翻译：张 丽 徐医2022级麻醉学研讨生
审校：赵林林 徐医附院麻醉科

american society of anesthesiologists and anesthesia patient safety foundation
joint statement on elective surgery/procedures and anesthesia for patients after
covid-19 infection
美国麻醉医生协会和麻醉患者平安基金会关于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 to perform elective surgeries while the covid-19 pandemic continues, determining the optimal timing of procedures for patients who have recovered from covid-19 infection and the appropriate level of preoperative evaluation are challenging given the current lack of evidence or precedent. the following guidance is intended to aid hospitals, surgeons, anesthesiologists, and proceduralists in evaluating and scheduling these patients. the updated recommendations detailed in this document are based upon new evidence that has come to light over the past year. the recommendations will be subject to continued evolution as new evidence emerges.
covid-19大盛行仍在持续，医院可以持续打开择期手术，鉴于当前短少根据或先例，为从covid-19感染中恢复的患者断定最佳手术机缘和恰当的术前评价水平具有应战性。以下攻略旨在协助医院、手术医生、麻醉医生和外科医生评价和组织这些患者。这篇文章具体介绍的更新主张是根据曩昔一年中发现的新根据。这些主张将跟着新根据的呈现而不断更新。
elective surgeries should be performed for patients who have recovered from covid-19 infection only when the anesthesiologist and surgeon or proceduralist agree jointly to proceed.the decision for surgery/procedure is centered on two factors: 1. is the patient still infectious? and 2. for patients that are no longer infectious what is the appropriate length of time to wait between recovery from covid and surgery/procedure in terms of risk to the patient.
关于covid-19感染恢复的患者，只需在麻醉医生和外科医生都附和的情况下，才应进行择期手术。手术的两个抉择要素：1、患者是不是还有感染性? 2、关于不再具有感染性的患者，从covid恢复到可以手术之间的恰当等候时刻是多长?
what determines when a patient confirmed to have covid-19 is no longer infectious?
怎么断定确诊患有covid-19的患者何时不再具有感染性?
the centers for disease control and prevention (cdc) provides guidance for physicians to decide when transmission-based precautions (e.g., isolation, use of personal protective equipment and engineering controls) may be discontinued for hospitalized patients, or home isolation may be discontinued for outpatients.
疾病控制和避免中心(cdc)为医生供给辅导，以抉择何时可以中止对住院患者进行根据传达的避免办法(例如阻隔、运用自个防护设备和工程控制)，或中止对门诊患者进行居家阻隔。
patients infected with sars-cov-2, as confirmed by reverse transcriptase-polymerase chain reaction (rt-pcr) testing of respiratory secretions, may be asymptomatic or symptomatic. the national institutes of health has recently updated the categories of sars-cov-2 infection into the following phenotypic expressions of covid severity. (see appendix i for full description).
对呼吸道分泌物进行回转录-聚合酶链反应(rt-pcr)检测，确诊感染sars-cov-2的患者可以无表现，也可以有表现。美国国立清洁研讨院迩来将sars-cov-2感染的品种更新为以下按covid严峻程度的表型表达(详见附录一)。
? asymptomatic or presymptomatic infection
? mild illness.
? moderate illness
? severe illness
? critical illness
?无表现或表现前感染（暂时还没有呈现表现，但今后会有表现呈现）
?纤细疾病
?中度疾病
?重度疾病
?危重疾病
severely immunocompromised patients, whether suffering from asymptomatic or symptomatic covid-19, are considered separately.
免疫功用严峻受损的患者，不管是无表现的covid-19患者仍是有表现的covid-19患者，都被单独思考。
current data indicate that, in patients with mild to moderate covid-19, repeat rt-pcr testing may detect sars-cov-2 rna for a prolonged period after symptoms first appear.according to the centers for disease control and prevention (cdc), it is rare to recover replication-competent virus after 10 days from onset of symptoms, except in people who have severe covid-19 or who are moderately or severely immunocompromised.
当前的数据标明，在轻度至中度covid-19患者中，重复rt-pcr检测可以在表现初度呈现后的很长一段时刻内检测到sars-cov-2 rna。根据美国疾病控制和避免中心(cdc)的数据，除了患有严峻covid-19或中重度免疫功用低下的人外，很少在表现呈现10天后恢复有仿制才能的病毒。
considering this information, the cdc recommends that physicians use a time- and symptom-based strategy to decide when patients with covid-19 are no longer infectious.
