以下文章来源于麻醉新超人 ，作者麻醉新超人

Timing of elective surgery and risk assessment afterSARS-CoV-2 infection: an updateSARS-CoV-2感染后手术时机的选择和风险评估：更新A multidisciplinary consensus statement on behalf of the Association of Anaesthetists,Centre for Perioperative Care, Federation of Surgical Specialty Associations, RoyalCollege of Anaesthetists, Royal College of Surgeons of EnglandK. El-Boghdadly,1,2T. M. Cook,3,4T. Goodacre,5 J. Kua,6S. Denmark,7 S. McNally,8N. Mercer,9 S. R. Moonesinghe10 and D. J. Summerton11,121 Consultant, Department of Anaesthesia and Peri-operative Medicine, Guy’s and St Thomas’ NHS Foundation Trust,London, UK2 Honorary Senior Lecturer, King’s College London, London, UK3 Consultant, Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS FoundationTrust, Bath, UK4 Honorary Professor, University of Bristol, Bristol, UK5 Consultant, Department of Plastic and Reconstructive Surgery, Manor Hospital, Oxford, UK6 Fellow, Health Services Research Centre, London, UK7 Chair, Patient and Public Group, Royal College of Surgeons of England, London, UK8 Consultant, Department of Orthopaedic Surgery, Eastbourne Hospital, Eastbourne, UK9 Consultant, Cleft Unit of the South West of England, Bristol Dental School, Bristol, UK10 Professor and Head of Centre for Peri-operative Medicine, University College London, London, UK11 Consultant, Department of Urology, Leicester General Hospital, Leicester, UK12 Honorary Professor, University of Leicester, Leicester, UKSummaryThe impact of vaccination and new SARS-CoV-2 variants on peri-operative outcomes is unclear. We aimed to update previously published consensus recommendations on timing of elective surgery after SARS-CoV-2 infection to assist policymakers, administrative staff, clinicians and patients. The guidance remains that patients should avoid elective surgery within 7 weeks of infection, unless the benefits of doing so exceed the risk of waiting. We recommend inpidualised multidisciplinary risk assessment for patients requiring elective surgery within 7 weeks of SARS-CoV-2 infection. This should include baseline mortality risk calculation and assessment of risk modifiers (patient factors; SARS-CoV-2 infection; surgical factors). Asymptomatic SARS-CoV-2 infection with previous variants increased peri-operative mortality risk three-fold throughout the 6 weeks after infection, and assumptions that asymptomatic or mildly symptomatic omicron SARS-CoV-2 infection does not add risk are currently unfounded. Patients with persistent symptoms and those with moderate-to-severe COVID-19 may require a longer delay than 7 weeks. Elective surgery should not take place within 10 days of diagnosis of SARSCoV-2 infection, predominantly because the patient may be infectious, which is a risk to surgical pathways, staff and other patients. We now emphasise that timing of surgery should include the assessment of baseline and increased risk, optimising vaccination and functional status, and shared decision-making. While these recommendations focus on the omicron variant and current evidence, the principles may also be of relevance to future variants. As further data emerge, these recommendations may be revised.摘要：疫苗接种和新的SARS-CoV-2变异对围手术期结果的影响尚不清楚。我们的目的是更新先前发表的关于SARS-CoV-2感染后手术时机的选择的共识建议，协助决策者、行政人员、临床医生和患者。指导方针仍然是，患者应在感染后7周内避免择期手术，除非这样做的好处超过了等待的风险。我们建议对SARS-CoV-2感染后7周内需要择期手术的患者进行个体化的多学科风险评估。这应包括基线死亡风险的计算以及评估风险调节因素（患者因素、SARS-CoV-2感染、手术因素）。无症状的SARS-CoV-2感染在感染后的6周内使围手术期死亡风险增加了3倍，无症状或轻度症状奥密克戎SARS-CoV-2感染并不增加风险的假设目前没有根据。症状持续和中度至重度COVID-19患者可能需要延迟时间超过7周。不应在确诊为SARS-CoV-2感染后10天内进行择期手术，主要是因为患者可能具有传染性，这对手术途径、工作人员和其他患者都有风险。我们现在强调，手术时机应该包括评估基线和增加的风险，优化疫苗接种和功能状态以及共同决策。