The anaesthetic robotic revolution?

The July issue is now available online and next month will see a return to the distribution of printed copies of the journal to our readers. You can read all about the reasons for this, along with how we have adapted to the pandemic, in our new editorial which now features in our ‘accepted articles’ section. In this month’s issue, Biro et al. describe robotic endoscope-automated laryngeal imaging for tracheal intubation. A prototype robotic endoscope device was inserted into the trachea of an airway manikin by seven anaesthetists and seven novice participants. There was little difference between the groups in terms of success rate and duration of insertion (Fig. 1). Ahmad et al. list the many limitations of this study, such as the fact that tracheal intubation was not performed. That said, the device recognised glottic features and was able to steer the endoscope tip into the trachea automatically. This is truly novel. Will robots take our jobs? We only need to look to surgery to tell us that robots have made good surgeons better, and although anaesthesia might be an innovative specialty, we have not fully embraced the robotic revolution, just yet.

Figure 1 User interface composed of the tip camera video (a) and the device configuration feedback (b), and anatomical features detection (c to e). The square indicates the successful recognition of the laryngeal inlet. The white dot represents the detected entrance of the glottis, while the white cross aims into the direction the tip is pointing. This difference triggers the proposal to ‘move the device to the left’, which appears in the left upper corner of the screen. The entire larynx (double line square), the corniculate cartilages (dotted small square), glottis (full line square) and subglottic trachea (segmented square). On the video screen (a), these squares are colour coded for better differentiation.

This month’s issue contains several high impact papers on various aspects of caring for patients with COVID-19. First, Lyons and Callaghan discuss the use of high-flow nasal oxygen (HFNO) for such patients. We use it commonly for patients with respiratory failure, but there are theoretical concerns around the potential for aerosol generation. This is all challenged by the authors, who point to a lack of evidence on aerosol generation and the risk of infection with HFNO, and call for clinicians to remain open minded. The question is, do alternatives have a better risk-benefit profile, for both patients and healthcare workers? Ventilator splitting has received much attention, and this new paper describes how it might be achieved with standard hospital equipmentLee et al. report their experiences of battling COVID-19 from a tertiary academic medical centre in Singapore. Strategies included: containment; avoidance of health resource overburdening; optimisation of healthcare resources; and factoring in welfare and logistics. This can be compared with hospital surge capacity in a tertiary emergency referral centre during the COVID-19 outbreak in Milan, Italy. They issued an early warning (in late March) that hospitals should be prepared to face severe disruptions to their routine, and that it was very likely that protocols and procedures might require re-discussion and updating daily. The care of patients with chronic pain has been significantly impacted by the pandemic, and these new consensus recommendations from an international expert panel provide guidance on: the immune response; steroids; psychological, physical and social functions; in-person visits; telemedicine; biopsychosocial management; opioid prescriptions; anti-inflammatory drugs; and procedural precautions. Of course, no discussion of COVID-19 is complete without talking about personal protective equipment, and this review by Tim Cook is arguably the best there is. The infographic below contains all the key messages, but the full paper is well worth a read for everyone. You can also listen to a podcast on the topic from last month here

We also have a number of high-quality ‘NO-VID’ papers this month, including this narrative review of the anticipated difficult airway during obstetric general anaesthesia from Mushambi et al. They provide generic recommendations as well as updated decision aids for: the time and mode of delivery for a pregnant woman with an anticipated difficult airway; the general anaesthetic approach to such a patient; and an overview of all the included practice recommendations. This new safety guideline, jointly produced between the Obstetric Anaesthetic Association and the Association of Anaesthetists, describes practices around neurological monitoring associated with obstetric neuraxial block. Four main recommendations are given, which include: triggers to alert the anaesthetist; the use of straight-leg raise as a screening method; the likely timescale for resolution of neuraxial blockade; and the guidelines and policies maternity units should be expected to have in place (Fig. 2).

Figure 2 Summary of postpartum neurological deficits.

Elsewhere we have a study of the association of pre-operative anaemia with morbidity and mortality after emergency laparotomya prospective cohort study of clinician perception of long-term survival at the point of critical care discharge; and a retrospective observational study of variables associated with survival in patients with invasive bladder cancer with and without surgery. Over in Anaesthesia Reportsthis new report of a junior doctor’s experience of critical illness due to COVID-19 now had an Altmetric score of > 1000! It was featured by > 100 news organisations, including the mainstream media, and has won acclaim from doctors and patients alike. Other reports include: local anaesthetic resistance in a patient with Ehlers-Danlosintra-abdominal nasogastric tube placementparatracheal abscess formation following tracheal intubationthe anaesthetic management of a patient with an isolated cortical vein thrombosis for emergency caesarean sectiontransient paraplegia due to subarachnoid haemorrhage following spinal anaesthesia; and unexpected difficult airway management in a transgender female patient

Join us over on Twitter as we discuss every paper from the issue in detail, with each made free for a day for all!

Mike Charlesworth and Andrew Klein

Preventing major airway complications

Every anaesthetist fears the moment they might become faced with a ‘can’t intubate, can’t oxygenate’ (CICO) scenario, but thankfully such events are exceedingly rare. They nevertheless receive much attention in the academic literature. The results from this online survey of Australian and New Zealand anaesthetists finds that most hospitals keep CICO equipment in every anaesthetic room in dedicated packs. As this is probably not common practice elsewhere, maybe it is probably about time we all caught up. Kelly and Duggan discuss preparing for and preventing CICO events, and call for clinicians’ worldwide to examine the design of their working environment. At the same time, the need to prepare for CICO events is superseded, arguably, by the need to prevent them from happening in the first place. Perhaps it is good timing then, that Chrimes, Higgs and Sakles write in this month’s issue to welcome us to the era of universal airway management. Their guidelines are anticipated eagerly.

