Towards consensus on COVID-19

As the COVID-19 pandemic sees the UK enter lockdown, here we provide you with a summary of all our new COVID-19 material together with a moment’s respite from COVID-related information overload as we introduce the April 2020 issue of Anaesthesia

The first paper comes from Cook et al. and describes consensus principles for managing the airway in patients with COVID-19. The three overriding principles are SAS – Safe, Accurate and Swift. A one-page checklist is provided for tracheal intubation as are: tools for the prediction of difficulty; a plan for personal protective equipment; an example of kit dump mat; and a cognitive aid for an unexpected difficult tracheal intubation, including a ‘can’t intubate, can’t oxygenate’ scenario. The videolaryngoscope seems to be emerging as a key piece of equipment during this pandemic and this new paper from Hall et al. adds evidence to support this practice. They found that it significantly extends the ‘mouth-to-mouth’ distance from laryngoscopist to patient as compared with direct laryngoscopy. A lot of our learning comes from the experiences of our Italian colleagues, who have been at least two weeks ahead of most other nations. This new paper from Sorbello et al. describes these experiences together with clinical recommendations (Fig. 1). We were delighted to see the paper featured in the Independent. The key messages are planning, training and teamwork. With that in mind, Fregene et al. describe the use of in-situ simulation to evaluate the operational readiness of a high-consequence infectious disease critical care unit. They found that in-situ simulations identified multiple operational deficiencies on the critical care isolation room which allowed for corrective action before the admission of their first patient with COVID-19. Finally, this letter from Ong and Khee describes some key practical considerations in the anaesthetic management of patients during the COVID-19 pandemic

Figure 1 Suggested team roles and ergonomics for elective tracheal intubation.

One of the many significant findings of NAP4 was that awake tracheal intubation (ATI) – a technique enjoying high success and low complication rates – was frequently not utilised despite anticipation of difficult airway management. The new Difficult Airway Society guideline for ATI launched this month both empowers non-airway specialists to perform this when indicated and provides them with the technical tools to successfully do so. The document proposes a new lexicon for ATI according to technical approach: flexible bronchoscopy (ATI:FB), videolaryngoscopy (ATI:VL), or front of neck access (ATI:FONA), to name a few. Also outlined is a suggested method of ATI for the generalist, presented in an appealing visual format.

Figure 2 The Difficult Airway Society awake tracheal intubation (ATI) technique. This figure forms part of the Difficult Airway Society guidelines for ATI in adults and should be used in conjunction with the text. HFNO, high‐flow nasal oxygen; LA, local anaesthetic; FB, flexible bronchoscopy; MAD, mucosal atomising device; TCI, target‐controlled infusion; Ce, effect‐site concentration; VL, videolaryngoscopy. ©Difficult Airway Society 2019.

In the associated editorial, Aziz and Kristensen highlight the novel consultation of patients as part of the guideline’s creation, given the nature of ATI as requiring a well-informed, calm and cooperative patient. Also worthy of mention is the reliance on expert opinion, emphasising its capacity as advisory and not prescriptive, whilst advocating consistency of approach in a bid to promote patient safety. Aziz and Kristensen do not shy away from robust critique of other areas of the document, including its assertion that bleeding should be viewed as a relative contra-indication for ATI; the ‘sTOP’ acronym, which may be open to misinterpretation (appearing to suggest the correct sequence of events to be ‘sedate, topicalise, oxygenate, perform’); and how to proceed in the event of ATI failure. 

As the use of ATI increases, peri-operative blood transfusion is decreasing. In a five-year observational study from the USA, Nordestgaard and colleagues examined the peri-operative pathways of well over four million surgical patients, finding transfusion rates to have fallen from 8.4% in 2011 to 4.6% in 2016: a dramatic reduction of 45%.

Figure 3 Odds ratios for peri‐operative red blood cell transfusions for 2012–2016 vs. 2011. Error bars represent 95%CI.

Over the same period, there was no increase in myocardial infarction, stroke or all-cause 30-day mortality, suggesting that fewer transfusions had not unwittingly contributed to an increase in adverse events. Shah, Stanworth and Docherty, in the related editorial, explore the many reasons for this observed reduction, including survivorship bias and improvements in surgical technique. Data on cell salvage – a technique which rose to popularity over the course of the study – was unfortunately unavailable and could have provided valuable insights. Care must be taken not to assume that reduced transfusion is an entirely positive phenomenon – indeed, more liberal transfusion thresholds are appropriate in certain patient populations, such as traumatic brain injury. 

Blood transfusion has been variously implicated in the literature in terms of cancer recurrence and reduced survivorship. Tai and colleagues present retrospective data on this association in the context of post-surgical recurrence of liver cancer. Using a technique known as restricted cubic splines, permitting the application of linear regression models to non-linear data, they were able to demonstrate adjusted hazard ratios of 1.3 (95%CI 1.1-1.4) and 1.9 (95%CI 1.6-2.3) for recurrence and mortality, respectively. Moreover, the greater the number of units received, the stronger became the association with adverse outcomes. It is difficult to tease apart myriad confounding factors and assess causality here. In the related editorial, Dickson and Acheson rightly identify that any randomised controlled trial in this area would be ethically fraught – and so Tai and colleagues’ propensity matching is the closest approximation. Transfusion-related immunomodulation (TRIM) has been shown over time to not fully explain the deleterious effects of transfusion, given that we now live in the era of leucodepletion. Other related factors to consider are the role of individualised patient blood management (PBM) and the possible connection between certain anaesthetic and analgesic drugs and cancer recurrence. 

The latter controversial link is not, however, a central thread in White and Shelton’s compelling editorial arguing the case against inhalational anaesthetic agents. The considerable damage done to the environment from volatile agents has only recently entered the collective anaesthetic consciousness, with desflurane now eschewed by many institutions owing to its significant carbon footprint. White and Shelton reason that there is no single instance in which inhalational agents are absolutely indicated over total intravenous anaesthesia with or without locoregional anaesthesia, and that the conventional narrative of volatile anaesthesia as ‘standard’ and other methods as ‘alternative’ deserves to be challenged. They go on to outline the professional and governmental interventions that may support such a seismic shift in the future. 