虽然这些建议集中在奥密克戎变异株和当前的证据上，但这些原则也可能与未来的变异株相关。随着进一步数据的出现，这些建议可能会被修改。Recommendations1There is currently no evidence on peri-operative outcomes after SARS-CoV-2 vaccination and the omicron variant. Therefore, previous recommendations that, where possible, patients should avoid elective surgery within 7 weeks of SARS-CoV-2 infection remain, unless the benefifits of doing so exceed the risk of waiting. We recommendinpidualised risk assessment for patients with elective surgery planned within 7 weeks of SARS-CoV-2 infection.2 Surgical patients should have received pre-operative COVID-19 vaccination, with three doses wherever possible, with the last dose at least 2 weeks before surgery. Confirming and optimising vaccination status should be actioned as soon as possible, either before primary care referral or at surgical decision-making.3 Current measures designed to reduce the risk of patients acquiring SARS-CoV-2 infection in the perioperative period should continue and, in view of the increased transmissibility of omicron, should be augmented (e.g. respiratory protective equipment) where evidence supports this.4 Patients should be requested to notify the surgical team if they test positive for SARS-CoV-2 infection within 7 weeks of their planned operation date. From there, a conversation should take place between the peri-operative team and the patient about the risks and benefits of deferring surgery.5 Elective surgery should not take place within 10 days of diagnosis of SARS-CoV-2 infection, predominantly because the patient may be infectious, which is a risk to surgical pathways, staff and other patients.6 Asymptomatic SARS-CoV-2 infection with previous variants increased mortality risk three-fold throughout the 6 weeks after infection. Given the lack of evidence with peri-operative omicron infection, assumptions that asymptomatic or mildly symptomatic infection does not add risk are currently unfounded.1目前没有关于接种SARS-CoV-2疫苗和奥密克戎变异株后的围手术期结局的证据。因此，以前的建议是，患者应避免在SARS-CoV-2感染后7周内进行择期手术，除非这样做的好处超过了等待的风险。我们建议对SARS-CoV-2感染后7周内计划进行择期手术的患者进行个体化风险评估。2手术患者术前应接受COVID-19疫苗接种，尽可能接种3剂，术前至少2周接种最后一剂。在初级保健转诊或手术决策之前，应尽快采取确认和优化疫苗接种状态。3目前旨在减少患者在围手术期获得SARS-CoV-2感染风险的措施应继续实施，鉴于奥密克戎变异株的传播能力增加，当有证据支持时，应加强（如呼吸保护设备）。4如果患者在计划手术日期后7周内对SARS-CoV-2感染检测呈阳性，应要求他们通知手术团队。从这里开始，术前团队和患者应该就推迟手术的风险和益处进行谈话。5在确诊SARS-CoV-2感染后10天内不应进行择期手术，主要是因为患者可能具有传染性，这对手术路径、工作人员和其他患者都有风险。6在感染后的6周内，先前变异的无症状SARS-CoV-2感染使死亡风险增加了3倍。鉴于缺乏围手术期感染的证据，无症状或轻度症状感染不会增加风险的假设目前是没有根据的。7 If elective surgery is considered within 7 weeks of diagnosis of SARS-CoV-2 infection, we recommend multidisciplinary discussions with the patient occur with documentation of the risks and benefits.a） All patients should have their risk of mortality (and complications, where possible) calculated using a validated risk score.b）Risk modifiers based on patient factors (age; comorbid status); SARS-CoV-2 infection (timing; severity of initial infection; ongoing symptoms); and surgical factors (clinical priority; risk of disease progression; complexity of surgery) can then be applied to help estimate how underlying risk would be altered by undertaking surgery within 7 weeks of infection.c） Patients should be advised that a decision to proceed with surgery within 7 weeks will be pragmatic rather than evidence-based.8 Patients with persistent symptoms and those with moderate-to-severe COVID-19 (e.g. those who were hospitalised) remain likely to be at greater risk of morbidity and mortality, even after 7 weeks. Therefore, delaying surgery beyond this point should be considered, balancing this risk against any risks associated with such delay.9 In patients with recent or peri-operative SARS-CoV-2 infection, avoidance of general anaesthesia in favour of local or regional anaesthetic techniques should be considered.10 Rather than emphasising timing alone, we emphasise timing, assessment of baseline and increased risk, and shared decision-making.11 All patients awaiting surgery should address modifiable risk-factors, such as through pre-operative exercise, nutritional optimisation and stopping smoking.7如果在确诊SARS-CoV-2感染后7周内考虑择期手术，我们建议与患者进行多学科讨论，并记录风险和益处。