This new pilot study from Deng et al. is an excellent example of how such a study should be designed and reported. They present important data that will hopefully allow for a larger, definitive randomised controlled trial of standard vs. augmented systolic blood pressure management during endovascular thrombectomyWiles discusses the relevant literature on the relationship between anaesthetic technique, blood pressure monitoring and outcomes for patients undergoing mechanical thrombectomy after ischaemic stroke. He argues a greater focus on precision medicine is required, which includes individualised objectives and attention to detail. Is it time for bespoke haemodynamic targets? Such an aim might seem more biologically plausible than a simple choice between general anaesthesia and conscious sedation (Table 1).

AdvantagesDisadvantages
Airway protection with reduced risk of pulmonary aspiration of gastric contents (most patients do not present fasted).Slower door‐to‐groin puncture time and thus may delay vessel recanalisation.
Less patient movement which is desirable from the perspective of the interventional radiologist and may reduce procedural time and complications.Potential for a greater degree of iatrogenic hypotension
Lower potential for patient discomfort.Unable to monitor neurological status intra‐operatively.
Ensures direct anaesthetic involvement in the procedure which may secondary benefits such as: dedicated intra‐operative clinical monitoring; assessment and correction of volaemic status; and assistance with postoperative care destination (e.g. critical care admission).Risk of postoperative hangover effect with potential for POCD/POD.
Table 1 Advantages and disadvantages of general anaesthesia (including tracheal intubation) for mechanical thrombectomy.

This new editorial is extremely timely, even though it was written at the end of 2019. Kelly et al. discuss resilience in the context of lessons learnt from the military. They remind us that resilience is more than ‘toughness’, and involves the ability to manage the breadth, depth, intensity and chronicity of the demands placed upon us. In the wake of passing the peak of COVID-19 cases in the UK and elsewhere, the messages contained, such as strategies to improve team resilience, are essential reading for all. In early March, we received our first COVID-19 paper from a group of Italian authors documenting their clinical experiences and recommendations. It has since been cited 32 times and achieved an Altmetric score of > 340! We then went on to publish these consensus guidelines for managing the airway in patients with COVID-19, which has now been cited 34 times and has an Altmetric score of > 500! We hope these and other publications, such as this simulation study to evaluate the operational readiness of a high-consequence infections disease intensive care unit, have contributed to better clinical care during what has been an extremely difficult time for us all.

This new review from Lindsay et al. examines representation of patients in peri-operative randomised controlled trials in terms of age, sex, race and ethnicity. They found included trials were insufficiently representative, with race and ethnicity seldom reported. Overall, study populations were younger (Fig. 1), which perhaps presents issues in areas such as orthopaedic and trauma surgery research. They recommend that unnecessary age discriminatory exclusion criteria, including age limits, should be avoided. This systematic review by Heesen et al. pits phenylephrine and noradrenaline against each other for the management of hypotension associated with spinal anaesthesia in women undergoing caesarean section. They found that noradrenaline may preserve haemodynamic stability to a better extent than phenylephrine. They also conclude that an effect of noradrenaline on the rate of fetal acidosis cannot be excluded, which could be due to the β‐stimulating properties of noradrenaline. However, they warn of a lack of data as these conclusions come from single trials only. It looks like this one is far from over!

Figure 1 Bubble plots for each surgical category showing the difference between the mean or median age of the randomised controlled trial population and the mean age of the equivalent populations in the English hospital registry, according to the middle year of study recruitment. Marker radius is proportional to the number of study participants.

Elsewhere this month, we have: a sub-analysis of pooled data from two prospective studies on 10 kHz spinal cord stimulation for the treatment of non-surgical refractory back painan analysis of patient and surgery factors associated with the incidence of failed and difficult intubation; and a randomised controlled trial of the effect of low-dose naloxone infusions on the incidence of respiratory depression after intrathecal morphine administration for major open hepatobiliary surgery. Over in Anaesthesia Reports, we have a report of airway obstruction during general anaesthesia in a patient with a vagal nerve stimulator. Make sure you send your reports today for an efficient and friendly peer review service, together with the chance to get a publication in a well-read PubMed listed publication!

Keep your eyes out for new about our next TweetChat, which we hope to bring to you very soon, and make sure you check out our complete free to access COVID-19 collection!

Mike Charlesworth and Andrew Klein

Thank you for your service

I moved halfway across Canada to start a new position in a dynamic academic department shortly before SARS-CoV-2 moved to Canada. An understatement, as we Canadians are known for, is that COVID-19 has fundamentally changed the way we practice medicine. My first night of call, I asked a maintenance worker to point me to the trauma room. As I walked away, he said “Thank you for your service”. I was first humbled by this statement, then somewhat unsettled. Isn’t that what we say to members of the military? Don’t members of the military consciously sign-up for the potential of personal harm? 

As a civilian, I never anticipated practising anaesthesia would mean placing myself at real risk of personal harm. Sure, we have all donned personal protective equipment (PPE) for the patient who may have tuberculosis, but I wasn’t performing any procedure that actually increases my risk compared to everyone around me. Now we are. In this COVID-19 new normal, the procedures we perform as anaesthetists are placing us (and the healthcare providers who assist us) in high-risk situations repeatedly. We are now consciously signing up for the potential for personal harm. A pandemic calls for the ultimate in human factors training; how to maintain competency and effectiveness in the setting of a potential threat to your own life. How do we integrate this training into medicine?