A reduction in reliance on inhalational agents is likely to coincide with increased innovation in regional anaesthesia – already a ‘bumpy ride’, according to Mariano and El-Boghdadly’s editorial. In the accompanying randomised controlled trial, Ferre and colleagues present fascinating data on two different approaches to suprascapular nerve block and the corresponding risk of hemidiaphragmatic paralysis

Table 1 Incidence of hemidiaphragmatic paralysis in patients randomly allocated to anterior or posterior approach suprascapular nerve block. Values are number (proportion).

Obstetric anaesthesia is a famously litigious sub-specialty, as demonstrated anew by McCombe and Bogod’s review of over two decades’ worth of data on legal claims for nerve injury after neuraxial procedures by anaesthetists. This is the second in Anaesthesia’s new series, on ‘Learning from the Law’. The usual suspects, such as lack of informed consent (a factor in no fewer than 15% of the cases examined), and inadequate speed of response in the event of abnormal symptoms or delayed recovery of function, feature heavily. An analysis of the differing aetiologies of nerve injury is also presented alongside case excerpts. 

Buthelezi and colleagues present an important obstetric study from South Africa exploring the utility of phenylephrine and intravenous fluid co-loading in women undergoing elective Caesarean section. When compared with a conventional rescue bolus phenylephrine strategy, co-administration of the vasopressor with fluid decisively reduced the incidence of hypotension (systolic arterial pressure < 90 mmHg), without adverse effects or reduced Apgar scores in the neonates. These findings therefore demonstrate an efficient method to counter spinal-induced hypotension without the need for a syringe pump. The authors of this pragmatic trial are to be congratulated and their findings will be of assistance to clinicians in other resource-limited settings. 

Elsewhere we have: an exploration of the link between pre-operative anaemia and survival after orthotopic liver transplantation using regression modelsa prospective cohort study of intra-operative cell salvage in revision hip arthroplastya randomised controlled trial comparing shoulder block with interscalene brachial plexus block for shoulder arthroscopy; and a systematic review of single-use and reusable bronchoscopes with an accompanying cost effectiveness analysis. Over in Anaesthesia Reports we have reports of: airway fire during awake tracheostomy using high-flow nasal oxygentracheal resection and the importance of the team brief in multi-stage airway surgerypersistent intracardiac air bubbles after mitral valve surgerypostoperative hemiparesis due to conversion disorder; and pneumothorax following serratus anterior plane block

Finally, be sure to follow the blog in the upcoming weeks and months as we publish insights from across the globe into the COVID-19 crisis, having begun already with the Australian perspective by Dr Tanya Selak. In the meantime, check the excellent online COVID-19 repository for regular updates as the situation unfolds. 

Dr E-J Smith and Dr Andrew Klein

Unprecedented times

For many, life has changed beyond all recognition in the short space of just a few weeks. On the 9th of March we published an extraordinary #TheAnaesthesiaBlog from Tim Cook and Kariem El-Boghdadly calling for all to plan and act. It generated more than 50k reads and we hope it disseminated important messages about the looming crisis for healthcare, and society more generally. The follow-up Australian perspective from Tanya Selak was again ahead of the curve and helped raise awareness of what was to come.

In these unprecedented times, the need for fast, reliable, fact-checked knowledge and recommendations is insatiable. Thankfully, there now exists one portal through which anyone can access a range of COVID-19 resources, including: updates on the current situation; clinical guidance; national guidance; and patient information. Medical journals also have a key role to play and we wish to update you briefly on our response and what we can offer readers, authors, reviewers and patients in these unprecedented times.

We continue to deal with all previously submitted papers, which will undergo all our usual processes. We remain open to submissions on any topic related to peri-operative medicine, critical care, pain medicine and all other associated topics. All original articles, reviews and correspondence in relation to COVID-19 will undergo rapid peer review and if accepted, rapid publication on early view. We have already accepted several papers from the UK and elsewhere and as soon as these are available, they will be freely available and tweeted from the journal account. Finally, continuing professional development remains important at this difficult time and we believe it must continue. We hope to provide you with a range of high-quality educational content on COVID-19 and other topics.

We will keep you updated as the situation evolves. But please rest assured that we are doing everything we can to support our readers and authors through this challenging time. Please look after each other and yourselves.

Mike Charlesworth and Andrew Klein

COVID-19: the view from Australia

Australia had its first case of coronavirus on January 25th, and as of today there are 376 confirmed cases with many test results pending. Cases are doubling every three days, with modelling predicting 153,000 cases by EasterAustralian case numbers more closely align with the experience in Europe, rather than the slower case doubling time in Korea and Singapore. I work in Wollongong, a town south of Sydney in New South Wales with a population of 400,000. If conservative models are correct and 20% become infected, with 5% requiring critical care, this equates to 4000 patients, which is in addition to the usual caseload. We have around 20 critical care beds. 

Until recently, health care professionals and the general public have been largely indifferent to the disease. This is despite widely reported experiences in China, Korea, Iran and Italy, with exhausted frontline clinicians imploring us to prepare. Many felt that this disease was ‘just a mild cold’ and that although there were many deaths, these were limited to the frail, elderly and those with medical comorbidities. There was full confidence that the Australian medical system could manage the disease, as it has world-class people and resources. Most seemed to think that this would not impact us. Many were still laughing at toilet paper jokes and coronavirus memes. Some still are. 