a)所有患者的死亡风险(和并发症，如果可能的话)应使用有效的风险评分进行计算。b)基于患者因素(年龄；共病状态)；SARS-CoV-2感染(时机；初次感染的严重程度；持续症状)；和手术因素(临床优先；疾病进展的风险；手术的复杂性)可用于帮助评估在感染后7周内进行手术将如何改变潜在风险。c)应告知患者，在7周内做出手术的决定是务实的，而不是基于证据的。8即使在7周之后，症状持续的患者和中重度新冠肺炎患者(如住院患者)仍有可能面临更高的发病率和死亡率风险。因此，应该考虑将手术延迟超过7周，权衡这种风险和与这种延迟相关的任何风险。9对于近期或围手术期SARS-CoV-2感染的患者，应考虑避免全身麻醉而采用局部或区域麻醉技术。10我们不仅仅强调时机，而是强调时机、基线和增加风险的评估以及共同决策。11所有等待手术的患者都应解决可改变的危险因素，例如通过术前锻炼、营养优化和戒烟。IntroductionPre-operative SARS-CoV-2 infection was previously shown to be associated with signifificantly increased risks of morbidity and mortality. Data in the early phases of the pandemic demonstrated that peri-operative SARS-CoV-2 infection was associated with clinically important increases in mortality, in some cases more than a 10-fold increase. Furthermore, when surgery was undertaken within 6 weeks of infection, postoperative morbidity and mortality were also increased. Notably, increased peri-operative risk remained consistently elevated until 7 weeks after SARS-CoV-2 infection, at which point it returned to baseline. Therefore, recommendations were made to delay elective surgery for 7 weeks after SARS-CoV-2 infection, unless the risks of deferring surgery outweighed the risk of postoperative morbidity or mortality associated with SARS-CoV-2 infection.As the COVID-19 pandemic has progressed, disease therapy and prevention have developed, including vaccination. Variants have emerged that differ in terms of their transmissibility, the severity of illness they cause and their ability to infect vaccinated patients. The omicron SARS-CoV-2 variant in particular has increased transmissibility and the potential to evade immunity acquired through previous SARS-CoV-2 infection, vaccination or both. This variant also leads to less severe clinical illness than previous variants and this is particularly so for patients who are vaccinated, which, in some countries is the majority of surgical patients. Compounding these concerns, disruption to the delivery of surgical care during the pandemic has signifificantly increased the number of patients awaiting surgery globally. In the face of these uncertainties, and the expectation of the imminent return to augmented surgical activity, clinical decision-making regarding timing of surgery has become challenging. We therefore aim to provide an update to the previously published consensus statement on SARS-CoV-2 infection, COVID-19 and timing of elective surgery in adults to assist policymakers, administrative staff, clinicians and patients. This document focuses on the omicron variant, which is now strongly dominant in many countries. However, the principles may also be of relevance to future variants.之前的研究表明，术前SARS-CoV-2感染与发病率和死亡率的显著增加相关。疫情早期阶段的数据表明，围手术期SARS-CoV-2感染与临床上重要的死亡率增加相关，在某些情况下增加超过10倍。此外，如果在感染后6周内进行手术，术后发病率和死亡率也会增加。值得注意的是，围手术期风险的增加持续升高，直到SARS-CoV-2感染后7周，此时恢复到基线水平。因此，建议在SARS-CoV-2感染后将择期手术推迟7周，除非推迟手术的风险超过与SARS-CoV-2感染相关的术后发病率或死亡率的风险。随着新冠肺炎疫情的进展，疾病治疗和预防也有了发展，包括疫苗接种。已经出现的变异株的传染性、它们引起的疾病的严重程度和它们感染接种疫苗的患者的能力方面有所不同。特别是奥密克戎SARS-CoV-2变种具有更高的传播性和逃避通过以前的SARS-CoV-2感染、疫苗接种或两者获得的免疫的潜能。这种变异株还导致比以前的变异株更轻的临床疾病，这对于接种疫苗的患者尤其如此，在一些国家，大多数是外科手术患者。更令人担忧的是，疫情期间手术服务的中断大大增加了全球等待手术的病人数量。面对这些不确定性，以及外科手术活动即将恢复的预期，关于手术时机的临床决策变得具有挑战性。