To answer this, I asked my friend and colleague Dr. Leilani Doyle to tell me about how her military training prepared her for situations where her life could be at stake. We also examined our civilian medical experiences and training. The COVID-19 pandemic calls for a change in medical training to acknowledge and manage the stress and anxiety of providing high-risk healthcare through focussed training and simulation. It also calls for integration of a heightened emotional state into protocols such as the mandatory use of checklists and clarity regarding acceptable and unacceptable equipment supply chain issues. Finally, pandemic response calls for a fundamental shift from our usual civilian practise of attempting to do more with less, to acknowledging changes in protocols take more time and personnel until they become ‘routine’.

Physicians are often reluctant to adopt safety initiatives such as simulation training, checklists, algorithms, protocols and drills that have been embraced in other high-risk industries such as the aircrews, the military or nuclear power plant operators. Simulation is often thought as a useful exercise during training to master decision-making, but not necessarily required once one is a consultant. Algorithms and protocols have been criticised in medicine as an abdication of decision-making. Checklists have also been criticised as causing unnecessary delays prior to surgery. Drills, or practice involving the repetition of an activity to improve a skill, to the point of being able to execute it perfectly even when sympathetically driven, is simply not a part of medical culture. A deficit perhaps only now appreciated during a pandemic.

Some may perceive resistance to these safety initiatives as signs of arrogance or hubris, but we disagree. Medical training and evaluation build and test recalled facts assembled into knowledge used at appropriate times.  A ‘good’ physician can recall enormous amounts of information and is definitive in their decision-making. Does that mean a physician seeking the help of others and using written checklists is not? Knowledge retrieval, contextual awareness and communication are all severely tested when our own health is at stake. The COVID-19 pandemic has leveled the playing field between healthcare providers, aircrew or nuclear power plant operators; now our lives are at risk too. 

There has been a paradigm shift in civilian healthcare; our workplace may now be a hostile environment where we may be at risk of illness and or death, whether or not a patient appears unwell. Our medical training has left us ill-equipped to deal with this dynamic. Understandably, this has caused great anxiety in many health care providers. As more is known about how COVID-19 spreads, or as supplies of PPE diminish or are substituted, guidelines and checklists will change. Constant change when one’s own health is threatened can also be a nidus of anxiety of what can be perceived as an opaque or confusing healthcare system, a system we once knew so well. Anaesthetists are very familiar with making do despite unavailable or backordered medications and supplies, being presented substitutes without consultation or discussion, or simply ‘MacGyvering’ equipment where there is a perceived need. Anaesthetists are also very used to being asked to do more with less and making their own individual decisions about the management of each patient. Safe anaesthesia care now requires we have a team-based approach where our patient management is predictable and more protocolised. We required more support and more time for procedures while acknowledging, in the short term if not longer, less patient throughput. This calls for a fundamental cultural shift of measuring productivity not simply by patient throughput, but by maintenance of healthcare provider safety and avoidance of harm. 

Are there lessons to be learned from aviation or the military where the simple act of going to work, can put our lives at risk? How do pilots and soldiers face these risks and maintain their mental health? There may be a perception that it is simply an acceptance of the risk inherent in these career choices. This is not the only difference. Pilots and soldiers simulate emergencies. It is a mandatory part of training and maintenance of competence. Until recently we’ve only been simulating emergencies where the patient’s life is at risk. We may have intubated thousands of times, but now we’re being told to do it differently, in different environments and wearing PPE that is uncomfortable and inhibits our performance. We became novices again. Recall how anxious you were the first time you performed tracheal intubation on a well patient. Next, recall how anxious you were performing tracheal intubation a very sick and unstable patient. We are almost back to that level of ‘competence’ because we are essentially performing a new procedure. We need to now perform a familiar procedure in accordance to an unfamiliar protocol, in unfamiliar uncomfortable PPE, oftentimes in an unfamiliar environment with healthcare professionals we may be working with for the first time. We must adhere to protocol or risk our own health and the health of those around us. What will help alleviate this stress and speed up our progress to competency? Simulation. Practising over and over again what is required for safety and competency while maintaining the skills of an experienced airway manager. Change as little as possible with how you perform a tracheal intubation in a patient with COVID-19 disease. Be open to changes that make airway management a predictable safe team effort. If you almost never use a bougie, now is not the time to start. Additionally, we need practice. Lots of practise. We need to embrace drills, protocols, checklists and one another’s corrections and suggestions. 

A second issue is kit, and PPE is particularly emotive. I’ve heard the cries “COVID-19 is a war. We’d never send our soldiers out without proper weapons and PPE!“. This is not as black and white as civilians would think. There are many examples even from the most recent conflicts of lack of contingency planning, unintended consequences and unanticipated needs. We plan based on past experience, both in medicine and in the military. COVID-19 a novel disease, consequently we have very little evidence what level of PPE is actually required for different procedures; therefore, protocols are a changeable montage. Are protocols changing because we have more evidence, or are they changing in an attempt to preserve PPE stores? Health care providers are understandably skeptical and are assuming the latter. 

