Science bites back

This month, we were delighted to publish two contrasting articles on aerosolisation during tracheal intubation. The first by Brown et al. was published on the 6^th of October, and has since become our fourth most popular paper on social media, ever! They conducted an experiment involving quantitative aerosol measurements during tracheal intubation and extubation in real-time in ultraclean ventilation operating theatres. They found that tracheal intubation produces a barely recordable increase in aerosol, which is at odds with previous retrospective evidence that was used to designate tracheal intubation as an aerosol generating procedure. Remarkably, this was followed only a few days later by a study from Dhillon et al. which seems to suggest the opposite. They found that face-mask ventilation, tracheal tube insertion and cuff inflation generated small particles 30-300 times above background noise that remained suspended in airflows and spread from the patient’s facial region throughout the confines of the operating theatre. This all begs the questions, who was right? We are looking forward to the associated editorial and we hope to bring both groups of authors together to discuss the many complicated issues at play. We are, however, thrilled that we are now beginning to see the science tackle some of the key clinical questions which affect practice as we enter what seems to be the second wave of COVID-19 in Europe. 

Turning attention back to the November issue, aerosol generation and airway management remain key topics. This prospective international multicentre cohort study from El-Boghdadly et al. was first published four months ago and is the first output from the IntubateCOVID registry (Fig. 1). They found that around 1 in 10 healthcare workers involved in tracheal intubation of patients with suspected or confirmed COVID-19 subsequently reported a COVID-19 outcome. When interpreting these data, it is worth remembering the limited availability of tests for healthcare staff and members of the public alike at the time data were collected. This and many other aspects of the study are discussed in the paper and have been commented on by others in associated correspondence. Kakodkar et al. undertakes some mathematical manipulations to estimate a baseline risk after a COVID-positive aerosol-generating procedure, which is generally reassuring for those treating ‘green’ pathway patients. Crawley and Maguire likewise discuss airway management in the COVID-19 era, oxygenation, videolaryngoscopy, risk to healthcare staff and future directions, considering the findings of El-Boghdadly et al. 

Figure 1 Symptoms reported in the 184 participants meeting the primary endpoint.

Another risk to healthcare staff is of the future legal implications of decisions taken during the present time.This new review from Coghlan et al. outlines the broad framework within which we can consider the medicolegal and ethical aspects of some of the more readily identified issues experienced during the surge in demand for critical care. In particular: legal aspects of care and the legal and ethical aspects of rationing critical care. The associated editorial from Ferguson and Johnston provides some commentary, and call for us all to move ahead collectively, learning lessons and effecting changes that provide long-term benefit. How frequently does anaphylaxis occur during pregnancy, what are the causative agents and how is it managed? This new population-based multinational European study by McCall et al. finds a similar incidence across five European countries of 1.5 per 100,000 women among almost 4.5 million births. Most reactions happen around the time of birth, and there are wide variations in management strategies. Savic and Lucas argue that although this may seem reassuring at first, there is a risk of underreporting and there is a need not to overlook this important differential when an obstetric patient deteriorates unexpectedly. 

Figure 2 Video calls between ICU patients and their family: data protection issues. GDPR, General Data Protection Regulation; MCA, Mental Capacity Act.

How well do you understand the COVID-19 coagulopathy spectrum? This new editorial from Thachil and Agarwal describes immunothrombosis, localised pulmonary and systemic coagulopathy antithrombotic management, the role of viscoelastic testing, bleeding and future directions in the area. Although outcomes may improve as our understanding of the coagulopathy spectrum increases, how can we better assess the risk to our own health that COVID-19 poses? This new review from Tim Cook is a must read for all, as it brings together all the relevant evidence to remind us that age is the chief risk factor. Furthermore, absolute rather than relative risk is more important and dynamic, particularly in the context of healthcare workers. The paper includes an excellent risk assessment tool, and we encourage organisations to consider the interaction between personal and environmental risk, as well as mitigation measures, rather than just personal risk alone. Finally, Thornton et al. present recommendations for management of the airway and lung isolation for thoracic surgical patients during the pandemic. Their paper has generated much discussion already and we hope its publication has kept healthcare staff safe, at a time where thoracic surgery continued for patients with lung cancer.

Figure 3 Antithrombotic management of COVID‐19 coagulopathy based on D‐dimers and platelet counts.

Elsewhere we have: a narrative review of tracheal tube size in adults undergoing elective surgery; a randomised trial of fibrinogen concentrate during scoliosis surgery; a randomised controlled trial of intra-operative dexmedetomidine in children; and a randomised trial of intravenous dexamethasone after volar plate surgery. Over in Anaesthesia Reports, we have reports of: extracorporeal carbon dioxide removal in a patient with COVID-19; surgery for tracheal obstruction due to a tumour; an emergency caesarean section in a patient with pre-eclampsia and multifactorial thrombocytopenia; mallet finger in an anaesthetist; and many other interesting cases. Finally, make sure you book your place at #WSMLondon21, as we go virtual! Our new Editor Ed Mariano is speaking about lessons learned from the US opioid epidemic, and speakers at the journal session on Thursday morning include Seema Agarwal and Laura Duggan. 

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Mike Charlesworth and Andrew Klein