因此，我们旨在对之前发布的关于SARS-CoV-2感染、新冠肺炎和成人择期手术时机的共识声明进行更新，以帮助决策者、行政人员、临床医生和患者。本文件重点介绍奥密克戎变异株，该变异株目前在许多国家占据主导地位。但是，这些原则也可能与未来的变异株相关。Prevention of peri-operative SARS-CoV-2 infectionThere is no robust evidence demonstrating whether the risks of morbidity and mortality after pre-operative or peri-operative infection with the omicron SARS-CoV-2 variant are lower than with earlier variants. Evidence informing this question is expected but, meanwhile, it remains important to minimise the risk of patients either arriving at hospital incubating SARS-CoV-2 or acquiring it in hospital. Both are signifificant challenges with the omicron variant due to high transmissibility and high community, nosocomial and healthcare staff infection rates. With millions of patients on waiting lists, actions that reduce the risk of service disruption by protecting the healthcare workforce and service are important in addition to inpidual patient outcomes.Vaccination is the most effective intervention to reduce the severity of infection and thus peri-operative complications, and should be strongly encouraged pre-operatively. Vaccination with two doses has only a modest impact on the risk of infection with the omicron variant but has a moderate impact on reducing the severity of COVID-19, while a third vaccination dose signifificantly reduces the risk of infection and severity of illness. Vaccination is likely to have clinical effificacy within 2 weeks and therefore patients who are partially vaccinated are likely to benefifit from a further dose or doses in the pre-operative period, ideally arranged in primary care at the point of referral for consideration of surgery. If not done by the time patients have presented for surgical assessment, then vaccination should be strongly encouraged by surgical teams at this time. Modelling estimates that the impact of vaccination against COVID-19 on reducing mortality was more marked in patients undergoing surgery than that of the general population. This emphasises the importance of pre-operative patient vaccination. Prevention of staff–patient disease transmission in hospitals is also important to reduce risk. Mandatory vaccination of healthcare staff is currently under review as a condition of retaining or gaining such employment in the UK. Irrespective of national policy, staff caring for patients having surgery, and particularly those who are high risk, should be vaccinated against COVID-19, wherever possible.Patients should be informed that, should they become SARS-CoV-2 positive before surgery, a risk assessment and possible deferment of surgery will be triggered (see online Supporting Information Appendix S1). Further actions to reduce the risk of peri-operative patient infection with SARS-CoV-2 include:•Adherence by patients awaiting surgery to practices that reduce the risk of community-acquired SARS-CoV-2 infection, such as mask-wearing, social distancing, hand hygiene, appropriate pre-operative self-isolation and adherence to shielding advice, where indicated;• Screening of hospital staff to prevent contact with infectious staff ;• Maintaining dedicated pathways that separate patients who have been screened and tested negative for SARS-CoV-2 infection from contact with patients with suspected or confifirmed infection and the staff and locations involved in their treatment;•Adherence by staff to practices that reduce the risk of in-hospital SARS-CoV-2 transmission, such as the use of appropriate respiratory protective equipment, social distancing, hand hygiene and adherence to self-isolation rules, where indicated;• Institutional implementation of environmental ventilation, air fifiltering, decontamination and provision of appropriate respiratory protective equipment consistent with best practice;• Minimising time spent by patients within healthcare environments;• Maintaining SARS-CoV-2 risk-reducing measures once discharged from hospital to avoid potential infection during the early postoperative recovery phase, which could negatively affect patient outcomes.