John Murphy, The COVID Long-haul Foundation

Abstract As long COVID emerges as a persistent clinical syndrome affecting millions globally, its implications for surgical outcomes are increasingly evident. This article synthesizes findings from ten peer-reviewed studies to explore how long COVID exacerbates perioperative risk, particularly in major surgeries. We examine neurocognitive decline, cardiovascular morbidity, immune dysregulation, and delayed recovery trajectories, urging a paradigm shift in surgical planning and postoperative care.

1. Introduction

Major surgeries have long been associated with risks such as postoperative cognitive dysfunction (POCD), cardiovascular events, and immune suppression. The emergence of long COVID—characterized by fatigue, brain fog, dysautonomia, and systemic inflammation—adds a new layer of complexity. With up to 30% of COVID-19 survivors experiencing long-term symptoms, understanding its impact on surgical outcomes is critical.

2. Neurocognitive Vulnerability

Patients with long COVID exhibit persistent deficits in memory, attention, and executive function. These symptoms overlap with perioperative neurocognitive disorders (PNDs), which affect 10–12% of surgical patients1. The additive effect of long COVID may amplify POCD risk, particularly in older adults and those undergoing cardiac or orthopedic procedures.

“Patients with long COVID perform worse in cognitive measures of working memory, attention, and processing speed compared to controls.” — Visvabharathy et al., 2024

3. Cardiovascular Complications

A retrospective cohort study of 3,997 patients found that surgery within 90 days of COVID-19 diagnosis significantly increased the risk of postoperative cardiovascular events—including myocardial injury, stroke, and thromboembolism. Long COVID patients may remain at elevated risk due to persistent endothelial dysfunction and hypercoagulability.

4. Immune Dysregulation and Infection Risk

Long COVID is associated with immune dysregulation, including T-cell exhaustion and cytokine imbalance. These changes may impair wound healing and increase susceptibility to surgical site infections. Immunosuppressive effects of anesthesia and surgical stress further compound this risk.

5. Pulmonary Compromise

Residual pulmonary impairment—such as reduced diffusion capacity and chronic dyspnea—is common in long COVID patients. These impairments heighten the risk of postoperative respiratory failure, especially in thoracic and abdominal surgeries requiring prolonged intubation.

6. Delirium and Anesthesia Sensitivity

Postoperative delirium is a known complication in major surgeries, particularly among older adults. Long COVID patients may be more susceptible due to pre-existing neuroinflammation and autonomic instability3. Anesthetic agents may exacerbate cognitive symptoms, necessitating tailored protocols.

7. Delayed Recovery and Rehabilitation Challenges

Long COVID patients often experience prolonged fatigue and exercise intolerance. These symptoms can delay mobilization, increase hospital length of stay, and reduce participation in rehabilitation programs—ultimately impairing functional recovery.

8. Timing of Surgery Post-COVID

Evidence suggests that delaying surgery for at least 12 weeks post-COVID diagnosis reduces cardiovascular and pulmonary complications. However, long COVID symptoms may persist beyond this window, requiring individualized risk assessment.

9. Ethical and Operational Implications

Surgeons face ethical dilemmas in balancing surgical urgency with long COVID risks. Preoperative screening for long COVID symptoms, shared decision-making, and multidisciplinary planning are essential. Institutions may need to revise perioperative protocols to accommodate this emerging patient population.

10. Conclusion

Long COVID introduces a multifaceted risk profile for surgical patients, intersecting with traditional perioperative vulnerabilities. Surgeons, anesthesiologists, and rehabilitation teams must adapt to this evolving landscape through enhanced screening, tailored anesthesia, and extended recovery planning. As long COVID persists, so too must our vigilance.

🔍 References

1. Visvabharathy L, Berian JR, Alverdy JC. Long COVID May Have Long-Term Impact on Surgery. American College of Surgeons
2. Dougherty D et al. Impact of Post-COVID-19 Conditions on Surgery. Royal Australasian College of Surgeons
3. Bryant JM et al. Association of Time to Surgery After COVID-19 Infection With Risk of Postoperative Cardiovascular Morbidity. JAMA Network Open