In early March 2020, I never could have anticipated how the COVID-19 pandemic would shape our area of practice of perioperative medicine. Yes, I anticipated that patients may cancel their surgeries. Yes, I anticipated that some of our clinic staff, along with our surgeon and anesthesiologist colleagues, would be deployed to inpatient COVID-19 units. I did not anticipate the innumerable ways that COVID-19 affected the practice of perioperative medicine.

The last nearly two years have been a whirlwind of clinical updates, research, and policy change. This article shares clinical pearls and lessons learned as much of preoperative care and risk assessment and optimization is delivered in the primary care setting.

Calculating Clinical Risk and Preoperative Assessments

COVID-19 versus perioperative medicine began with concerns about the risk of exposure in the operating room and PPE shortages. By late March 2020, we were screening all surgical patients for COVID-19 two days before surgery and cancelling cases for patients who tested positive. By May 2020, we started to frame the next clinical question: how and whenhow do we know if a COVID-19 survivor is medically ready for surgery?

Initially, only a few small case series from China and Iran were available, demonstrating that patients with acute COVID-19 perioperatively appeared to have dramatically higher rates of mortality. Our periop team merged these observations with analyses of what we were learning then about COVID-19: especially is its most severe forms, it is a multiorgan system illness with the potential for significant end-organ damage (including pulmonary and cardiac) with an intense pro-inflammatory, pro-thrombotic cytokine response. Similarly, surgery is a pro-inflammatory, pro-thrombotic, cytokine-induced state. Other medical events such as acute myocardial infarctions, decompensated heart failure, or stroke need recovery time before surgery. Might recent COVID-19 similarly be a risk factor for postoperative complications?

By June 2020, larger multicenter studies showed perioperative complications and mortality were substantially higher than the population average when COVID-19 was diagnosed close to a surgery.^{1, 2} Older, sicker patients having major and/or emergency surgeries had the highest risk—but even younger, healthier patients or those having minor elective surgeries had dramatically increased surgical mortality. In March 2021, a large international prospective study showed that perioperative risk persists after COVID-19, even asymptomatic infection, for at least 7 weeks.³

We still do not have clear data on how to modify the perioperative risk of COVID-19 survivors. Other than time, we do not yet know when COVID-19 survivors are medically ready to proceed with acceptable risk. I anticipate that this will be a “hot topic” within the perioperative and surgical literature for years to come, and our research group is analyzing the results of the post-COVID-19 preoperative assessment protocol that we implemented in summer 2020.⁴

The Term Elective Surgery Leaves a Lot to Be Desired

I hate the term elective surgery more than ever. In March 2020, “elective surgeries” were cancelled. During various surges across the United States and the world, “elective surgeries” were cancelled. For the last several months, my own state and institution faced hundreds of cancelled “elective surgeries.”

The term is too vague: the opposite of “emergency” surgery is not “elective surgery.” “Elective” generally implies scheduled in advance. However, many time-sensitive surgeries fall into that category, especially malignancy-related surgeries.

“Elective” does not mean “optional.” Very few surgeries are truly optional—I think of purely cosmetic surgeries falling into that category. But so many “elective” surgeries are indicated to have significant improvements on health and quality of life. Using the term “elective surgeries” to talk about the burden of cancelled surgeries undermines the impact of this ongoing pandemic on patients’ care.⁵ I think of the patient waiting a year for a knee replacement and is now very deconditioned, the patient waiting another eight months for bariatric surgery, or the patient waiting four months for gender-affirming mastectomy—their physical and mental health may have all suffered while waiting for an “elective” surgery.

Moral Injury Manifests in Many Ways

We hear about moral injury in the inpatient and ICU setting, especially when predominantly unvaccinated patients were filling hospitals during the late summer COVID-19 surge. We continued to advocate for masks, distancing, and vaccines against mounting backlash towards clinicians.

Moral injury also occurs in the outpatient setting:

1. from observing patients traverse barriers to care, including surgical and perioperative care
2. when we see patients present with late-stage malignancies due to delayed diagnosis
3. when we face another wave of surgical cancellations to help hospitals handle the capacity of COVID-19 patients.

Surgeons are not upset and experiencing moral injury because they are losing revenue—they are burnt out because their patients cannot get the care they need. We experience emotional exhaustion when we sit in the preop or surgery clinic exam room with patient after patient worried their surgery would get cancelled, or fear not being able to have inpatient visitors. Cancelled surgeries do not make the work of perioperative medicine any easier.

Acknowledge Colleagues for Dynamic Flexes

Stereotypes abound in medicine. However, the flexibility, creativity, and humility of dramatic pivots abound during the last 22 months—and I am privileged to be able to witness and amplify it from my vantage point in perioperative medicine.

I have seen colleagues from across perioperative specialties embrace roles on COVID-related committees, and I have seen this brought to patients at the bedside. Anesthesiologists have turned post-anesthesia care units into ICUs and become experts on COVID-19 lab testing. Surgical colleagues have embraced the onus of vaccine advocacy and education. I know perioperative colleagues whose respect for the foundational work of primary care has grown infinitely during this pandemic. We are all in this together to fight this pandemic, medicine and non-medicine specialties included.

We Will Be Embracing Uncertainty for Years to Come

As we approach 2022 and the two-year mark of the pandemic, unknowns persist. Remaining questions for perioperative medicine include the following:

• What is the perioperative risk for patients with Long COVID? How do we know if/when they are optimized for surgery?
• If a patient has a breakthrough case of COVID-19 after being vaccinated, do they have the same perioperative risk of non-vaccinated patients?
• How long does the perioperative risk from COVID persist? Months? Years? Will a history of COVID-19 always need to be on the preoperative history/risk assessment just as a past MI or past stroke?

Twenty-two months ago, I had no way of predicting that this would be the landscape of my clinical practice. The stressors to work-life integration have been innumerable, and the challenges persist. However, contributing via my unique niche and with the multidisciplinary teamwork I am accustomed to have been lifelines during an unprecedented time.