预防SARS-CoV-2围手术期感染没有强有力的证据表明，奥密克戎SARS-CoV-2变异体在术前或围手术期感染后的发病率和死亡率风险是否低于早期变异体。预计将有证据说明这一问题，但同时，最大限度地降低患者抵达医院时或住院时感染SARS-CoV-2的风险仍然很重要。由于高传播性和高社区、医院和医护人员感染率，这两者对奥密克戎变异株都是重大挑战。由于等候名单上有数百万患者，除了患者个人的之外，通过保护医护人员和服务来降低服务中断风险的行动也很重要。疫苗接种是减少感染严重程度和围手术期并发症的最有效的干预措施，应在手术前大力提倡。两剂疫苗接种对感染奥密克戎变异体的风险影响有限，但对降低COVID- 19的严重程度影响中等，而第三剂疫苗接种则显著降低了感染的风险和疾病的严重程度。疫苗接种可能在2周内产生临床疗效，因此，部分接种疫苗的患者很可能从术前期间的进一步剂量中获益，理想的安排在初级保健的转诊点考虑手术。如果在患者接受手术评估时还没有接种疫苗，那么手术团队此时应该强烈鼓励接种疫苗。模型估计，与普通人群相比，接受手术的患者接种新冠肺炎疫苗对降低死亡率的影响更显著。这强调了术前患者接种疫苗的重要性。预防医院内的员工-患者疾病传播对于降低风险也很重要。作为在英国保留或获得此类工作的一个条件，医护人员的强制性疫苗接种目前正在审查中。不管国家政策如何，只要有可能，照顾手术病人的工作人员，特别是那些高危病人，都应该接种新冠肺炎疫苗。应告知患者，如果他们在术前确诊SARS-CoV-2阳性，将引发风险评估并可能推迟手术。降低围手术期患者感染SARS-CoV-2病毒风险的进一步措施包括:l等待手术的患者坚持减少社区获得性SARS-CoV-2感染风险的做法，如戴口罩、保持社交距离、手部卫生、适当的术前自我隔离以及在需要时坚持防护建议；l对医院工作人员进行筛查，以防止与有传染性的工作人员接触；l保持专用通道，将SARS-CoV-2感染筛查和检测呈阴性的患者与疑似或确诊感染患者以及参与其治疗的工作人员和地点隔离开来；l工作人员遵守减少医院内SARS-CoV-2病毒传播风险的做法，如使用适当的呼吸防护设备、社交距离、手部卫生和遵守自我隔离规则(如有说明)；l从制度上实施环境通风、空气过滤、净化，并提供符合最佳做法的适当呼吸保护设备；l最大限度地减少患者在医疗环境中的时间；l出院后继续采取降低SARS-CoV-2风险的措施，以避免术后早期恢复阶段的潜在感染，这可能会对患者的预后产生负面影响。Timing of elective surgery after SARS-CoV-2 infectionA combination of widespread testing and high community infection rates means that it is likely that many surgical patients will present with pre-operative or peri-operative SARS-CoV-2 infection. They might be asymptomatic, mildly symptomatic or pre-symptomatic. Contact tracing data indicate high rates of symptomatic infection, with 89.8% for omicron compared with 85.5% of delta cases. However, the severity of COVID-19 following omicron infection appears to be milder than with previous variants. Rates of hospitalisation, hospital length of stay and case fatality rate are all reportedly lower. This logically leads to the hypothesis that the absolute risk of harm (morbidity or mortality) of undergoing surgery following recent SARS-CoV-2 infection could be lower than with previous variants. However, this hypothesis is untested with no data so far to confifirm or refute it.While there may be a temptation to ignore omicron SARS-CoV-2 infection with no or mild symptoms as a pre-operative risk-factor, it is notable that with previous variants, asymptomatic SARS-CoV-2 infection increased mortality risk around three-fold throughout the 6 weeks after infection. No data on omicron SARS-CoV-2 infection are available, and therefore assumptions that asymptomatic or mildly symptomatic infection does not add risk are currently unfounded.Given the uncertainty of the impact of novel variables (variants, symptoms and vaccination) on peri-operative outcomes, the default position should be to avoid elective surgery within 7 weeks of a diagnosis of SARS-CoV-2 infection, even in asymptomatic patients. However, we emphasise that this should be balanced against the consequences of this delay. If this is outweighed by the clinical risk of deferring surgery, such delay would be inappropriate. Baseline risk should be calculated using a validated risk assessment tool, such as the Surgical Outcome Risk Tool v2 (SORT-2). How this risk could be altered by surgery within 7 weeks of diagnosis of SARS-CoV-2 infection may be estimated by consideration of risk modififiers, including: patient factors (age; comorbid and functional status); SARS-CoV-2 infection (timing; variant; severity