思考到这一信息，美国疾病控制与避免中心主张医生运用根据时刻和表现的战略来抉择covid-19患者何时不再具有感染性。
for patients with confirmed covid-19 infection the cdc recommends discontinuing isolation and other transmission-based precautions per the following：
关于确诊的covid-19感染患者，cdc主张中止阻隔和其他根据传达的避免办法，具体如下:
? children and adults with mild, symptomatic covid-19: isolation can end at least 5 days after symptom onset and after fever ends for 24 hours (without the use of fever-reducing medication) and symptoms are improving, if these people can continue to properly wear a well-fitted mask around others for 5 more days after the 5-day isolation period. day 0 is the first day of symptoms.
?患有纤细表现的covid-19的儿童和成人：假定这些人在5天阻隔期后，还能持续正确地在其别人周围再戴5天口罩，那么在表现呈现后至少5天，发烧结束24小时(不运用退烧药)而且表现正在改进后，阻隔可以结束。第0天是呈现表现的第一天。
? people who are infected but asymptomatic (never develop symptoms): isolation can end at least 5 days after the first positive test (with day 0 being the date their specimen was collected for the positive test), if these people can continue to wear a properly well-fitted mask around others for 5 more days after the 5-day isolation period.

however, if symptoms develop after a positive test, their 5-day isolation period should start over (day 0 changes to the first day of symptoms)*
?无表现感染者(从未呈现表现)：阻隔可在初度阳性检测后至少5天结束(第0天为搜集标本进行阳性检测的日期)，条件是这些人在5天阻隔期后仍能持续正确佩戴的口罩与别人触摸5天。可是，假定在检测呈阳性后呈现表现，则应从头初步5天的阻隔期(第0天改为呈现表现的第一天)*
? people who have moderate covid-19 illness: isolate for 10 days.
?covid-19中度患者：阻隔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 10 days and up to 20 days after symptom onset, and after fever ends (without the use of fever-reducing medication) and symptoms are improving, may be warranted.
?病况严峻的人(即需要住院、重症监护或通气撑持的人)：可以有必要将阻隔和避免办法的持续时刻延伸至表现呈现后至少10天至20天，而且在发烧结束(不运用退烧药)和表现有所改进后。
? people who are moderately or severely immunocompromised might have a longer infectious period: extend isolation to 20 or more days (day 0 is the first day of symptoms or a positive viral test). use a test-based strategy and consult with an infectious disease specialist to determine the appropriate duration of isolation and precautions.
?中度或严峻免疫功用低下的人可以会有更长的感染期：将阻隔时刻延伸至20天或更长时刻(第0天是呈现表现或病毒检测呈阳性的第一天)。运用根据查验的战略，并征询感患病专家，以断定恰当的阻隔时刻和避免办法。
*the additional 5-day isolation period with masking for asymptomatic and mildly symptomatic patients has no practical implication in anesthesia care.patients in these categories should be considered infectious for anesthesia care purposes for the full 10 days.
*对无表现和轻度表现患者额定的5天口罩阻隔期在麻醉照护中没有实践意义。在麻醉照护的10天内，这些品种的患者大约被认为是有感染性的。
consultation with infection control experts is strongly advised prior to discontinuing precautions for patients with severe to critical illness or who are severely immunocompromised. clinical judgment ultimately prevails when deciding whether a patient remains infectious. maintaining transmission-based precautions and repeat rt-pcr testing may be appropriate if clinical suspicion of ongoing infection exists.
关于重症、危重症患者或免疫功用严峻受损的患者，在中止避免办法之前，激烈主张征询感染控制专家。在抉择患者是不是仍然具有感染性时，临床判别究竟占优势。假定临床置疑存在持续感染，坚持根据传达的避免办法和重复rt-pcr检测可所以适合的。
if a patient suspected of having sars-cov-2 infection is never tested, the decision to discontinue transmission-based precautions can be made using the symptom-based strategy described above.
假定置疑患有sars-cov-2感染的患者从未进行过检测，则可以运用上述根据表现的战略来抉择避免传达的避免办法。
other factors, such as advanced age, diabetes mellitus, or end-stage renal disease, may pose a much lower degree of immunocompromise; their effect upon the duration of infectivity for a given patient is not known.
其他要素，如高龄、糖尿病或终晚期肾病，可以构成教逑堤度的免疫损害；它们对特定患者的感染性持续时刻的影响尚不理解。
ultimately, the degree of immunocompromise for the patient is determined by the treating provider, and preventive actions are tailored to each individual and situation.
究竟，患者的免疫损害程度由医治供给者抉择，避免办法关于每自个及其情况而定。
what is the appropriate length of time between recovery from covid-19 and surgery/procedure with respect to minimizing postoperative complications?
