病率风险增加，特别是肺部并发症。该数据发现，无论无症状或有症状，年龄大于或小于70岁，接受大手术或小手术，或接受择期或急诊手术，5-6周时风险均增加。死亡率数据摘要载于下表。最后，与无症状患者相比，持续症状≥7周的患者发生并发症的风险增加。

登录/注册后可看大图

4ee6a8fd10e9ca427a31b72e2c32961d.png (97.29 KB, 下载次数: 4)

下载附件

2023-1-8 21:33 上传

A second U.S. study covering a timeline ofpatients with a COVID-19 diagnosis and surgery up to May 31, 2021 reviewed 5479surgical patients following COVID-19 infection.Immunization status was not given but the study period ranged from atime of zero vaccination until a period when about 30% of the US adultpopulation had received at least one vaccination. The results corroborate the above findingsand report higher postop complications of pneumonia and respiratory failure at0-4 weeks and continued higher postoperative pneumonia complications 4-8 weekspost PCR diagnosis.

美国的第二项研究涵盖了截至2021年5月31日的COVID-19诊断和手术患者的时间表，研究了5479名COVID-19感染后的手术患者。研究人员没有给出免疫状况，但研究期间从零疫苗接种到约30%的美国成年人至少接种了一次疫苗。结果证实了上述发现，并报道了在PCR诊断后0-4周肺炎和呼吸衰竭的术后并发症较高，4-8周后持续较高的术后肺炎并发症。

Of note, a consensus-based statement fromthe United Kingdom recommends “delaying surgery, whenever feasible for aminimum of 7 weeks after known SARS-CoV-2 infection.“

值得注意的是，来自英国的一份基于共识的声明建议“在已知的SARS-CoV-2感染后，尽可能推迟手术至少7周”。

To date, there are no robust data onpatients recovering from more recent Delta and Omicron variants. According tothe CDC, the Omicron variant causes less severe disease, and is more likely toreside in the oro- and nasopharynx without infiltration and damage to thelungs.It should also be noted thatseverity likely varies by vaccination status. Some have extrapolated thesefacts to a conclusion that risk in patients who are vaccinated and arerecovering from Omicron should be less. However plausible, such a conclusion remains unproven. SARS-CoV-2 affects other organ systems beyondthe pulmonary system (e.g., thromboembolic events including stroke,myocarditis, renal failure).

迄今为止，还没有关于患者从最近的Delta和Omicron变异中恢复的可靠数据。根据美国疾病控制与预防中心的说法，Omicron变异导致的疾病不那么严重，而且更有可能存在于口咽部和鼻咽部，不会浸润和损害肺部。还应注意的是，严重程度可能因接种疫苗情况而异。有人根据这些事实推断出这样一个结论：接种了疫苗并正在从Omicron中恢复的患者的风险应该更小。无论这一结论多么可信，它仍未得到证实。SARS-CoV-2影响肺部系统以外的其他器官系统(例如血栓栓塞事件，包括中风、心肌炎、肾衰竭)。

登录/注册后可看大图

98d83776518a201dd62cd5ba59ee9dcd.png (421.02 KB, 下载次数: 8)

下载附件

2023-1-8 21:33 上传

Residual symptoms such as fatigue,shortness of breath, and chest pain are common in patients who have hadCOVID-19 (10,11). These symptoms can be present more than 60 days afterdiagnosis (11). In addition, COVID-19 may have long term deleterious effects onmyocardial anatomy and function (12). A more thorough preoperative evaluation,scheduled further in advance of surgery with special attention given to thecardiopulmonary systems, should be considered in patients who have recoveredfrom COVID-19 and especially those with residual symptoms.

疲劳、呼吸短促和胸痛等残留症状在COVID-19患者中很常见。这些症状可在诊断后60天以上出现。此外，COVID-19可能对心肌解剖和功能有长期的有害影响。对于从COVID-19中恢复的患者，特别是那些有残留症状的患者，应考虑在手术前进一步安排更彻底的术前评估，并特别注意心肺系统。

Is repeat SARS-CoV-2 testing needed?