A good military officer can make their soldiers feel that despite putting them risk (no risk in combat is impossible), that they’ve done everything possible to mitigate unnecessary risks. Additionally, good officers will spend at least some time with the troupes. Decision-makers, from government officials to hospital administrators, are also facing duties the likes they have not seen before. Connecting with one another ‘on the front line’ may benefit both healthcare providers and decision-makers by adding clarity to the physical and emotional issues at hand. There is no substitute for seeing with one’s own eyes what’s going on on the battlefield. Captain Crozier, commanding officer on the USS Theodore Roosevelt, experienced this first-hand. He was faced with a growing number of sailors suffering from COVID-19 disease in crowded conditions. Despite being commanded not to disembark the majority of the 4,865 sailors on board, he sounded a very public alarm in a way he knew would be career ending. He viewed the lives and safety of his crew as more important and placed them before his own career. Healthcare workers need to feel that our leaders would do the same for us.

Finally, what motivates solders to risk their lives is not patriotism, or a good leader, it’s the band of brothers – the women and men in the trenches with them every day. The comradery coming out of Milan, London, New York etc. are similar – the shared experience that has formed bonds between healthcare providers that last a lifetime. We trust and understand one another. In fact, this bond and shared experience is what may help some health care providers weather their psychological trauma storms. We have only recently recognised post-traumatic stress as a formal diagnosis in soldiers. We have known for some time that soldiers facing extreme psychologic distress sometimes needed a break from the horror of the battlefield, but that keeping them away from the front and their buddies for too long would almost guarantee that that soldier would never be able to return to battle. Simply being amongst a group that knew what horrors you’ve lived through somehow helps you weather them. This will no doubt also be the case in healthcare workers who’ve been on the front lines of this pandemic, however we need to be vigilant of the workers who came from away (either other departments or even other cities) as they will lose this close support once they return to their home units. Additionally, we need to be mindful that for many, even with the support of a group, they may need extra resources to overcome their moral injury. 

It is an accepted truism that war leads to advances in medicine. This war against Covid-19 is no exception. What I find the most heartening is how silos are being broken down, and not only people from many different specialties are joining the fight, but people from around the world are sharing information too. Opinions and ideas from groups that are diverse (people from different countries, specialties, ethnic backgrounds, gender, etc.) perform better, make better decisions, and are more innovative. This is the battle of our generation; we need to ensure we mobilise all of our resources by building and fostering diverse teams.

We can combine all three things: healthcare providers confident in their new skills because they have drilled them; feel supported by a leadership that has their safety and best interests in mind; and who feel a common bond with the other healthcare providers they’ve worked with. We believe we would not simply feel safer, we would actually be safer, both physically and psychologically as we connect more with those around us. 

Leilani N. Doyle and Laura V. Duggan

Can sugammadex reverse hypnosis?

The May issue is now available online and is full of excellent content. We encourage all readers to study carefully its contents and a enjoy a break from the infodemic amongst the COVID-19 pandemic. Firstly, this new randomised controlled trial seems to suggest that rapid reversal of deep neuromuscular blockade with sugammadex is associated with a rise in the BIS value and clinical signs of awakening. Can sugammadex really lead to sudden arousal? Avidan suggests there are several possible explanations for the findings, including that avoidance of neuromuscular blocking drugs is the best way to reduce the incidence of accidental awareness during general anaesthesia. Furthermore, he offers interesting commentary on how we sometimes might draw the wrong inference from the correct observation. 

In this study of pre-hospital emergency front-of-neck airway procedures from a nationwide trauma database in Japan, the authors describe the development and validation of a predictive model (Fig. 1). They argue it may aid in the prepare for and predict such events. In the associated editorial, Flexman et al. discuss the problems facing trialists when attempting to study rare clinical events, as well as the need for consensus guidelines for the use, reporting and analytical approaches to healthcare database research

Figure 1 The predicted, observed probability and diagnostic ability in each risk group by ‘eFONA’ score. The predicted and observed probability grouped by sum of the risk score are shown in each cohort. The observed probability is the proportion of actual eFONA procedures performed. The predictions are well‐calibrated with the observations. Error bars, 95%CI.

Robot‐assisted radical prostatectomy causes considerable discomfort, mainly during the first postoperative day. This new randomised controlled trial seems to support the use of a single shot of intrathecal bupivacaine/morphine as part of the anaesthetic technique, as it was associated with increased quality of recovery (Fig. 2). Burns and Perlas discuss the use of QoR-15 to provide a standardised, validated measure of postoperative recovery. Those wishing to determine the value of new peri-operative interventions are encouraged to use it. This new Delphi project identifies a core set of standards to be the most important and useful as quality indicators for an obstetric anaesthetic service. These include: the rate of accidental dural puncture during epidural insertion; the use of guidelines for antenatal anaesthetic referral; the use of dedicated teams for elective caesarean section; whether point-of-care testing haemoglobin testing is available; and the effectiveness of epidural labour analgesia. Carvalho and Kinsella argue this is an important step towards the creation of quality indicators for obstetric anaesthesia care. That said, more patient-centred input, rational performance metrics and evaluation of the impact of such standards are required. A further obstetric anaesthesia paper is this biased-coin up-down sequential allocation trial of the effective pre-oxygenation interval. Worryingly, one in ten parturients will be inadequately pre-oxygenated after 3.6 minutes of tidal volume breathing with a standard flow rate facemask, and the use of high-flow nasal oxygen with and without a facemask was less effective.  

Figure 2 The total Quality of Recovery (QoR)‐15 scores per time‐point. The data are presented as mean with SD error bars. The percentage and absolute decrease between pre‐operative QoR‐15 and postoperative 1 were different (p = 0.019 and p = 0.013) between the intervention and control groups. There were no significant differences between absolute values between the groups. A score of 118 (dashed line) is defined as acceptable symptom state.