The mood is rapidly changed. There are increasing numbers of clinicians, medical administrators, politicians and members of the community becoming fearful and frantic. Clinicians in particular have been motivated into action following the Italian reports of overwhelming numbers of critically ill patients and deaths. The exponential growth in case numbers and the subsequent social distancing measures introduced by the Australian government yesterday have also increased the impact of the disease. Legislation will enforce the banning of organised mass gatherings of over 500 people, and self-isolation for all travellers from all countries for 14 days, echoing New Zealand’s move to this the day prior. New Zealand has fewer cases yet has been more proactive. Perhaps the recent White Island Volcano tragedy has made them less willing to become overwhelmed again. Awareness was also raised by Hollywood stars Tom Hanks and Rita Wilson, who tested positive and were admitted to Gold Coast University Hospital last week. The government has announced a multi-billion-dollar stimulus package to address the widespread economic devastation the disease will cause. 

The looming disaster is slowly dawning on regulators, administrators and community members. Most Australian hospitals have been slow to act and are only now beginning to look seriously at the logistics of the likely tsunami of potential patients.


Practical difficulties in accessing COVID-19 testing for the public and healthcare workers have led to many frustrations. Some wait up to five days to get tested, and streamlined testing clinics are just starting to appear. The public health advice around testing has changed as the data comes to hand, and is currently limited to those with symptoms and a contact or relevant travel history. 

Personal protective equipment

From my own Twitter activity, I noticed and wondered why international colleagues were shaving beards. This led me to discover the much more serious approach to PPE adopted in other countries, particularly those who have experienced respiratory outbreaks before such as Canada. Formal fit-testing of N95 masks is not mandated in most of Australia and New Zealand. Very few have ever heard of fit-testing, let alone formally had it done. I suspect that Australian guidelines for PPE when we are post-COVID will reflect the more pro-active approach adopted by countries who have been here before. 

There have been concerns around the ability of institutions to supply sufficient PPE. Although state and federal governments have announced funding for PPE, individual hospitals have not completed stocktakes of equipment. Most do not know how many COVID and other emergency patients they can care for. Few have received training, although this is now starting in earnest for some, with others told that there is insufficient gear to rehearse. Although a few units have conducted simulations, they are in the minority. There are a number of different management guidelines and few institutions have agreed on approaches between departments. 

Elective surgery

The management of patients requiring elective surgery is becoming increasingly topical. Elective surgery targets are highly politically driven and direct activity in hospital, sometimes at the expense of emergency surgery. It has been very difficult to shift this mindset. In fact, the state of Victoria has announced an ‘elective surgery blitz’ prior to the arrival of the COVID-19 peak. This is difficult to understand in view of the lack of preparedness and the anticipated patient numbers with the impending healthcare crisis. The Australian Society of Anaesthetists has recommended postponement of elective surgery in order to allow preparation time, as have the Royal Australian and New Zealand college of Obstetricians and Gynaecologists. The Royal Australian College of Surgeons have called for surgical fellows to ‘follow local hospital requirements’ around elective surgery and ANZCA is yet to comment specifically on the matter. 

Organised meetings 

Over the last week, medical conference organisers have one by one made difficult but necessary decisions to cancel their events, including the largest anaesthesia event of the year, the ANZCA annual scientific meeting in Perth. Smaller hospital meetings continue, although some clinicians have cancelled. The medical viva part of the ANZCA final exam was cancelled last weekend, and there are concerns about education implications of the crisis for fellows and trainees with diversion of work and cancellation of CPD activities. 


Many individuals have cancelled overseas trips for the upcoming school holidays and Easter. Some clinicians are now stranded at home in self-isolation requiring the cancellation or rescheduling of clinical work. Panic buying continues with difficulty accessing toilet paper, hand sanitisers, pasta, and meat. A supermarket chain has introduced an early morning quarantine shopping time for the elderly and vulnerable to protect them from the masses. 

Although some schools who have had members test positive for the disease have closed briefly, schools have largely remained open. The rationale for this from public health is that it may do more harm than good. School closures may cause children to be cared for by their grandparents, who are vulnerable to the disease, or parents who are healthcare workers and other essential services and may be unable to present for work if children are at home. 

Information flow  

Key clinicians have been employing social media channels to advocate for governmental action. There are a number of private groups also which are sharing information and getting organised. It has been difficult to keep up with official advice from state and federal government, the hospitals, professional societies, my children’s schools and co-curricular activity providers, my private and public social media. Information overload has been particularly difficult with the rapidly changing nature of this epidemic and the ever-increasing need for information. 

Pleasingly, there has been the rapid production of a number of excellent educational resources from those who have experienced previous epidemics, and those who are currently in the thick of it. Resources have been shared widely and freely on public and private social media sites. This crisis has demonstrated the value of social media where healthcare workers across the world have generously supported each other with information, advice and moral support in real-time.

I repeat and reinforce the advice of Prof Tim Cook and Dr Kariem El-Boghdadly for healthcare workers to familiarise themselves with their institutional PPE policies, practice and train for the management of COVID-19 patients, and agree robust local procedures for the pandemic. I also implore institutions to increase preparedness by postponing non-essential elective surgery, arrange training in COVID management, release all non-essential staff to protect their health and assemble groups of multidisciplinary leaders to organise and lead institutions. We must work together. We have no time left. 

Dr Tanya Selak

Senior Consultant Anaesthetist, Wollongong Hospital, Wollongong, NSW, Australia

International Advisory Panel member, Anaesthesia

The UK COVID-19 epidemic: time to plan and time to act

“The critical feature of all pandemics is uncertainty”

Coronavirus disease (COVID-19) literally needs no introduction. It arrived in China as an unwelcome New Year’s Eve present and although it may have taken a few weeks for many to become aware of it, it has become an ever-present in our lives since. It is, as we write, creating an epidemic across the world and is now sweeping across Europe. It is impacting everyday life in many ways and this impact is likely to become much more marked in the coming months.

Novel coronavirus

The single-strand RNA virus was named novel coronavirus 2019 (2019-nCoV), but due to its pulmonary consequences has been renamed as severe acute respiratory syndrome corona virus type 2 (SARS-CoV-2). It arises from mutation of a virus an animal reservoir, and origins from laboratory sources has been ruled out. It is related to the common cold virus and that causing severe acute respiratory syndrome (SARS) and middle east respiratory syndrome (MERS). Vaccines against these viruses are complex to develop, as illustrated by the fact we currently have no vaccine against the cold, SARS or MERS. The disease caused by SARs-CoV-2 is termed corona virus disease-19 (COVID-19) because the World Health Organization (WHO) was first notified of the localised surge in cases of pneumonia of unknown cause in Wuhan, China on 31 December 2019. 

