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.