How efficient are your operating theatres? How are your lists scheduled and who does it? Given operating theatres across the country are about the open again for elective work, efficiency will be key to ensuring resources are used in the best possible way. This new study from Professor Pandit undertakes a comparison of ‘booking to the mean’ vs. ‘probabilistic case scheduling’, and finds that the former is an extremely poor method of scheduling lists. With this method, 88% of lists may over-run by > 30 min and 40% will cancel patients (Fig. 3). You can read more about operating theatre efficiency in this article from our joint supplement with the British Journal of Surgery

Rightly or wrongly, Impact Factor remains the most widely used performance metric against which scientific journals are judged. According to this new analysis from McHugh and Yentis, we published 115 original articles, 22 reviews, 56 editorials and 186 letters in 2016. In the following two years, these 379 articles were cited in 1506 articles. Of these, 476 (32%) were from Anaesthesia and 1030 (68%) were from elsewhere. Some might argue 32% is too high, but there is currently no consensus on what an ‘optimal’ self-citation rate should be. Too low, and the relevance or appropriateness of the journal comes into question. Too high, and there might be a suggestion of Impact Factor gaming. One possible solution is transparency, and it is the policy for all Anaesthesia editors and reviewers not to ask authors to add or remove specific references/citations to any journal, including Anaesthesia, in their final revisions.

Figure 3 Results of booking to the mean. The actual list duration is plotted against the intended list duration (from y‐axis in Fig. 1). Had booking to the mean been accurate, most points would lie on or close to the line of identity, but the majority lie above it. Hollow circles are lists that suffered a patient cancellation (for these times, the mean time of the cancelled cases is included in the actual list time).

Elsewhere we have: a review of choice of local anaesthetic for epidural caesarean sectiona PROSPECT guideline for oncological breast surgeryan observational study of the impact of fluid optimisation before induction of anaesthesia on hypotension after inductiona discussion of carbon dioxide clearance during apnoea with high-flow nasal cannula; and a survey of regional anaesthesia practice for arteriovenous fistula formation surgeryOver in Anaesthesia Reports this new paper from Ahmad reports the first awake tracheal intubation in a suspected COVID-19 patient. You can read all new articles on COVID19 that have been accepted for publication here or that have gone through the typesetting and proofing process here.

Finally, make sure you catch up with the new guidelines for the management of glucocorticoids during the peri-operative period, which currently has an Altmetric score of 348!

Stay safe.

Mike Charlesworth and Andrew Klein

Whither ethics – on triage and Nightingales

“It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm.” 

Florence Nightingale, Notes on Nursing: What It Is, and What It Is Not.

The coronavirus disease 2019 (COVID-19) continues to define 2020. Across the world it is causing medical, financial and social distress. It is destructive both physically and psychologically. Many countries have been grappling with national lockdown and wholescale reorganisation of their healthcare systems to cope with the expected epidemic surge (or wave) of cases – the purpose of social distancing (perhaps better referred to as aiming for people to be physically distanced and socially connected) and latterly lockdown, has been to flatten the wave from a tsunami to something smaller, and the purpose of the healthcare reorganisation has been to scale up services to deal with that wave.

In the UK we have been luckier than some. In Wuhan, China the healthcare system was rapidly overwhelmed by an epidemic surge it could not have prepared for. One well-highlighted response was to build several new hospitals – at breakneck speed and to use other communal areas for stepdown-care and oxygen delivery. Outside of the hospitals the country was put into a rigorous lockdown and this reduced R0 to < 1 and controlled the epidemic in the rest of the country – at least for now. When Lombardy, Italy became the epicentre of the emerging pandemic, its healthcare system was also overrun with Northern Italy and then the whole country entering a strongly policed lockdown.

The ‘fortune’ we have had in much of the UK is both time and information to make preparations. To get our health service in the most suitable state to deal with the pandemic effects of COVID-19, major changes to all aspects of care have been implemented. All but the most urgent surgery has been stopped. Non-urgent outpatients ceased. Hospitals have been emptied in preparation. Staff have been given crash courses in use of PPE and skills that may aid the respiratory and critical care services. ‘Cross-skilling’ has entered the medical lexicon.

Despite the time for preparation and the enormous efforts on all levels to be ready, the UK NHS has, in some parts, struggled. Hospitals have been overwhelmed by the scale of admissions, leading one to put out a desperate call for volunteer assistance to transfer critically ill patients to other hospitals when the scale of its influx was too high. In another incident, hospital oxygen supplies failed, again requiring urgent transfer of critically ill patients to other hospitals. Behind these front-page stories there are likely many more hospitals operating at or beyond their limits – even after increasing their capacity as much as they can. 

So why the title of this blog? At first glance the topics seem unrelated; but some thought reveals that triage and the new Nightingale hospitals, rapidly commissioned and brought into service across the UK, are two sides of the same coin – or perhaps two solutions to the same problem.

The models have predicted that, despite best preparations within and outside hospitals, the service will be stretched or overwhelmed in most parts of the country for a sustained period of time. That the surge of patients needing admission, oxygen and ICU care may all be several-fold too high for even the maximum capacity. There are, broadly speaking, two potential solutions: triage and Nightingales. 

Triage

Triage is a term borrowed from the battlefields of war and usually involves attempting to select, in a mass casualty situation, those patients who are most in need of immediate medical care in order to survive. The walking wounded and those unlikely to be saved are not prioritised. In the pandemic situation the process may be turned on its head (so called reverse triage) and, in the setting of inadequate resource, selection seeks to identify those patients unlikely to survive. These patients are then not offered advanced treatment but must be cared for differently, treating them symptomatically and compassionately in anticipation of their death. 