The numbers

The world’s understanding of the disease owes much to massive international collaboration between scientists but most to the efforts of the Chinese clinicians and researchers collecting and making available data on the disease right from the start. The fundamental metrics as we currently understand them are shown in Table 1. As usual the numbers need to be well understood to tell the story.

R02–3 people
Ascertainment rate10–25%
Attack rate30–60%
IncubationUp to 14 days
Most infective time1–14 days
Table 1 Current metrics on COVID-19 (up to date as of 08/03/2020).

The R0 describes the number of patients that a single patient will infect, in an uncontrolled setting. In the early stages of the epidemic it is believed that this figure may have been much higher, and R0s tend to reduce during the evolution of an epidemic. Control measures such as isolation and quarantine reduce R0. If these measures are effective, R0 may be reduced to below 1 and if this is sustained the epidemic will eventually wane and stop. As long as the R0 is >1, the epidemic will continue and there will be a geometric rise in cases. The impact of R0 is important. Influenza has an R0 of approximately 1.3: after 10 infective cycles this would lead to 14 infected patients from a single source. For SARS-CoV-2 after 10 infective cycles 59,000 patients would be infected. By comparison Ebola has an R0 of around 2, SARS of approximately 3 and MERS ranged from 1 to 5.7 until finally it reduced to <1. 

Combined with this high R0 is a high virulence, so while many cases cause mild disease the mortality rate is many fold higher than that of even pandemic influenza. Various figures for mortality have been quoted, but each is dependent on the numerator and denominator chosen. Of the first 100,000 confirmed cases approximately 3,400 died: thus, the case fatality rate (CFR) is 3.4%. However, it is likely that many cases, mostly because they cause asymptomatic or mild symptoms, are not detected. If this ‘ascertainment rate’ is only 10% this means 90% of cases are missed and the infected mortality risk (IFR) is 0.34%. But these figures only consider those who are infected, and the burden of disease in the population is also dependent on the proportion of the population who are infected (attack rate): many estimates are around 30%, but some as high as 60% or even 80%. If the attack rate is 30% and the IFR 0.34% the overall mortality rate would be close to 0.1% (1 in 1000 of the population). Lead-time bias (the fact that many patients will undergo several weeks of treatment before dying) complicates factors further and currently means that the initial 3.4% CFR is likely to be an underestimate.

However, illness and mortality are not spread evenly across the population. A remarkable epidemiological report from the Chinese Centre for Disease Control (CDC), published only a few days after data collection finished reported differential mortality rates by sex, age, comorbidity. 

Baseline characteristicsConfirmed cases; n (%)Deaths; n (%)Case fatality rate, %
Age, years
 0–9416 (0.9%)
 10–19549 (1.2%)1 (0.1%)0.2%
 20–293,619 (8.1%)7 (0.7%)0.2%
 30–397,600 (17.0%)18 (1.8%)0.2%
 40–498,571 (19.2%)38 (3.7%)0.4%
 50–5910,008 (22.4%)130 (12.7%)1.3%
 60–698,583 (19.2%)309 (30.2%)3.6%
 70–793,918 (8.8%)312 (30.5%)8.0%
 ≥801,408 (3.2%)208 (20.3%)14.8%
 Male22,981 (51.4%)653 (63.8%)2.8%
 Female21,691 (48.6%)370 (36.2%)1.7%
Comorbid condition
 Hypertension2,683 (12.8%)161 (39.7%)6.0%
 Diabetes1,102 (5.3%)80 (19.7%)7.3%
 Cardiovascular disease873 (4.2%)92 (22.7%)10.5%
 Chronic respiratory disease511 (2.4%)32 (7.9%)6.3%
 Cancer (any)107 (0.5%)6 (1.5%)5.6%
 None15,536 (74.0%)133 (32.8%)0.9%
 Missing23,690 (53.0%)617 (60.3%)2.6%
Case severity§
 Mild36,160 (80.9%)
 Severe6,168 (13.8%)
 Critical2,087 (4.7%)1,023 (100%)49.0%
 Missing257 (0.6%)
Period (by date of onset)
 Before Dec 31, 2019104 (0.2%)15 (1.5%)14.4%
 Jan 1–10, 2020653 (1.5%)102 (10.0%)15.6%
 Jan 11–20, 20205,417 (12.1%)310 (30.3%)5.7%
 Jan 21–31, 202026,468 (59.2%)494 (48.3%)1.9%
 After Feb 1, 202012,030 (26.9%)102 (10.0%)0.8%
Table 2 Patients, deaths, and case fatality rates, as well as observed time and mortality for n=44,672 confirmed COVID-19 cases in Mainland China as of February 11, 2020. Modified from

Mortality is higher in males and particularly in those aged over 70 and with cardiovascular disease. This is most notably a disease that kills the elderly: patients aged over 70 represented fewer than 1 in 8 of those infected, but more than half of those who died. Deaths in those under 40 years-of-age account for < 3%. Early evidence outside of China is not reassuring and epidemiological patterns and mortality rates seem to be broadly in line with those from China.

Figure 1 The pyramid of mortalities

The disease

The main feature of severe COVID-19 disease is a viral pneumonia. This presents as fever, cough and dyspnoea progressing to hypoxaemia and respiratory failure and ARDS. Importantly it often presents at least a week after symptoms start. Cardiovascular co-morbidity as a risk for mortality and evidence of hypertroponinaemia, myocarditis and sudden cardiovascular death are notable but incompletely characterised. Acute kidney injury affects up to a third of patients. 

Approximately 1 in 12 patients identified with the disease are hospitalised and 1 in 6 of these are critically ill. Of the critically ill approximately half require mechanical ventilation with more than half of these patients dying in most series.