为了尽量削减术后并发症，从covid-19恢复到可以手术之间的适合时刻是多长?
currently there is a backlog of surgical procedures that have been delayed but are necessary to improve the health and quality of life of our patients.although there is increasing information to address the timing of surgery after covid-19 infection, studies continue to lag behind the emerging variants and the likelihood that vaccinated patients have a lower a risk of postoperative complications as compared to unvaccinated patients. almost all available data come from study periods with zero to low prevalence of vaccination.
当前，推迟的外科手术现已呈现积压，但关于改进咱们患者的安康和日子质量是必要的。尽管关于covid-19感染后手术机缘的信息越来越多，但研讨仍然落后于新呈现的变异，以及与未接种疫苗的患者比较，接种疫苗的患者术后并发症风险较低。几乎一切可用数据都来自疫苗接种率低的研讨时期。
the preoperative preparation of a surgical patient who is recovering from covid-19 involves evaluation and optimization of the patient’s medical conditions and physiologic status. since covid-19 can impact virtually all major organ systems, the timing of surgery after a covid-19 diagnosis is important when considering the risk of postoperative complications.heretofore, protocols have been based on limited data specific to sars-cov-2, expert opinion, and previous data from other post-viral syndromes.
covid-19恢复期外科患者的术前预备包括评价和优化患者的医疗条件和生理状况。因为covid-19几乎可以影响一切首要器官体系，在思考到术后并发症的风险时，covid-19确诊后的手术机缘非常重要。迄今中止，方案一向根据sars-cov-2特有的有限数据、专家定见以及早年来自其他病毒后归纳征的数据。
an early limited study of 122 patients found a significantly higher risk of pulmonary complications within the first four weeks after sars-cov-2 diagnosis. a brazilian study of 49 patients who underwent surgery with a median delay of 25 days after asymptomatic covid-19 did not have increased complications when compared to a cohort of patients with a negative sars-cov-2 test.
一项对122名患者的前期有限研讨发现，在sars-cov-2确诊后的前邻近内，肺部并发症的风险显着更高。巴西的一项研讨对49名无表现covid-19患者进行了手术，与一组sars-cov-2检测阴性的患者比较，这些患者的并发症没有添加。
subsequently, a multi-country (116 countries), multi-center (1674 hospitals) study, in a mixture of high income and low/middle income countries, followed more than 140,000 patients with 3,127 having covid-19 infections before surgery.data were collected from surgery in october 2021, meaning that none of these patients had received even one vaccination. they reported increased risks of mortality and morbidity—especially with pulmonary complications–up to 7 weeks post covid diagnosis, although the confidence interval for patients in the 5-6 week cohort suggests that there may not be a true difference in this group. this data found increased risks to be present at 5-6 weeks regardless of being asymptomatic or symptomatic, older or younger than 70, having major or minor surgery, or undergoing elective or emergency surgery. mortality data is summarized in the table below. finally, patients with ongoing symptoms at ≥7 weeks were at increased risk for complications versus patients without symptoms.
随后，一项多国(116个国家)、多中心(1674家医院)的研讨，在高收入和中低收入国家进行，随访了14万多名患者，其间3127人在手术前感染了covid – 19。数据是从2021年10月的手术中搜集的，这意味着这些患者都没有接种过疫苗。尽管5-6周行列患者的相信区间标明该组可以没有真实的差异，可是他们陈述了covid确诊后长达7周的去世和发病率风险添加，特别是肺部并发症。该数据发现，不管无表现或有表现，年纪大于或小于70岁，承受大手术或小手术，或承受择期或急诊手术，5-6周时风险均添加。去世率数据摘要载于下表。最终，与无表现患者比较，持续表现≥7周的患者发生并发症的风险添加。

a second u.s. study covering a timeline of patients with a covid-19 diagnosis and surgery up to may 31, 2021 reviewed 5479 surgical patients following covid-19 infection.immunization status was not given but the study period ranged from a time of zero vaccination until a period when about 30% of the us adult population had received at least one vaccination. the results corroborate the above findings and report higher postop complications of pneumonia and respiratory failure at 0-4 weeks and continued higher postoperative pneumonia complications 4-8 weeks post pcr diagnosis.
美国的第二项研讨包括了到2021年5月31日的covid-19确诊和手术患者的时刻表，研讨了5479名covid-19感染后的手术患者。研讨人员没有给出免疫情况，但研讨时刻从零疫苗接种到约30%的美国成年人至少接种了一次疫苗。成果证明晰上述发现，并报导了在pcr确诊后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 from the united kingdom recommends “delaying surgery, whenever feasible for a minimum of 7 weeks after known sars-cov-2 infection.“
值得留心的是，来自英国的一份根据共同的声明主张“在已知的sars-cov-2感染后，尽可以推迟手术至少7周”。
to date, there are no robust data on patients recovering from more recent delta and omicron variants. according to the cdc, the omicron variant causes less severe disease, and is more likely to reside in the oro- and nasopharynx without infiltration and damage to the lungs.it should also be noted that severity likely varies by vaccination status. some have extrapolated these facts to a conclusion that risk in patients who are vaccinated and are recovering from omicron should be less. however plausible, such a conclusion remains unproven. sars-cov-2 affects other organ systems beyond the pulmonary system (e.g., thromboembolic events including stroke, myocarditis, renal failure).