of initial infection; ongoing symptoms); and surgical factors (clinical priority; risk of disease progression; complexity of surgery) (Fig. 1, Box 1). Understanding these risks should inform shared decision-making between the multidisciplinary team and the patient. Documentation should record the risks and benefifits of timing of surgery and the process of decision-making. Ideally, patients should be advised that a decision to proceed with surgery within 7 weeks will not be evidence-based, but pragmatic.The increased risk associated with surgery after SARS-CoV-2 infection does not fall until 7 weeks, thus there is no benefifit in partial delay (e.g. the increased risk at 6 weeks is similar to that at 3 weeks). Therefore, decision-making should be dichotomised: defer for 7 weeks or do not defer.Patients with persistent symptoms and those with moderate-to-severe COVID-19 (e.g. those who were hospitalised) remain likely to be at greater risk of morbidity and mortality, even after 7 weeks. Therefore, delaying surgery beyond this point should be considered, balancing this risk against any risks associated with such delay. Specialist assessment and inpidualised, multidisciplinary peri-operative management are advised.Elective surgery should be avoided during the period that a patient may be infectious (10 days). This includes patients who test positive for SARS-CoV-2 during pre-operative screening (incidental SARS-CoV-2). Patients who are infectious pose a risk to healthcare workers, other patients and safe pathways of care. Furthermore, incidental SARS-CoV-2 may be pre-symptomatic and may be associated with increased risk of postoperative morbidity and mortality in patients having elective surgery. When emergency surgery is required during this period, full transmission-based precautions should be undertaken.Risk assessments should take place at the time of scheduling surgery. Patients should also be informed that a positive pre-operative SARS-CoV-2 test may trigger a review of risks of proceeding with surgery. This can be supported with a risk communication tool (Fig. 1).SARS-CoV-2感染后择期手术的时机广泛的检测和高社区感染率的结合意味着许多手术患者可能会出现术前或围手术期SARS-CoV-2感染。他们可能没有症状，轻度症状或症状前症状。接触者追踪数据表明症状性感染率很高，奥密克戎为89.8%，而delta为85.5%。然而，奥密克戎感染后新冠肺炎的严重程度似乎比以前的变异株要轻。据报道，住院率、住院时间和病死率都较低。这从逻辑上导致了一个假设，即近期SARS-CoV-2感染后进行手术的绝对危害风险(发病率或死亡率)可能低于以前的变异株。然而，这一假设未经检验，至今没有数据来证实或反驳它。虽然可能存在忽略无症状或轻微症状的奥密克戎SARS-CoV-2感染作为术前风险因素，但值得注意的是，与以前的变异株相比，无症状的SARS-CoV-2感染在感染后6周内将死亡风险增加约3倍。没有关于奥密克戎SARS-CoV-2感染的数据可用，因此无症状或轻度症状感染不会增加风险的假设目前是没有根据的。鉴于新变量(变异、症状和疫苗接种)对围手术期结局影响的不确定性，默认的立场应该是避免在SARS-CoV-2感染诊断后7周内进行择期手术，即使是无症状患者。但是，我们强调，这应该与延迟的后果相平衡。如果推迟手术的临床风险超过了这一点，这种推迟将是不适当的。应使用经验证的风险评估工具计算基线风险，如手术结果风险工具v2 (SORT-2)。这种风险如何通过在SARS-CoV-2感染诊断后7周内进行手术来改变，可以通过考虑风险修正因素来评估，包括:患者因素(年龄；共病和功能状态)；SARS-CoV-2感染(时机；变体；初次感染的严重程度；持续症状)；和手术因素(临床优先；疾病进展的风险；手术的复杂性)(图1，方框1)。了解这些风险应该为多学科团队和患者之间的共同决策提供信息。文件应记录手术时机和决策过程的风险和益处。理想情况下，患者应该被告知在7周内进行手术的决定不是基于证据的，而是务实的。SARS-CoV-2感染后与手术相关的风险增加直到7周才下降，因此部分延迟没有益处(例如，6周的风险增加与3周相似)。因此，决策应该一分为二：推迟7周或不推迟。即使在7周之后，具有持续症状的患者和患有中度至重度新冠肺炎的患者(例如，那些住院的患者)仍然可能具有更高的发病率和死亡率风险。因此，应该考虑将手术延迟超过这个时间点，权衡这种风险和与这种延迟相关的任何风险。建议进行专家评估和个体化、多学科围手术期管理。在患者可能具有传染性期间(10天)，应避免择期手术。这包括在术前筛查中SARS-CoV-2检测呈阳性的患者(偶发SARS-CoV-2)。具有传染性的患者对医护人员、其他患者和安全照护路径构成风险。此外，偶发性SARS-CoV-2可能是先兆症状，并可能与择期手术患者术后发病率和死亡率的风险增加有关。当在此期间需要紧急手术时，应采取完全基于传播的预防措施。风险评估应在安排手术时进行。还应告知患者，术前SARS-CoV-2试验呈阳性可能会引发对手术风险的评估。这可以通过风险沟通工具来支持(图1)。