What about the UK?

It is likely the epidemic will provide a daunting challenge to healthcare services for a period of approximately three months, a period we are just entering and which is likely to last until at least the end of May. The Chief Medical Officer estimates that 95% of cases will emerge over an 9-week period and 50% of cases in a 3-week period

The UK’s critical care capacity, which is one of the lowest in Europemay need to be expanded at many-fold during this surge in demand. This will seriously challenge provision of the 4-Ss of surge capacity in critical care: space; staff; systems; and stuff (equipment). Expansion of critical care capacity requires planning on a massive scale. Critical care provision for COVID-19 patients will likely displace all elective surgical work as critical care units are expanded in many hospitals into operating theatres and anaesthetists and theatre staff become the first staff to augment the insufficient numbers of critical care staff. Emergency surgery will still be required as will provision of critical care for non-COVID-19 illnesses.

Central to care of these patients is staff safety. In the early stages, patients will need to be isolated from other patients and as the epidemic progresses, they will need to be cohorted away from non-infected patients. Staff protection will require a system that includes, but is not restricted to, strict use of personal protective equipment (PPE). Donning and doffing PPE, using a buddy system to ensure this is optimised and engaging in low patient contact methods will need to become second nature for all healthcare workers. Anaesthetists and intensivists are highly invested in this topic because airway management, including tracheal intubation, is associated with some of the highest risks of transmission of infection. PPE is likely to be effective, so too are simple methods of decontamination of surfaces, equipment and ourselves with soap and alcohol-based cleaning processes.

PPE is an emotive and important subject. In China, healthcare workers experienced high rates of infection in the early period of the epidemic, when PPE use may not have been optimal. Over time this rate of infection has reduced but it remains significant, and there is soft evidence from both China and Italy that healthcare workers who are infected have a higher rate of severe and critical illness than the normal population, plausibly because of exposure to a higher viral load. There are likely to be limited PPE stocks and appropriate use of it is essential to maintain stocks throughout the epidemic. 

What can we do?

If not already done, it is time to plan and time to act. Every hospital needs to plan its response to admission of its first patients with COVID-19 (phase 1 and 2), its first critically ill patient, and cohort of patients (phase 3). There is a pressing need for anaesthetists and intensivists to talk to each other, join forces and work together to organise and test the best response they are able. Collaboration in planning and delivery of critical care services in the predicted epidemic offers the greatest chance of weathering the storm. Given that the UK has half of the critical care beds per 100,000 capita of population than in Italy who have branched into the operating theatres already, there is a clear risk that our current resources will not suffice [8]. There will also be great strain on PPE supplies and medical, nursing and other workforces.


The numbers do however provide some hope. The spread of the disease beyond Hubei province in China is wide geographically but the number of cases and deaths is rapidly diminishing. The considerable efforts made by the Chinese government and people to control the epidemic appear to have worked and R0 is now less than 1. On 8th March there were no new cases reported in China outside Hubei. Drug trials are underway and will be reported soon, there may be therapies that reduce the severity of illness or help manage critically ill patients. 

In the meantime, it is going to be a very difficult period for frontline clinicians and all those we work with. Information and guidance changes often and rapidly. For anaesthetists and intensivists in the UK, a central source of information is likely to be a joint hub page run by all the key organisations who have joined together at this time for simplicity and clarity.

We encourage all readers to take stock at this time, get fit mask tests as a priority, familiarise themselves with their institutional PPE policies, practice and train for the management of COVID-19 patients, and agree robust local procedures for the likely epidemic to come.

Association of Anaesthetists members can also register for this free webinar update which takes place on the 14th of March from 0900-1100.

Professor Tim Cook and Dr Kariem El-Boghdadly

Regional anaesthesia for all

There has been recently an explosion of new regional anaesthesia techniques that seem to promise better outcomes for patients undergoing surgery. That said, most anaesthetists will probably never perform a PECS, QLB, BD-TAP, ACB, RLB, RISS, PENG, MICB or TQL block, to name but a few. Fear not, this excellent new editorial from Turbitt, Mariano and El-Boghdadly aims to recalibrate current practice and lists a limited selection of high value, basic blocks. You can hear more about this extremely popular paper, including why the authors wrote it and what they have planned for the future, in the next #TheAnaesthesiaPodcast on the 16th of March. For now, readers might also be interested in this systematic review, meta-analysis and trial sequential analysis of the posterior suprascapular block in shoulder surgery and this meta-analysis of local anaesthetic delivery regimens for peripheral nerve catheters.

This new rapid sequence intubation survey from Zdravkovic et al. is impressive work for several reasons (Fig. 1). Firstly, they recruited over 10,000 anaesthetists from across the world using platforms such as LinkedIn. Secondly, they compared responses with the opinions of recognised international airway management experts. Finally, their results have consequences for clinical practice and a wide range of future research priorities. Will we ever achieve consensus for an area of practice with such wide variations and controversy? Charlesworth and El-Boghdadly argue such aims might be outdated, and the old questions about thiopentone vs. propofol, suxamethonium vs. rocuronium and opioid vs. no opioid are no longer relevant. Perhaps the new PUMA guidelines, expected later this year, will add some much-needed clarity. For now, readers might also be interested in this new multidisciplinary consensus statement on fasting before procedural sedation in adults and children, which we discussed recently in the #NotSoFast TweetChat

Figure 1 Preferences for rapid sequence intubation from respondents from high‐income countries (filled circles), upper middle‐income (diamond), lower middle‐income (triangle) and low‐income (empty circles). The upper three panels (a) are for a hypothetical patient with intestinal obstruction. The lower three panels (b) are for any other rapid sequence intubation indication.

Obstructive sleep apnoea (OSA) is common, with most cases in the peri-operative setting presenting without a formal diagnosis. This new prospective trial from Christensson et al. suggests that partial neuromuscular blockade in patients with OSA inhibits hypoxic ventilatory response, which is restored through full recovery from paralysis. The physiology behind this study and the methods used to investigate the hypothesis are simply fascinating! Thankfully, Raju and Pandit are at hand to explain all this along with the associated clinical context (Fig. 2). 

