Staff are our most valuable asset

In the UK, COVID-19 continues to impact upon the provision of all NHS services. This new serial service evaluation from Kursumovic et al. was able to measure and report on the impact on anaesthesia and critical care services in the UK between October 2020 and January 2021. Interestingly, this study made use of the NAP6 infrastructure, as the project was on hold during the pandemic. During this time, one in eight anaesthetic staff were not available for work and one in five operating theatres were closed, with activity falling significantly in those theatres that were open. During January 2021, the system was largely overwhelmed. Redeployed anaesthesia staff increased the critical care workforce by 125% and three quarters of critical care units were expanded. This all helps us to work out what happened which will hopefully mean we are better placed to respond to future pandemics. 

The survey focusses on three key factors – staff, space and stuff. In the accompanying editorial, Wong et al. argue that staff are our most valuable asset. We have all and will continue to work in new ways because of the pandemic, and there has been much focus on ways in which to combat the effects of workforce burnout. It nevertheless remains to be seen whether recommendations such as better provision of mental health support, improved pay, combating workplace bullying and delivering better workforce planning will be implemented. The arguments provided by Wong et al. are compelling and their thoughts seemed to resonate with our followers over on Twitter. For this workforce will also be the one that looks after our nation’s health for years to come. 

There have been numerous observational studies reporting on outcomes in patients with COVID-19 admitted to intensive care. This new systematic review and meta-analysis from Taylor et al. finds that increasing age, pre-existing comorbidities and greater severity of illness are associated with mortality in patients admitted to ICU with COVID-19, but male sex and increasing BMI were not. This surprising finding attracted a lot of attention on social media and with nine news outlets also featuring the study. In the associated editorial from Cook and Comporota, state the case for core datasets for critical care outcomes from COVID-19. These will not only be of benefit for this and other pandemics, but also for the major health challenges that affect ICUs across the world. 

How best to pre-oxygenate patients prior to rapid sequence intubation (RSI) continues to be debated. This new randomised controlled trial from Sjöblom aimed to compare high-flow nasal oxygen with tight-fitting facemask pre-oxygenation during RSI in patients undergoing emergency surgery in several different centres. They showed no difference in the number of patients desaturating < 93% between pre-oxygenation using high-flow nasal oxygen vs. tight facemask. Lam and Irwin ask, is high-flow nasal oxygen worth the hassle? It does seem to be safe, but it is more expensive, time-consuming, technically more difficult to prepare does not appear to have any major benefits over other accepted techniques. We need more research in specific patient groups such as obese, pregnant and high-risk patients more generally. Also this month, Sud et al. compare gastric gas volumes measured by computed tomography between high-flow nasal oxygen therapy and conventional facemask ventilation. They find that high-flow nasal oxygen does not increase gastric gas volume in fasted patients undergoing induction of anaesthesia in the supine position, which adds further support to the safety of its use. 

Figure 1 Oxygenation until 1 min after intubation. Lowest SpO2 (%) from start of pre-oxygenation until 1 min after intubation and apnoea time (s) is plotted for every patient pre-oxygenated with high-flow nasal oxygen (n = 174) or facemask (n = 175). High-flow nasal oxygen (red squares); facemask (blue dots). Desaturation was defined as SpO2 < 93% (dotted line). *No intubation time was noted. Therefore, this patient had the mean intubation time in the high-flow nasal oxygen group added to its apnoea time up until the laryngoscope passed the teeth.

Every year, > 130k patients survive an episode of critical illness in the UK. Focus on this patient group will no doubt increase as the pandemic hopefully eases. This new mixed-methods systematic review from Bench et al. finds that fatigue is common in critical illness survivors, with a prevalence ranging from 13.8–80.9%. This rises around one month following ICU discharge and improves over time but seldom resolves completely. There is a paucity of evidence on how best it should be detected or managed. In the accompanying editorial, Hosey et al. argue that we must help ICU survivors find new ways to live with chronic symptoms, with clinicians and researchers striving to design and evaluate multidisciplinary and comprehensive treatment modalities that support recovery from the ICU to home. 

Figure 2 SF-36 vitality scores over time for data from (a) observational cohort studies and (b) randomised controlled trials. Values are mean (95%CI).

The new Association of Anaesthetists 2021 recommendations for standards of monitoring during anaesthesia and recovery have now been cited 7 times and attracts an Altmetric score of > 250. Areas of controversy include new guidance on: capnography; transfer; quantitative neuromuscular monitoring; processed electroencephalogram monitoring; and electronic record keeping. They feature in this month’s issue, and they are essential reading for all. Elsewhere we have: a randomised controlled trial of deep serratus anterior plane block vs. sham block in ambulatory breast cancer surgerya narrative review of adjunctive treatments for the management of septic shocka systematic review of the association between intra-operative cardiac arrest and country Human Development Index statusan evaluation of group teaching before surgery (Fit-4-Surgery School); and a feasibility and pilot study of volatile anaesthesia and peri-operative outcomes related to cancer

Many of this month’s articles have an associated podcast which you can listen to here. It also features the most recent podcast which looks at the new COVIDSurg international prospective cohort study on the effects of pre-operative isolation on postoperative pulmonary complication rates. The paper remains free to access forever!

Mike Charlesworth and Andrew Klein

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