是否需要重复SARS-CoV-2检测?

At present, the CDC does not recommendre-testing for COVID-19 within 90 days of symptom onset (13). Repeat PCRtesting in asymptomatic patients is strongly discouraged since persistent orrecurrent positive PCR tests are common after recovery. However, if a patientpresents within 90 days and has recurrence of symptoms, re-testing andconsultation with an infectious disease expert should be considered.Once the 90-day recovery period has ended, thepatient should undergo one pre-operative nasopharyngeal PCR test ideally ≤three days prior to the procedure.

目前，美国疾病控制与预防中心不建议在症状出现后90天内重新检测COVID-19。在无症状患者中，强烈不鼓励重复PCR检测，因为持续或复发的PCR检测阳性在康复后很常见。但是，如果患者在90天内出现症状并复发，则应考虑重新检测并咨询传染病专家。90天恢复期结束后，患者应在术前≤3天进行一次鼻咽PCR检测。

These recommendations are undercontinuous review and will be updated as additional evidence becomes available.

这些建议正在不断审查中，并将在获得更多证据时予以更新。

Appendix I

• Asymptomatic or Presymptomatic Infection:Individuals who test positive for SARS-CoV-2 using a virologic test (i.e., anucleic acid amplification test [NAAT] or an antigen test) but who have nosymptoms that are consistent with COVID-19.

• Mild Illness: Individuals who have any ofthe various signs and symptoms of COVID-19 (e.g., fever, cough, sore throat,malaise, headache, muscle pain, nausea, vomiting, diarrhea, loss of taste andsmell) but who do not have shortness of breath, dyspnea, or abnormal chestimaging.

• Moderate Illness: Individuals who showevidence of lower respiratory disease during clinical assessment or imaging andwho 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 ofoxygen to fraction of inspired oxygen (PaO2/FiO2) <300 mm Hg, a respiratoryrate >30 breaths/min, or lung infiltrates >50%.

• Critical Illness: Individuals who haverespiratory failure, septic shock, and/or multiple organ

dysfunction.

•无症状或症状前感染：通过病毒学检测(即核酸扩增检测[NAAT]或抗原检测)检测出SARS-CoV-2阳性，但没有与COVID-19一致的症状。

•轻度疾病：有任何COVID-19的体征和症状(例如，发烧、咳嗽、喉咙痛、不适、头痛、肌肉疼痛、恶心、呕吐、腹泻、味觉和嗅觉丧失)，但没有呼吸短促、呼吸困难或胸部影像学异常。

•中度疾病：在临床评估或成像中显示下呼吸道疾病证据，并且氧饱和度(SpO2)≥94%。

•严重疾病：SpO2 <94%，动脉氧分压与吸入氧分数之比(PaO2/FiO2) <300毫米汞柱，呼吸频率>30次/分钟，或肺浸润>50%。

•危重疾病：有呼吸衰竭、感染性休克、多器官功能障碍。

往期精彩内容:

新冠病毒感染患者麻醉科重症监护室（AICU）诊疗参考方案（南京市第一医院）

直播预告｜特别专题讲座：美国抗疫治疗经验和最新进展（三）：病例讨论（1月8日）

麻醉和“新冠后综合征”：既往 SARS-CoV-2 感染患者的围手术期注意事项新冠感染和择期手术的麻醉以及时间安排：当前的一些证据
知识更新 | 新冠病毒感染后的择期手术最佳时机是何时？该如何进行风险评估？
来自美国的实践：如何最大程度降低医护人员感染风险？如果医务人员发生感染，何时可以返岗？

......

END

登录/注册后可看大图

		自动登录	找回密码
密码			会员注册

中英双语：美国麻醉医师协会ASA和麻醉患者安全基金会关于COVID-19感染后患者的择期

马上注册，享用更多功能，让你轻松玩转论坛

个人中心