When can a patient with COVID-19 (Coronavirus Disease 2019) undergo surgery after symptom onset?

Timing of Surgery After COVID-19 Diagnosis

For a patient who tested positive for COVID-19 today with symptoms starting last Thursday, surgery should be delayed for at least 10 days from symptom onset, provided symptoms are resolving and the patient has been fever-free for at least 24 hours without fever-reducing medications. 1

Timing Guidelines Based on Disease Severity

Mild to Moderate COVID-19

• Patients with mild to moderate COVID-19 symptoms should self-isolate for at least 10 days from symptom onset before undergoing elective surgery 1
• The patient is most contagious in the 2 days before and 5 days after symptom onset, with infectivity decreasing significantly after 10 days 1
• Live virus is rarely cultured beyond 10 days in patients with mild to moderate disease, which forms the basis for the 10-day isolation recommendation 1

Severe COVID-19

• For patients with severe COVID-19 requiring hospitalization or oxygen therapy, surgery should be delayed for 15-20 days from symptom onset 1
• The risk of having replication-competent virus is approximately 5% at 15 days after symptom onset and extremely rare at 20 days in severely ill patients 1
• Severely immunocompromised patients may require specialist advice on duration of isolation before surgery 1

Considerations for Emergency Surgery

• If emergency surgery is required during the infectious period, the patient should be managed with full transmission-based precautions 1, 2
• This includes:
  • Treating the patient in a dedicated COVID-19 operating room 1
  • Using appropriate PPE (N95 masks, goggles, double gloves, face shields, and protective gowns) 1
  • Isolating the patient postoperatively in a dedicated COVID-19 surgical unit or ICU 1

Testing and Confirmation Protocol

• A positive RT-PCR test has high specificity but moderate sensitivity 1
• A single negative test should not be used to rule out COVID-19 in patients with strongly suggestive symptoms 1
• For patients with uncertain COVID-19 status requiring immediate surgery:
  • Manage as a confirmed COVID-19 case until diagnosis is confirmed 1
  • Repeat RT-PCR testing after 48-72 hours if initial test is negative but clinical suspicion remains high 1

Post-COVID-19 Surgery Considerations

• PCR positivity does not necessarily correlate with secretion of live virus, especially after the infectious period has passed 1, 3
• The decision to proceed with surgery should be based on:
  • Time since symptom onset (minimum 10 days for mild/moderate cases) 1
  • Resolution of symptoms (particularly fever and respiratory symptoms) 1
  • Patient's overall clinical status and comorbidities 1

Common Pitfalls to Avoid

• Do not rely solely on a negative PCR test to determine infectivity status, especially early in the disease course 1
• Do not schedule surgery during the period when the patient may be infectious (typically within 10 days of symptom onset for mild/moderate cases) 1
• Avoid assuming that persistent PCR positivity beyond 10 days indicates ongoing infectivity in mild/moderate cases 1, 3
• Do not underestimate the importance of isolating COVID-19 patients from non-COVID patients in surgical settings 1

In this patient's case, since symptoms started last Thursday and the test is positive today, surgery should be scheduled no earlier than 10 days from symptom onset, assuming mild to moderate disease and resolution of symptoms.