迄今中止，还没有关于患者从迩来的delta和omicron变异中恢复的可靠数据。根据美国疾病控制与避免中心的说法，omicron变异致使的疾病不那么严峻，而且更有可以存在于口咽部和鼻咽部，不会润泽和损害肺部。还应留心的是，严峻程度可以因接种疫苗情况而异。有人根据这些实际揣度出这样一个结论：接种了疫苗并正在从omicron中恢复的患者的风险大约更小。不管这一结论多么可信，它仍未得到证明。sars-cov-2影响肺部体系以外的其他器官体系(例如血栓栓塞作业，包括中风、心肌炎、肾衰竭)。

residual symptoms such as fatigue, shortness of breath, and chest pain are common in patients who have had covid-19 (10,11). these symptoms can be present more than 60 days after diagnosis (11). in addition, covid-19 may have long term deleterious effects on myocardial anatomy and function (12). a more thorough preoperative evaluation, scheduled further in advance of surgery with special attention given to the cardiopulmonary systems, should be considered in patients who have recovered from covid-19 and especially those with residual symptoms.
疲惫、呼吸时刻短和胸痛等残留表现在covid-19患者中很常见。这些表现可在确诊后60天以上呈现。此外，covid-19可以对心肌解剖和功用有长时刻的有害影响。关于从covid-19中恢复的患者，特别是那些有残留表现的患者，应思考在手术行进一步组织更完全的术前评价，并特别留心心肺体系。
is repeat sars-cov-2 testing needed?
是不是需要重复sars-cov-2检测?
at present, the cdc does not recommend re-testing for covid-19 within 90 days of symptom onset (13). repeat pcr testing in asymptomatic patients is strongly discouraged since persistent or recurrent positive pcr tests are common after recovery. however, if a patient presents within 90 days and has recurrence of symptoms, re-testing and consultation with an infectious disease expert should be considered.once the 90-day recovery period has ended, the patient should undergo one pre-operative nasopharyngeal pcr test ideally ≤ three days prior to the procedure.
当前，美国疾病控制与避免中心不主张在表现呈现后90天内从头检测covid-19。在无表现患者中，激烈不鼓舞重复pcr检测，因为持续或复发的pcr检测阳性在恢复后很常见。可是，假定患者在90天内呈现表现并复发，则应思考从头检测并征询感患病专家。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 under continuous review and will be updated as additional evidence becomes available.
这些主张正在不断检查中，并将在获得更多根据时予以更新。
appendix i
? asymptomatic or presymptomatic infection: individuals who test positive for sars-cov-2 using a virologic test (i.e., a nucleic acid amplification test [naat] or an antigen test) but who have no symptoms that are consistent with covid-19.
? mild illness: individuals who have any of the various signs and symptoms of covid-19 (e.g., fever, cough, sore throat, malaise, headache, muscle pain, nausea, vomiting, diarrhea, loss of taste and smell) but who do not have shortness of breath, dyspnea, or abnormal chest imaging.
? moderate illness: individuals who show evidence of lower respiratory disease during clinical assessment or imaging and who 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 of oxygen to fraction of inspired oxygen (pao2/fio2) <300 mm hg, a respiratory rate >30 breaths/min, or lung infiltrates >50%.
? critical illness: individuals who have respiratory failure, septic shock, and/or multiple organ
dysfunction.
?无表现或表现前感染：经过病毒学检测(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共同的表现。
?轻度疾病：有任何covid-19的体征和表现(例如，发烧、咳嗽、喉咙痛、不适、头痛、肌肉痛苦、厌烦、吐逆、拉肚子、味觉和嗅觉损失)，但没有呼吸时刻短、呼吸困难或乳房印象学异常。
?中度疾病：在临床评价或成像中闪现下呼吸道疾病根据，而且氧饱满度(spo2)≥94%。
?严峻疾病：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，或肺润泽>50%。
?危重疾病：有呼吸衰竭、感染性休克、多器官功用妨碍。

……

新青年翻开新冠病毒智能查询词条，重视：新青年网络家乡 回复：新冠 快速获取抗疫有用材料。