A central tenet of any medical care is that it should provide benefit and be consistent with what the patient would want. It should only be for those who can survive and only for those for whom it offers a future with a quality of life they would want. The treatment itself should not cause suffering that the patient would find intolerable. Where possible, the question of benefit is grounded in clear knowledge of what will happen to that patient, but in truth clinicians are not great predictors of outcome and so we often err on the side of caution and offer trials of treatment, including ICU care in the hope it will work. In normal circumstances the ethics of patient care is straightforward, even if predictions of outcomes and decisions are not. The ethical framework of medical care – beneficence, non-maleficence, justice and autonomy – means that the basics of decision-making around critical care (both starting and stopping it) are entirely focused on the individual. In some countries, ‘community’ is also considered a part of the ethical framework – what is right for society.

For COVID-19 in particular, we lack clear predictors of good or poor outcome, relying instead on univariate predictors of mortality such as age, high blood pressure and cardiac disease which may in reality all co-exist. We also may not have the luxury of offering trials of intensive care treatment. For it must be remembered that when COVID-19 causes critical illness, it kills most patients. Studies of those requiring ICU care, and particularly ventilation, from China, Italy and the US have all reported mortality rates of half to two thirds of patients. In the UK outcomes are the same, suggesting this illness is twice as deadly as other viral pneumonias. The myth that those dying are old and dependent is slowly being dismantled as we realise what a truly awful disease this is. Perhaps the cruellest element of the illness is that patients admitted to ICU will receive no visitors, and although who die there will not die alone, they will be surrounded only by caring staff, rather than family. 

If the number of COVID-19 cases is such that capacity is overwhelmed the prospect of triage is a real one. And this is a completely new ethical arena. It may be necessary to choose for instance between two or more patients needing one ICU bed or one ventilator, or to decide whether to stop ventilating one patient in order to offer it to a patient who is more likely to survive. These are extraordinary concepts for extraordinary times. The ethics of decision-making changes to what some describe as societal or public health decisions. Those who have argued that ‘doctors make these decisions all the time’ are wrong. Although we wrestle with decisions every day about what is right for our patient, balancing burden against benefit, this decision is about an individual. But when triage occurs the decisions are about what is in the ‘greater good’, ‘doing the best for the most’ and ‘the best for society’. This is not normal decision making but something quite alien, and which even the GMC states in normal times must not happen

In this setting doctors need help because the wider ethical environment must be considered, and the choice is—put simply—too important to be made just by doctors. Decisions about how we choose between members of society require a discussion about what society wants and will accept. A framework is needed (not a checklist) which will enable doctors to step away from the bedside, pause, consider and reach a decision which 100 days ago none of us would ever have considered. Numerous documents have been published in the last months that consider these issues – some in journals and some by learned bodies. Several are vague and opaque and some wise and helpful, particularly that from the BMA. Some of the ethical factors are shown below. It is worth pausing and contemplating these. But these frameworks need operationalising – turning conceptual and discursive documents into SOPs that real clinicians use make real decisions for real patents.

Figure 1. Some key ethical considerations for COVID-19. *Examples include healthcare workers, vaccinologists, farmers or politicians.

These are complex matters and the decisions are high-consequence. In a truly open and honest society, government or the central NHS would be providing national guidance, drawn up by our medical, philosophical and political leaders, and the National Health Service. However, that is not the case and the result is a vacuum which is being filled by necessity. The decision of how to turn principles into actions is delegated to regional networks or individual hospitals. The result is that guidelines may be drawn up by too small a group, of critical care clinicians alone, or a wider pool of doctors perhaps supported by hospital management. These guidelines may not account for the shift of focus from individual to society or factor in ethical challenges, resulting in blunt tools to score them with. With poor guidance, there is cloistered thinking and with it, the potential for moral, ethical and legal jeopardy. 

The possibility of having insufficient resources to care for all, and how that is managed has, with a few notable exceptions, not been well-grasped. But when there is inadequate resource those decisions must and will be made. Much work has been done by general practitioners and other outside hospitals to prepare the frail and ill. To advise them that hospital care may not be the right journey for them if severe COVID-19 affects them. To enable family discussions and decisions and to put alternative pathways in place, perhaps to stay at home if illness strikes. There is no doubt that this has saved many from a death alone, perhaps in distress, in hospital. This is something to be welcomed. 

Nightingales

An alternative to accepting that we have insufficient resource and planning for triage is to expand the resource to meet the demand. In the first weeks of the epidemic this effort focussed on ICU capacity – and specifically on ventilators (though now kidney machines may in fact be the greater problem). Hospitals were encouraged to expand ICUs internally up to sevenfold. The NHS ventilator challenge was established. But as well as ventilators, critical care requires (amongst many other things) space and staff. Expansion requires somewhere to else work and a bigger workforce. This was acknowledged with the GMC and other bodies writing to all doctors about the need to work in unfamiliar settings and a loosening of regulatory governance as a consequence. NHS workforce planning proposed a major change from normal standards of care (one trained ICU nurse at the bed of every ventilated patient and one intensive care consultant for each group of eight) to something quite different. In the revised guidelines, each ICU-trained nurse might have responsibility for six ventilated patients and each critical care consultant for 60. While tiers of support are layered below, this is provided by nurses and doctors who are either less experienced or whose training is from other areas of practice. It is hard to imagine that this will not have an impact on quality of care delivered – these are truly extreme measures.

