Preoperative Clinical Screening for COVID-19
Screening for and testing of SARS-CoV-2 may be implemented at multiple
points in the patient’s cancer journey. Already many outpatient clinics
and preoperative anesthesia care settings are screening patients via
symptom questionnaires and checking for active
fever.33,43,44 It must be recognized that confounding
symptom overlap can exist between respiratory viral pathogens and
cancer, which may create additional hurdles in the screening
process.45 Patients who screen positive in the
outpatient setting are immediately referred for testing as capacity
exists. In recognition of the increased risk of nosocomial transmission
of SARS-CoV-2 to healthcare providers during aerosol generating
procedures, multiple organizations including the American Head and Neck
Society, the American Academy of Otolaryngology-Head and Neck Surgery,
and the American Colleges of Surgeons are advocating for preoperative
testing for all patients undergoing these high-risk
procedures.4,12,46,47 Testing availability, timing of
testing relative to the date of surgery, whether one or multiple
negative tests are needed, and how to triage patients when found to test
positive all remain important, and as yet unanswered, questions. Many
local factors will thus impact decision making around preoperative
testing.
Our preoperative clinical screening for COVID-19 pathway is shown in
Figure 2. Within the past week, preoperative clinical testing for
selected, high-risk procedures, has become available at our institution.
If a patient is confirmed to require urgent head and neck surgery they
are sent to preoperative anesthesia clinic, just as they were prior to
the pandemic. Patients are then dichotomized based on surgical risk of
SARS-CoV-2 transmission (Table 3). If no mucosa is involved during
surgery, the procedure is deemed low-risk and the patient will only be
tested for SARS-CoV-2 (using standard polymerase chain reaction (PCR)
testing) if their COVID-19 clinical screening is positive (Table 4). If
SARS-CoV-2 PCR testing is negative, then the surgeon may proceed with
low-risk surgery.
Any trans-mucosal surgery is considered high-risk. For these patients,
PCR testing for SARS-CoV-2 will be performed regardless of clinical
screening status. If the patient’s clinical screening is positive but
SARS-CoV-2 PCR testing is negative, then the case may proceed at the
discretion of the surgeon, given the possibility of a false negative
test result. Any patient that tests positive for SARS-CoV-2 will have
their surgery delayed, unless there is imminent threat to life (e.g.,
impending airway compromise). We recommend retesting prior to proceeding
with surgery. The patient can be considered for retesting 7 days after
symptoms have receded, or 14 days after the date of the initial test,
whichever is longer. The timing of oncologic surgery after positive PCR
testing should be carefully considered by the patient, surgeon, and
critical care team managing this potentially life-threatening infection.
PCR testing for SARS-CoV-2 is associated with false negative results
(without publicly available data at the time of article submission),
therefore universal PPE precautions are still recommended during
high-risk procedures.