Figure 2 Schematic for oxygen sensing at type‐1 glomus cell of carotid body. (1) Hypoxia closes background K+ (TASK) channels, which normally permit background leak of K+ outside the cell; K+ is thus retained in the cell, causing depolarisation. (2) Depolarisation opens voltage‐gated Ca2+ channels, leading to Ca2+ influx. (3) This causes fusion of vesicles containing neurotransmitters (NT) with the cell membrane and acetylcholine (ACh; the likely clinically‐relevant neurotransmitter) is released into the synaptic cleft. (4) ACh binds to specific nicotinic receptors (nAChR) causing action potentials in the afferent glossopharyngeal neve, which travel to the respiratory centre. Volatile anaesthetics block the oxygen sensing by TASK channels at step (1). Propofol inhibits glomus cell response by an as yet undefined mechanism (possibly inhibiting voltage‐gated Ca2+ channels at (2); see reference 14). Neuromuscular blockade prevents binding of ACh at nAChR at (4).

Gastric ultrasound is becoming increasingly popular in the peri-operative setting, but it might also have a role in the critical care unit. This new prospective multicentre cohort study from Bouvet et al. suggests that gastric suctioning in mechanically ventilated patients is not a reliable tool for monitoring residual gastric volume. The question is, can gastric ultrasound be used in this setting to reduce the risk of regurgitation, vomiting and ventilator-associated pneumonia? Last year, we were delighted to publish our international consensus statement on the use of uterotonic agents during caesarean section. This highlighted the potential for a reduced dose of carbetocin of < 100 μg for low-risk women. This month, Drew et al. find that the ED90 for carbetocin in obese women with a BMI ≥ 40 kg.m-2 is less than this, and even less still for women with a BMI < 40 kg-2 (Figure 3). Their methods are an excellent example of how a dose-finding study can be conducted using a biased coin up-and-down sequential randomised allocation scheme.

Figure 3 Sequence of doses administered and subsequent response. Success – filled circle; failure – open circle.

Elsewhere we have a study of the Quantra® point‐of‐care haemostasis analyser during urgent cardiac surgeryan observational study of the effects of tracheal intubation and tracheal tube position on regional lung ventilationa study of the discrimination of quick Paediatric Early Warning Scores in the pre‐hospital setting; and a retrospective study of short‐term safety and effectiveness of sugammadex for surgical patients with end‐stage renal disease

Finally, we are delighted to announce that Anaesthesia Reports is now indexed on the PubMed database! Anaesthesia Reports represents the next generation of peer-reviewed journals that accepts case reports, videos, images and educational articles from authors anywhere in the world. Regardless of author background or subject area, it offers a cutting-edge platform for authors, readers and patients. PubMed listing is a major step forward, as it reflects the quality, legitimacy and scientific value of the journal. You can catch up with the most recent issue by reading this excellent summary from the editorial team.


Mike Charlesworth and Andrew Klein

Safe transfer of the brain-injured patient

Welcome to #TheAnaesthesiaBlog for the February 2020 issue of Anaesthesia, and with it comes the publication of a new guideline on safe transfer of the brain‐injured patient. Produced as a consensus document between the Association of Anaesthetists and the Neuro Anaesthesia and Critical Care Society, the guidelines serve to update the previous 2006 iteration. The document considers recent developments in the management of multiply-injured patients and those with acute ischaemic stroke. Whilst many of the principles of safe transfer are common to all seriously ill patients, specific risks and management strategies apply to those with acute brain injury. For example, the guideline provides new recommendations on the management of blood pressure parameters for common types of brain injury.

Table 1 Physiological variables and fluids for transfer of brain-injured patients. Of note, there is little high-quality evidence to support particular values and this table is the product of discussion and consensus between members of the Working Party. Where possible, the BP targets reflect the recommendations of the European Trauma Course.

The way in which we access information across all walks of life has changed beyond recognition over the last decade, and Johannsson and Selak discuss the implications of this for medical journals. Social media platforms are seemingly ubiquitous, and their use to disseminate new medical knowledge promises to increase the speed at which science is translated to improvements at the bedside.  Smartphones and other handheld digital devices are commonplace, with 65% of nurses reported to use mobile devices for work‐related tasks for at least 30 minutes each day. Unlike medical journals or conferences, accessing resources on social media platforms is usually free, always available and unrestricted by training budgets or work schedules. In the accompanying article, Ng et al. provide evidence that an intelligence‐led multimedia approach is an effective and efficient method to actively disseminate a clinical and educational patient safety message to a defined target audience. They produced videos to communicate recommendations from the safety project and Facebook, Twitter, YouTube and LinkedIn delivered these to their target users. There is now a need to think about measuring and comparing analytical outputs of social media such as reach, engagements, clicks and views, along with value for money.

Figure 1 Global social media activities relating to tracheostomies. A video of a three‐year‐old girl singing through her tracheostomy tube was posted on social media by her mother and was later reported by a newspaper (*). A television documentary about a synthetic organ surgeon, who was accused of falsifying his research on synthetic trachea transplantation, was broadcast (#). The news of a baby born without a nose dying at age two was posted on social media and was later reported by a multimedia news channel. He received a tracheostomy at five days old ($). An imprisoned Nobel Peace Prize laureate Liu Xiaobo’s was reported as being in a ‘life threatening’ state. His family opted against receiving a tracheostomy (^).