The Nightingale hospitals are a proposed solution. Rather than making ICUs out of repurposed wards, operating theatres and recovery units staffed by theatre staff, it is possible to create purpose built (or at least purposefully redesigned) mega-ICUs on a warehouse scale. These are the Nightingale hospitals, first in the Excel conference centre in London and now planned in a host of settings in the UK including Birmingham, Manchester, Harrogate and Bristol. The Excel Nightingale hospital has the capacity for 4000 ventilated beds  – this alone is far in excess of all the ICU beds in the UK before the current epidemic – and the other Nightingale hospitals are each designed to care for many hundreds of patients. The vast majority of these hospitals planned to admit only patients needing ventilation. Scale can provide efficiency and workforce planning breaks down the normal bedside delivery of ICU care into an almost bewildering list of teams – one each for airway, lines, nutrition, turning, comfort etc. At first sight this is a perfect solution to the capacity problem – physically expand the system to the extent that the capacity is sufficient, and the problem is solved. Hospitals will have their space back and may be able to start to recommence services they have had to mothball. Perhaps a semblance of normality can return to NHS services. 

However, this solution has its own challenges. The Nightingale hospitals solve only one of the main challenges to ICU expansion: space. ‘Stuff’ (equipment) and staff remain constrained. The Nightingale hospitals will necessarily be staffed by the same skilled staff who would otherwise be working in the hospitals they serve. And these staff will no longer be available there. As the Nightingale hospitals are set up on a regional basis this may mean either staff commuting long distances or relocating for a period. These staff will be working in a new environment in new teams and both changes will require training and adaptation. The same is true for equipment – if a ventilator or renal replacement machine is sent to a Nightingale hospital it cannot be used at a local hospital. So, it should be clear the Nightingale hospitals whose scale may be beneficial in providing economies of effort, are using staff and equipment that would otherwise be at the hospitals they serve. They are not so much additional capacity as relocated capacity. In order for patients to be treated at the Nightingale hospitals patents must be transported there – another service requiring significant redeployment of staff and equipment. The Nightingale hospitals are a bold and ambitious attempt to solve an extraordinary problem. Judging if, when and how to use them will be the challenge. The already stretched service will undoubtedly be further stretched by deployment of the Nightingale hospitals.

Hope

As always, we finish with a message of hope. If the surge of cases becomes too much for our NHS, either the Nightingale hospitals or triage may provide the necessary solution to the problem. And it is essential that we are prepared. Far better would be that neither are needed. Across the world, the impact of lockdown is being felt psychologically and financially – but it is working. It worked in China, it is working in Italy and Spain. It is starting to work in the UK. There is evidence that the rate of new cases is falling and the epidemic curve is flattening – with correlation between a region’s compliance with lockdown and the local flattening of the curve. Although the death rate is distressingly high there is evidence that the rate of new cases is falling. As deaths lag new cases by several weeks, it will take some time for this change to be seen. In a week or ten days a reduction in new infections will translate into a fall in hospital admissions, then to a reduction in ICU bed requirement and in a few weeks to a fall in deaths. Projections are changing rapidly but the evidence is mounting that the national effort — by the government, the NHS and the whole population— is working. If we are lucky, both triage and the Nightingale hospitals will become important academic projects but neither needed to be put fully into action. 

Tim Cook and Kariem El-Boghdadly

The (invisible) consequences of COVID-19

The global impact of the novel coronavirus 2019 (2019-nCoV) pandemic has been massive. Schools have been closed. Elite and recreational sport has been stopped. Conferences, medical and otherwise have been delayed or cancelled (including a coronavirus conference). Countries have closed their borders. Global economies have all but collapsed. This pandemic has left its mark on China and is now settling in the current epicentre: Europe, though this is likely transient, and it may soon move to America. Today the number of confirmed cases has passed 1 million.

The ever-changing numbers 

Epidemiological patterns that have previously been described in China are replicable in many other countries. This follows what is called exponential growth. This means that the number of new cases increases by a given factor every day (Fig. 1). In most countries, the first 100 confirmed cases of corona virus disease 2019 (COVID-19) are often sporadic and take some time to spread to large numbers of individuals. However, once the first 100 cases are confirmed in each country, the subsequent growth is remarkably predictable (Fig. 2). For example, the time it takes a country to get from 100 to 1000 confirmed cases is fairly consistently between 6–9 days. The next 1000 cases occur in the subsequent 3–4 days. By 14 days, most countries can expect to have had their first 6000 patients with COVID-19. 

Figure 1
Figure 2

In Italy and Iran, the exponential growth continued, and each reached more than 12,000 cases exactly 17 days after they hit 100. Today, the numbers in Italy and the USA are higher than those reported from China. However, the South Koreans managed to slow their spread much earlier than the Italians for example by implementing aggressive testing and isolation measures, a highly effective public information and social isolation campaign, early treatment of those that require it, and rigorous decontamination policies. This provides an opportunity for other nations to strongly consider some of these effective (albeit obvious) measures to be implemented early. The intermediate and longer-term impact of these policies are unclear.

The attack rate (the proportion of the population that will be affected by the virus), is likely to be anywhere between 30-80% of individuals. Thus, the importance of effective public health measures is less about limiting the total number of affected individuals, but more about spreading that number over a longer period of time to enable the health service to cope with the demands. Put another way, if a restaurant has capacity for 25 people and 100 people turn up for dinner on one night, the restaurant will be unable to accommodate them physically or with food. If those same 100 individuals attend over four days or more, the restaurant may still be busy, but still able to cope. 

