Performance of prognostic scores in prediction of 30-day postoperative mortality in COVID-19 patients after emergency surgery: A retrospective cohort study.

Background: : Risk assessment with prognostic scoring, though important, is scarcely studied in emergency surgical patients with COVID-19 infection. Methods and Material: We conducted a retrospective cohort study on adult emergency surgical patients with COVID-19 infection in our institute from 1 May 2020 to 31 October 2021 to find the 30-day postoperative mortality and predictive accuracy of prognostic scores. We assessed the demographic data, prognostic risk scores (American Society of Anesthesiologists-Physical Classification (ASA-PS), Sequential Organ Failure Assessment (SOFA), Quick SOFA (qSOFA), Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and Portsmouth-POSSUM (P-POSSUM) scores), surgical and anesthetic factors. We assessed the postoperative morbidity using the Clavien-Dindo scale and recorded the 30-day mortality. Correlation of prognostic scores and mortality was evaluated using Univariate Cox proportional hazards regression, receiver operating characteristic curve (ROC), Youden's index and Hosmer- Lemeshow goodness of fit model. Results: Emergency surgery was performed in 67 COVID-19 patients with postoperative complication and 30-day mortality rate of 33% and 19%, respectively. A positive qSOFA and ASAPS IIIE/IVE had a 9.03- and 12.7-times higher risk of mortality compared to a negative qSOFA and ASA-PS IE/IIE (P < 0.001), respectively. Every unit increase of SOFA, POSSUM and P-POSSUM scores was associated with a 50%, 18% and 17% higher risk of mortality, respectively. SOFA, POSSUM and P-POSSUM AUCROC curves showed good discrimination between survivors and non-survivors (AUC 0.8829, 0.85 and 0.86, respectively). Conclusions: SOFA score has a higher sensitivity to predict 30-day postoperative mortality as compared to POSSUM and P-POSSUM. However, in absence of a control group of non-COVID-19 patients, actual risk attributable to COVID-19 infection could not be determined.

Anesthetic challenges while performing emergency laparotomy in a patient having COVID-19 infection.

An elderly hypertensive lady presented with fever, respiratory symptoms, and mild abdominal discomfort and was diagnosed to have COVID-19 pneumonia. Respiratory symptoms improved with steroids, awake proning, high flow nasal cannula oxygen therapy and antibiotics. After 4 days, she developed non-occlusive superior mesenteric artery thrombosis, which initially responded to anticoagulants but was complicated on tenth day by intestinal obstruction necessitating emergency surgery. Challenges encountered perioperatively were multi systemic involvement, pneumonia, ventilation- perfusion mismatch, sepsis along with technical difficulties like fogging of goggles, stuck expiratory valve on anesthesia machine, inaudibility through stethoscope and discomfort due to personal protective equipment. Perioperative focus should be on infection prevention, maintenance of hemodynamics, and optimization of oxygenation with preoperative high flow nasal cannula oxygen therapy. Ultrasound lung helps in correct placement of endotracheal tube. We recommend daily machine check, taping of N95 mask to face and ambient operation theatre temperatures of 20-22°C to reduce technical problems.