Risk assessment becomes more complex during a pandemic—but even more necessary. Researchers from Virginia Commonwealth University and Hunter Holmes McGuire Veterans Afffairs Medical Center who studied a population of veterans who underwent leg amputation found that “preoperative testing may not be a feasible and well-applied standard, making risk assessment in the setting of a pandemic even more crucial for surgeons undertaking lower extremity amputations in this high-risk population.”
In their study, the researchers found that a majority of the patients had one or more risk factor from the list published by the European Centre for Disease Prevention and Control (ECDC). What’s more, based on their data, the researchers say veteran amputees are at a much higher risk for complications and negative outcomes if infected with COVID-19, compared with the general population.
Of 50,083 veterans who needed nontraumatic lower extremity amputations between 1999 and 2018, 82% of those with above-knee amputations and 89% of those with below-knee amputations had at least one ECDC risk factor comorbidity. Hypertension and diabetes were the two most prevalent conditions in all cohorts, regardless of race.
Between 40% and 50% of the patients studied were current or past smokers, “well beyond the prevalence of smoking” in the general US population,” the researchers say. One quarter of the veterans were Black. That also is a greater proportion than the proportion of Black patients in the national male veteran population; race is an “especially concerning” potential COVID-19 progression factor, the researchers say.
A year after the COVID-19 pandemic began, the researchers examined the association of Risk Analysis Index scores with postoperative outcomes in 47,197 patients who underwent lower extremity amputation: 27,098 below the knee and 20,099 above the knee amputations.
Frailty was associated with increased rates of major cardiac, pulmonary, and renal complications, as well as sepsis, intubation greater than 48 hours, reintubation, and increased length of stay. Higher frailty scores were associated with up to triple the likelihood of a postoperative complication and up to 32 times likelihood of death within 30 days.
In a previous study, the researchers concluded that standardized frailty indicators might be particularly relevant in a pandemic that has a heavy impact in elderly patients with comorbidities. The risk factors for COVID-19, they note, are similar to many of the factors assessed in surgical frailty scores. Surgical frailty and its assessment, they add, have become “essential considerations” in perioperative management for aging patients.