Variations in mortality

The case fatality rate (number of deaths/number of confirmed cases) continues to rise. Whilst in China, this rate is approximately 3.9%, in Italy it is just above 10%, and this figure will only increase. Mortality is age-sensitive, and the Italian population is on average older than that of China. Latest analyses suggests that the global case fatality rate may be closer to 5.4%, and the infection fatality rate (number of deaths/number of infections) could be as high as 0.9%. The daily increase in deaths per capita is also an important consideration, with both Spain and the UK showing worse trajectories than Italy and the USA (Table 1).

As devastating as these figures might be, they only tell one part of the story.

All of the victims

Beyond the number of individuals who contract COVID-19 and those that succumb to it, there is a population of people who become critically ill with it. It is estimated that 1.5% of all infected patients need to be admitted to the intensive care unit (ICU), which could be somewhere in the hundreds of thousands in the UK. 

Accepting that non-clinicians may be reading this: being admitted to the ICU is a traumatic experience. It  often involves being anaesthetised and placing a tracheal tube with ventilation delivered by an increasingly scarce resource. Cannulas and catheters are placed into arteries and veins, the nose, and the bladder.  Patients are given analgesia, vasopressors, antibiotics, fluids, neuromuscular blocking drugs and various other drugs. They are unable to move for themselves so must be turned regularly, including being nursed in the prone position for much of the time. If there is evidence of renal failure, their blood must be filtered with another limited resource: haemofilters. In their unconscious state they are unable to communicate with their families, but because of the contagious nature of the virus, no visitors are allowed anyway. This resource-intensive treatment is often initiated very quickly, but in patients with COVID-19, generally lasts for approximately 10 days. Some patients, particularly young patients who do not respond to treatment immediately, may remain in ICU for far longer. Around half of patients will survive their stay in ICU. For these the road to recovery is long. Patients will be weak, may have ongoing respiratory problems, and perhaps most importantly, the long-term psychosocial impact could be traumatic. 

Even during an epidemic, the patients with COVID-19 are only part of the responsibilities the health service has. Whilst the resources invested in COVID-19 are already, and will continue to be unprecedented, there is no doubt there will be a major impact on other services that each form part of an effective healthcare system: cancer treatment; cardiac surgery; orthopaedic surgery; psychiatric services; and much more. As resources are stretched to breaking point, those patients who would normally have received prompt and effective treatment may have this care delayed to the detriment of their short- or long-term health. The idea of a waiting list is effectively gone, and patients previously waiting for care could see that wait prolonged to the point of being suspended in an uncertain limbo. The health of some of these patients will deteriorate: they may have pain they might otherwise not have had. Some will die earlier than otherwise. The national mortality rate from disease unrelated to COVID-19 will increase for some time to come. 

The impact on healthcare workers cannot be underestimated. Frontline staff who place themselves in direct contact with patients with COVID-19 are at a greater risk of acquiring the disease. In Italy, nearly 1 in 10 new diagnoses have been in healthcare workers. Anaesthetists and intensive care physicians in particular are at high risk due to exposure to a high viral load during procedures performed close to the airway: called aerosol-generating procedures. So too are ear, nose and throat and eye surgeons, as well as dentists. The data remain unclear as to whether mortality rates are greater in healthcare workers or not, and studies are being undertaken to determine this, but it is clear that access to appropriate personal protective equipment (PPE) is of the highest priorities but the lack of access is perhaps one of the biggest threats. Moreover, there remains debate about what appropriate PPE is for different settings. Surgeons have suggested that everyone in an operating theatre setting should don full PPE for all patients, while this disagrees with other recommendations suggesting that full PPE should only be used when there is a significant risk of aerosolisation. These areas of contention leave healthcare workers confused and may compound the high levels of anxieties in healthcare workers. Healthcare workers may also be concerned about taking the infection home to their family and some are even making the decision to remain  isolated from their families in order to reduce risk.

To add to this burden, capacity and resource may simply not be enough to match demand. Frontline staff will shoulder a tremendous responsibility for difficult clinical decision-making, and ultimately in some cases for selecting who is given the best chance of survival and who cannot be saved. The NHS is currently commissioning, planning and constructing at great pace a network of Nightingale hospitals in exhibition centres and empty universities. The aim is to provide much needed additional capacity and to provide a safety valve for current hospitals. It is ambitious and to an extent a gamble to spread the resource and staff even further, but one we all hope will succeed. We will soon know.  

Hope

Despite the devastating numbers of diagnoses and deaths due to COVID-19, the reduction in R0 in China is reassuring, with the number of new cases falling dramatically and locally spread cases being almost zero. In Italy, their daily rate of new cases has plateaued at around 6000, and may have peaked. The world’s largest democracy, India, has locked down with fewer than 500 cases at that time. And the public health measures implemented in Switzerland mean that their rate of increase has also plateaued. All the evidence is that this will pass. 

In the UK, individual hospitals have spent the last few weeks preparing for the worst, and at an institutional level, preparation is probably as good as it could be given the circumstances. The availability of PPE and diagnostic testing for frontline staff is increasing. And the public have never been as well-informed about a health crisis as they currently are.

We encourage all readers to heed public health advice, healthcare professionals to continue to train and prepare for the management of patients with COVID-19, and for institutions to continue to be agile and responsive to the rapidly changing demands on healthcare resources. 

Dr Kariem El-Boghdadly and Professor Tim Cook

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 https://icmanaesthesiacovid-19.org/ 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.

Testing

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. 

Community

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%
Hospitalisation12%
Symptoms
        Mild80%
        Severe15%
        Critical2–10%
Mortality3.5%
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, %
Overall44,6721,0232.3%
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%
Sex
 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 http://weekly.chinacdc.cn/news/TrackingtheEpidemic.htm.

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.

Hope

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