In other editorials, the motto adopted in 1945 by the Association of Anaesthetists, when granted the right to bear arms by King George VIis called in to question as Ritchie-McLean and Davies discuss why patient safety training for UK doctors is inadequate. They put forward why they believe anaesthetists would benefit particularly from improved training, and how and when it should happenThe concept that fig leaves (in the guise of the words ‘pilot’ and ‘feasibility’) are used and attached to authors work to hide poorly conceived and conducted studies, is considered by Story in his editorial to accompany the review by Charlesworth et al. After hypothesising that only a small proportion of pilot or feasibility studies published in anaesthesia journals were correctly labelled as such, the authors show that only 34 of 266 (12.8%) pilot studies published in six anaesthesia journals between 2007 and 2017 were correctly labelled as such. Undoubtedly, these results have important consequences for patients, trialists, researchers and funders, and the authors argue that correctly labelled pilot studies enhance the quality of scientific research by encouraging methodological rigour, ensuring scientific validity and reducing research waste. 

Table 2 The difference between pilot/feasibility studies and non-pilot/non-feasibility studies as defined by the National Institute for Health Research and CONSORT guidance.

Finally, Oglesby, Sterne and Gibbison discuss the notion of using ‘big data’ to validate care bundles, consensus guidelines and protocolised care –  all of which have had a positive impact on patient care to date. In the related associated paper, Chiu et al. analysed over half a million sets of vital signs in 13,631 patients discharged from the cardiac intensive care unit to generate a logistic score. Comparisons were made between the national additive score and the composite outcome of: in‐hospital death; cardiac arrest; or unplanned intensive care admission. They conclude that a logistic version of the National Early Warning Score (NEWS), rather than the current additive model, better discriminates patients after cardiac surgery who suffer adverse outcomes following critical care discharge. Furthermore, logistic scores also provide a useful quantified tool of predicted risks for clinicians, which arguably NEWS cannot.

Figure 2 Black curves represent predicted probability of the physiological variable given the other predictors being controlled for logistic Early Warning Score (EWS). Horizontal red lines represent individual parameter dividing bins used by National EWS (NEWS, right axis).

Elsewhere (and not disguised with a fig leaf!), Webb et al. discuss their pilot study, which aimed to assess the feasibility and effectiveness of an offer of a free five-week supply of nicotine replacement patches provided to smokers at the time of listing for surgery, and to determine the effect on sustained abstinence for four weeks before surgery. Whilst the offer stimulated more cessation attempts before surgery, with many more in the intervention group either quitting or making attempts to quit, a large proportion (59%) had relapsed at six months.

Cricoid pressure has been a matter of debate since its introduction in 1961, and numerous studies have supported or contradicted its use. In this issue, Kim et al compared the effect of cricoid and paralaryngeal force on upper oeseophageal occlusion during induction of anaesthesia in a randomised crossover study involving 74 patients. Both cricoid and paralaryngeal force decreased the oesophageal inlet diameter, however, occlusion of the oesophageal entrance was more frequently observed with cricoid force application. As per recommended standards for monitoring during anaesthesia, a peripheral nerve stimulator should be used whenever neuromuscular blocking drugs are given during anaesthesia. That said, mechanomyography is seldom employed outside of the laboratory, and Bowdle find that acceleromyography and electromyography monitors are validated against such a device, with results consistent with previous comparative studies. Mechanisms underlying loss of consciousness following propofol administration remain incompletely understood. Sepúlveda et al. set out to study the pharmacodynamic effects of propofol through comparison of frontal lobe electroencephalography activity and brainstem reflexes during intravenous induction of general anaesthesia. Two independent mechanisms underlying the loss of consciousness have been postulated, and the authors demonstrate both to have a significant role depending on the rate of propofol infusion. 

For those of you with an interest in intensive care medicine and ultrasound, this new study from Dransart‐Rayé might be right up your street. Given that pulmonary complications have a significant impact on morbidity and mortality after major surgery, the authors conducted a prospective study in 109 patients to evaluate whether lung ultrasound could be used as a predictive marker for postoperative ventilatory support in high‐risk surgical patients. Using an easy‐to‐implement method, it was demonstrated that lung ultrasound abnormalities were indeed associated with postoperative pulmonary complications, and as such they conclude that the use of ultrasound could allow for earlier interventions and thus improve clinical outcomes.

Figure 3 Ability of lung ultrasound (LUS) score to predict requirement for postoperative ventilatory support (a) Receiver operating characteristic curve (b) inconclusive limits of LUS score (grey area).

Anaemia is an independent risk factor for poor peri‐operative outcomes after major intra‐abdominal surgery, and is associated with an increased risk of 30‐day postoperative mortality after non‐cardiac surgery. Miles et al. report data from 1554 women undergoing elective, major abdominal surgery stratified as a function of pre‐operative haemoglobin concentration. Borderline anaemia was associated with increased duration of hospital stay, fewer days alive and out of hospital, and an increased incidence of complications following major abdominal surgery. However, after correction for confounding factors the relationship between borderline anaemia and adverse outcomes was attenuated. 

Elsewhere, Jewer et al. report their findings of a Cochrane systematic review conducted on the effectiveness of supplemental intravenous crystalloid administration in preventing postoperative nausea and vomitingChae et al. discuss the development and validation of a dynamic predictive model for nausea and vomiting during the first 48 postoperative hours for patients receiving i.v. fentanyl PCA available as an online web application, and the Charlesworth and Shelton pose the question as to whether intravenous gelatins have a role in contemporary peri‐operative and critical care.

Finally, make sure you check out the first of our monthly podcasts, which will feature a key article from each issue. This month, Mike Charlesworth interviews Tanya Selak and Helgi Johannsson about all things social media, and how they collaborated on their work. Enjoy!

Dr Edward Gilbert-Kawai and Professor Andrew Klein

Advances in peri-operative care

Welcome to our special issue for 2020, which is a unique collaboration between anaesthetists and surgeons. We begin with an editorial from the Editor-in-chief of Anaesthesia, Professor Andrew Klein, and the Editor-in-chief of BJS, Mr Jonothan Earnshaw, which features in both journals. They argue ‘it’s about time’, as surgeons and anaesthetists work together not only in the operating theatre, but also in delivering high-quality peri-operative care and research. We hope these special issues lead to more sharing of ideas, a desire for clinicians to read each other’s journals and more collaboration with all members of the multidisciplinary team for the good of patient care. This month’s blog focusses on the papers published in Anaesthesia, but we call on all readers to study carefully the contents of both supplements in both journals.