IsolationIt has been reported that pre-operative isolation for longer than 3 days may be associated with an increased risk of postoperative pulmonary complications [19]. Although there is uncertainty in the interpretation of these results, prolonged pre-operative isolation should be avoided unless clearly indicated. Patients should be advised to increase physical activity where feasible and adhere to prehabilitation principles during isolation and throughout the pre-operative period. This includes pre-operative exercise, nutritional optimisation and smoking cessation.隔离据报道，术前隔离超过3天可能会增加术后肺部并发症的风险。尽管对这些结果的解释存在不确定性，除非有明确的指征，否则应避免长时间的术前隔离。应建议患者在可行的情况下增加体力活动，并在隔离期间和整个术前期间遵守预适应原则。这包括术前锻炼、营养优化和戒烟。Anaesthetic techniqueEarly evidence suggested no difference in peri-operative outcomes based on the mode of anaesthesia. However, more recent evidence indicates that in patients with recent or peri-operative SARS-CoV-2 infection, local or regional anaesthetic techniques may be associated with a moderate (e.g. point estimates varying between 50–150%) reduction in the risk of postoperative pulmonary complications and mortality when compared with general anaesthesia. It is possible that these data are prone to bias through unmeasured covariates and have yet to be reproduced in the setting of omicron and vaccination. On balance, in patients with recent or peri-operative SARS-CoV-2 infection, avoidance of general anaesthesia in favour of local or regional anaesthetic techniques should be considered.麻醉技术早期证据表明，基于麻醉方式的围手术期结果没有差异。然而，最近的证据表明，在近期或围手术期SARS-CoV-2感染的患者中，与全身麻醉相比，局部或区域麻醉技术可能与术后肺部并发症和死亡率的中度降低(例如，点估计值在50-150%之间变化)相关。这些数据可能会因为未测量的协变量而产生偏差，并且尚未在克隆和疫苗接种的环境中重现。总的来说，对于近期或围手术期有SARS-CoV-2感染的患者，应考虑避免全身麻醉而采用局部或区域麻醉技术。DiscussionThe necessity to proceed with elective surgical recovery must be balanced with delivering surgery as safely as possible. Previous guidance was more robustly evidence-based and much still applies. However, there is currently a lack of data to specififically inform changes in peri-operative risk. Although this information is expected, the anticipated high number of patients with pre-operative SARS-CoV-2 omicron infection with or without previous vaccination has created uncertainty prompting pragmatic revision of our recommendations.Decisions about proceeding with surgery after SARS-CoV-2 infection require a balanced risk assessment. While the default remains to avoid surgery within 7 weeks of infection or with ongoing symptoms, this should be balanced against the risk of delay, based on clinical priority and risk of disease progression.Where delay is indicated, this should be for the full 7 weeks. If elective surgery is to take place within 7 weeks of infection or with ongoing symptoms, a multidisciplinary discussion should be undertaken that either includes the patient or is discussed with the patient as part of the process of informed consent. Risk assessment should account for patient factors, infection and peri-operative considerations, and should be mindful of the impact of this on the absolute risk of harm to the patient. Rather than emphasising timing alone, we emphasise combining timing, assessment of risk and shared decision-making.进行择期手术恢复的必要性必须与尽可能安全地实施手术相平衡。以前的指导更加基于证据，现在仍然适用。然而，目前缺乏具体告知围手术期风险变化的数据。尽管这一信息是预料之中的，但预计术前有或无疫苗接种的大量SARS-CoV-2奥密克戎感染患者产生了不确定性，促使我们对建议进行务实的修订。SARS-CoV-2感染后决定是否进行手术需要一个平衡的风险评估。虽然默认情况下仍然避免在感染或有持续症状的7周内进行手术，但应根据临床优先级和疾病进展的风险，权衡延迟的风险。如果显示有延迟，则应为整整7周。如果在感染后7周内或症状持续时进行择期手术，应进行多学科讨论，包括患者或作为知情同意程序的一部分与患者进行讨论。风险评估应考虑患者因素、感染和围手术期因素，并应注意这对伤害患者的绝对风险的影响。我们强调结合时机、风险评估和共同决策，而不是仅仅强调时机。AcknowledgementsKE is an Editor of Anaesthesia. SM is the National Clinical Director for critical and peri-operative care, NHS England and NHS Improvement. No external funding or other competing interests declared.致谢KE是《麻醉学》的编辑。SM是英国国家医疗服务体系和英国国家医疗服务体系改进部的危重病和围手术期护理的国家临床主任。未申报外部资金或其他竞争利益。