Fletcher and Engelman present a broad international perspective on who should care for patients after surgery. In order to tackle this question, one must first distinguish between different patient populations and surgical procedures. They suggest four themes which must be considered to improve postoperative care and patient outcomes, which appear throughout the issue (Fig. 1). Quinlan et al. tackle the problem of persistent postoperative opioid use, and the possible unintended consequences of fast-track surgery, scoring systems and patient satisfaction outcomes measures. Perhaps it is now time for more focus on procedure-specific pain management (including, where appropriate, regional anaesthesia), and an end to applying the World Health Organization’s pain ladder to the management of all pain in the peri-operative period. Levy et al. argue that restoration of function is the holy grail of peri-operative care. A big step on that journey is more collaboration between surgeons and anaesthetists, as well as developing systems for the early identification of patients who are at risk of not achieving restoration of normal homeostatic, physical and psychological function, including independence. 

Figure 1 Diagram of the key themes of postoperative outcome improvement. ICU, intensive care unit; HDU, high-dependency unit; ERAS, enhanced recovery after surgery.

Our first review is a global perspective of the quest for high-quality peri-operative care from Santhirapala et al. They argue that, in high-income nations, improvements come about through a focus on diagnostics, risk-scoring mechanisms and technology. For most of the world’s population, who do not live in high-income nations, these advances are of little relevance. We should, therefore, place more focus in the future on making high-quality peri-operative care equitable. This makes the paper from the African Peri-operative Research Group of vital relevance, and their top 10 priorities for peri-operative research are a must read for all.

The design of processes, equipment and environments to optimise peri-operative performance might be seen by some as ‘common sense’, but many advances in this field of healthcare have arisen from applying well-established principles from disciplines such as psychology, design and engineering. Marshal and Touzell argue it is now time to embed safety science experts within health organisations, as is the case in every other safety critical industry. It has been established previously that we have a natural tendency to overestimate rare risks and underestimate common ones. Wiles et al. find considerable variation in the numerical translation of verbal probability expressions by both patients and clinicians (Fig. 2). They suggest that verbal probability expressions should not be used as part of doctor-patient discussions regarding peri-operative risk. 

Figure 2 Box-and-whisker plots showing the numerical translation of verbal probability expressions by anaesthetists (white columns) and surgeons (grey checked columns). The solid line within the box represents the median, the limits of the box the interquartile range (IQR) and the whiskers represent the range. Outliers were defined as 1.5 9 IQR and are shown by ○.

Between 1999 and 2015, the number of patients aged over 75 years undergoing surgery nearly doubled. This state-of-the-art review discusses outcomes, risk assessment, risk modification, and pre-operative assessment of the older surgical patient. It seems there is now a need to redesign peri-operative pathways for older surgical patients to allow for shared decision making and personalised, evidence-based care. Enhanced postoperative recovery pathways have been continually redesigned and refined over the past 20 years. Kehlet present an overview of the associated key developments and discuss the challenges for the future (Fig. 3).  

Figure 3 Pathophysiological factors to consider for future improvement of enhanced postoperative recovery.

There is no clear consensus on which patients should be admitted pre-emptively to critical care following surgery. Unplanned postoperative critical care admissions are associated with poor outcomes, and this new systematic review from Onwochei et al. aims to describe risk factors for unplanned admissionBoyd-Carson et al. describe the surgical peri-operative factors to consider in emergency laparotomy care. The one factor that stands out is the influence of the national emergency laparotomy database in the UK, which has led to reduced mortality and length of stay. Foss and Kehlet describe the challenges in optimising recovery after emergency laparotomy (Fig. 4). They argue the case for procedure-specific enhanced recovery protocols for such patients, such as is normally seen for elective cases. 

Figure 4 Challenges in optimising pathways in emergency laparotomy.

Proponents of total intravenous anaesthesia (TIVA) cite the anti-oxidant, anti-inflammatory and immunomodulatory effects of propofol as compared with volatile inhalational anaesthesia. This new narrative review from Irwin et al. is a must read for all! They discuss effects on postoperative nausea and vomiting, free radical scavenging, organ protection, pain, and immunity. Will TIVA one day be the technique of choice for all patients undergoing general anaesthesia? Find out more by reading the free full text! Some of our most popular papers have described advances in regional anaesthesia. This review from Albrecht and Chin brings them all together for the first time. Find out all about advances in: safety and performance; fascial plane blocks; and extending block duration, as well as what the future might hold for regional anaesthesia. 

Acute kidney injury is a common complication in surgical patients and is associated with morbidity and mortality. Ostermann et al. describe the impact of surgery and anaesthesia on acute kidney injury, as well as the application of new biomarkers that may one day allow for a more personalised management approach (Fig. 5). Loop diuretics are commonly used in surgical patients with a positive fluid balance, but the impact of their use is uncertain. This new retrospective study of 14,896 critical ill postoperative non-cardiac surgical patients finds no association with overall mortality or the incidence of severe acute kidney injury. In fact, patients that received loop diuretics required a longer duration of postoperative mechanical ventilation. 

Figure 5 Origin and function of different biomarkers for acute kidney injury.

Elsewhere we have reviews of: quality of recovery and long-term functional recovery after surgerythe role of patient-centred outcomes after hospital dischargethe importance of the postoperative recovery teamperi-operative cardiac biomarker screening; and an original article reporting a prospective observational study of the association between genome-wide polymorphisms and chronic postoperative pain. We hope you enjoy this year’s supplement, which is the most complete, accurate and up to date synthesis of evidence, consensus and expert opinion relevant to advances in peri-operative care. More importantly, we hope it contributes to more collaboration between surgeons and anaesthetists.

Join us over on Twitter as we discuss each paper from both journals in depth. See you later this week for #WSM2020

Dr Mike Charlesworth and Professor Andrew Klein