Box 1Relative vs. absolute risk and population vs. inpidual risk.Best estimates indicate that underlying risk of surgery soon after SARS-CoV-2 infection is altered by factors related to the patient, their SARS-CoV-2 infection and the procedure planned. These risk modififiers inform us how relative risk changes (e.g. whether it is doubled, trebled, halved) and is useful for considering population risk. Application of these guidelines and informed consent requires understanding of a patient’s baseline risk and the impact of applying risk modififiers.Consider two patients undergoing major surgery: Patient A who is ASA physical status 2 has an estimated 1% risk of death from surgery, while Patient B who is ASA physical status 4 has a 10% risk (10-fold higher relative risk). If both patients have elective surgery within 2 weeks of a SARS-CoV-2 infection, the relative risk of death for each patient may increase four-fold, for example. For Patient A, their risk of death increases from 1% to 4%, whereas for Patient B it increases from 10% to 40%. Applying the same relative risk increase has increased Patient A’s absolute risk by 3% and Patient B’s by 30%. Thus, when considering undertaking surgery within 7 weeks of SARS-CoV-2 infection, it is necessary to calculate the inpidual patient’s risk, using a validated risk score, and then apply the risk modififiers to understand how absolute risk changes.It is important to note that within populations, harmful events may affect varying proportions of that population, for instance 50% may become infected and 20% harmed with 5% dying. For an inpidual, outcomes are dichotomous, meaning that the outcomes infection, harm and death, “100% do or 100% do not happen”方框1相对与绝对风险和群体与个体风险。最佳估计表明，SARS-CoV-2病毒感染后不久进行手术的潜在风险受到与患者、其SARS-CoV-2病毒感染和计划手术相关的因素的影响。这些风险修正因子告诉我们相对风险是如何变化的(例如，是加倍、三倍还是减半)，并且对于考虑人群风险是有用的。应用这些指南和知情同意书需要了解患者的基线风险和应用风险修正因子的影响。考虑两个接受大手术的患者：ASA2级的患者A估计有1%的手术死亡风险，而ASA4级的患者B有10%的风险(相对风险高10倍)。例如，如果两个病人都在SARS-CoV-2感染后2周内进行了择期手术，那么每个病人的相对死亡风险可能会增加4倍。对于病人A，他们的死亡风险从1%增加到4%，而对于病人B，死亡风险从10%增加到40%。应用相同的相对风险增加，患者A的绝对风险增加了3%,患者B的增加了30%。因此，当考虑在SARS-CoV-2感染7周内进行手术时，有必要使用经验证的风险评分来计算个体患者的风险，然后应用风险修正因子来了解绝对风险是如何变化的。值得注意的是，在人群中，有害事件可能影响不同比例的人群，例如50%的人可能被感染，20%的人受到伤害，5%的人死亡。对个人来说，结果是两分法的，这意味着结果感染、伤害和死亡“100%发生或100%不发生”。感染SARS-CoV-2病毒后7周内在考虑手术时沟通风险该工具适用于不再具有传染性（诊断后≥10天）的患者。步骤1评估患者的基线风险，并向患者解释。基线风险是决定患者预后的最重要因素。

步骤2 考虑在7周内产生额外风险的因素，并向患者解释这一点（风险修正因子）风险是累积的：每个风险因素对高基线风险患者的影响大于对低基线风险患者的影响n年龄>70岁nASA3-5级n大手术n持续的COVID-19症状n曾因COVID-19住院

步骤3 现在考虑SARS-CoV-2感染后推迟手术7周的风险。临床医生和患者应平衡进行手术的基线（步骤1）和额外风险（步骤2）与等待的风险。步骤4完成商定结果

注释1.与高、中、低基线风险相关的患者和手术因素示例。大多数住院病人

2.应使用经过验证的工具评估基线风险。SORT-2是一个合适的选项（httpi//www.sortsurgery.comD3.以前的SARS-CoV-2变种的数据表明，如果存在任何这些风险因素，并且在SARS-CoV-2感染后6周内进行手术，则包括死亡在内的伤害风险增加一倍以上。这种增加的风险在7周后显著降低。这是否适用于奥密克戎变体目前尚不清楚。l年龄增长会增加风险，尤其是70岁以上。lASA身体状况3-4增加风险~比ASA身体状况1-2高4倍。l持续的症状显著增加了风险。已经住院或有持续症状的患者需要个性化的风险评估。l大手术的风险比小手术高两倍。4.ASA身体状况分类：ASA 1。一个正常健康的病人。ASA 2。患有轻度全身性疾病的病人。仅轻度疾病，无实质性功能限制，例如目前吸烟者。ASA 3。患有严重全身性疾病的病人；实质性功能限制；一种或多种中度至重度疾病。ASA 4。患有持续威胁生命的严重全身性疾病的病人。ASA 5。一个不做手术就无法存活的垂死病人。5.当无法立即作出决定时，应给予患者更多时间考虑在SARS-CoV-2感染后7周内进行手术的风险和益处。Figure 1 Communicating risk when considering surgery within 7 weeks of SARS-CoV-2 infection. This is a tool that may be used for patients who are no longer infectious. Clinicians should begin by assessing baseline risk, then consider risk modififiers, followed by determining the risk of deferring surgery for 7 weeks after infection. This communication tool should be used in conjunction with our recommendations to support shared decision-making.图1SARS-CoV-2感染后7周内考虑手术的沟通风险。这是一种可以用于不再具有传染性的患者的工具。临床医生应该从评估基线风险开始，然后考虑风险修正因子，接着确定感染后推迟手术7周的风险。该沟通工具应与我们的建议结合使用，以支持共同决策。

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