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.
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 Easter. Australian case numbers more closely align with the experience in Europe, rather than the slower case doubling time in Korea and Singapore. I work in Wollongong, a town south of Sydney in New South Wales with a population of 400,000. If conservative models are correct and 20% become infected, with 5% requiring critical care, this equates to 4000 patients, which is in addition to the usual caseload. We have around 20 critical care beds.
Until recently, health care professionals and the general public have been largely indifferent to the disease. This is despite widely reported experiences in China, Korea, Iran and Italy, with exhausted frontline clinicians imploring us to prepare. Many felt that this disease was ‘just a mild cold’ and that although there were many deaths, these were limited to the frail, elderly and those with medical comorbidities. There was full confidence that the Australian medical system could manage the disease, as it has world-class people and resources. Most seemed to think that this would not impact us. Many were still laughing at toilet paper jokes and coronavirus memes. Some still are.
The mood is rapidly changed. There are increasing numbers of clinicians, medical administrators, politicians and members of the community becoming fearful and frantic. Clinicians in particular have been motivated into action following the Italian reports of overwhelming numbers of critically ill patients and deaths. The exponential growth in case numbers and the subsequent social distancing measures introduced by the Australian government yesterday have also increased the impact of the disease. Legislation will enforce the banning of organised mass gatherings of over 500 people, and self-isolation for all travellers from all countries for 14 days, echoing New Zealand’s move to this the day prior. New Zealand has fewer cases yet has been more proactive. Perhaps the recent White Island Volcano tragedy has made them less willing to become overwhelmed again. Awareness was also raised by Hollywood stars Tom Hanks and Rita Wilson, who tested positive and were admitted to Gold Coast University Hospital last week. The government has announced a multi-billion-dollar stimulus package to address the widespread economic devastation the disease will cause.
The looming disaster is slowly dawning on regulators, administrators and community members. Most Australian hospitals have been slow to act and are only now beginning to look seriously at the logistics of the likely tsunami of potential patients.
Practical difficulties in accessing COVID-19 testing for the public and healthcare workers have led to many frustrations. Some wait up to five days to get tested, and streamlined testing clinics are just starting to appear. The public health advice around testing has changed as the data comes to hand, and is currently limited to those with symptoms and a contact or relevant travel history.
Personal protective equipment
From my own Twitter activity, I noticed and wondered why international colleagues were shaving beards. This led me to discover the much more serious approach to PPE adopted in other countries, particularly those who have experienced respiratory outbreaks before such as Canada. Formal fit-testing of N95 masks is not mandated in most of Australia and New Zealand. Very few have ever heard of fit-testing, let alone formally had it done. I suspect that Australian guidelines for PPE when we are post-COVID will reflect the more pro-active approach adopted by countries who have been here before.
There have been concerns around the ability of institutions to supply sufficient PPE. Although state and federal governments have announced funding for PPE, individual hospitals have not completed stocktakes of equipment. Most do not know how many COVID and other emergency patients they can care for. Few have received training, although this is now starting in earnest for some, with others told that there is insufficient gear to rehearse. Although a few units have conducted simulations, they are in the minority. There are a number of different management guidelines and few institutions have agreed on approaches between departments.
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.
Over the last week, medical conference organisers have one by one made difficult but necessary decisions to cancel their events, including the largest anaesthesia event of the year, the ANZCA annual scientific meeting in Perth. Smaller hospital meetings continue, although some clinicians have cancelled. The medical viva part of the ANZCA final exam was cancelled last weekend, and there are concerns about education implications of the crisis for fellows and trainees with diversion of work and cancellation of CPD activities.
Many individuals have cancelled overseas trips for the upcoming school holidays and Easter. Some clinicians are now stranded at home in self-isolation requiring the cancellation or rescheduling of clinical work. Panic buying continues with difficulty accessing toilet paper, hand sanitisers, pasta, and meat. A supermarket chain has introduced an early morning quarantine shopping time for the elderly and vulnerable to protect them from the masses.
Although some schools who have had members test positive for the disease have closed briefly, schools have largely remained open. The rationale for this from public health is that it may do more harm than good. School closures may cause children to be cared for by their grandparents, who are vulnerable to the disease, or parents who are healthcare workers and other essential services and may be unable to present for work if children are at home.
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.
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.
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 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.
Up to 14 days
Most infective time
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.
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.
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.
The UK’s critical care capacity, which is one of the lowest in Europe, may 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 . There will also be great strain on PPE supplies and medical, nursing and other workforces.
The numbers do however provide some hope. The spread of the disease beyond Hubei province in China is wide geographically but the number of cases and deaths is rapidly diminishing. The considerable efforts made by the Chinese government and people to control the epidemic appear to have worked and R0 is now less than 1. On 8th March there were no new cases reported in China outside Hubei. Drug trials are underway and will be reported soon, there may be therapies that reduce the severity of illness or help manage critically ill patients.
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.
Figure 1 Preferences for rapid sequence intubation from respondents from high‐income countries (filled circles), upper middle‐income (diamond), lower middle‐income (triangle) and low‐income (empty circles). The upper three panels (a) are for a hypothetical patient with intestinal obstruction. The lower three panels (b) are for any other rapid sequence intubation indication.
Figure 2 Schematic for oxygen sensing at type‐1 glomus cell of carotid body. (1) Hypoxia closes background K+ (TASK) channels, which normally permit background leak of K+ outside the cell; K+ is thus retained in the cell, causing depolarisation. (2) Depolarisation opens voltage‐gated Ca2+ channels, leading to Ca2+ influx. (3) This causes fusion of vesicles containing neurotransmitters (NT) with the cell membrane and acetylcholine (ACh; the likely clinically‐relevant neurotransmitter) is released into the synaptic cleft. (4) ACh binds to specific nicotinic receptors (nAChR) causing action potentials in the afferent glossopharyngeal neve, which travel to the respiratory centre. Volatile anaesthetics block the oxygen sensing by TASK channels at step (1). Propofol inhibits glomus cell response by an as yet undefined mechanism (possibly inhibiting voltage‐gated Ca2+ channels at (2); see reference 14). Neuromuscular blockade prevents binding of ACh at nAChR at (4).
Welcome to #TheAnaesthesiaBlog for the February 2020 issue of Anaesthesia, and with it comes the publication of a new guideline on safe transfer of the brain‐injured patient. Produced as a consensus document between the Association of Anaesthetists and the Neuro Anaesthesia and Critical Care Society, the guidelines serve to update the previous 2006 iteration. The document considers recent developments in the management of multiply-injured patients and those with acute ischaemic stroke. Whilst many of the principles of safe transfer are common to all seriously ill patients, specific risks and management strategies apply to those with acute brain injury. For example, the guideline provides new recommendations on the management of blood pressure parameters for common types of brain injury.
Table 1 Physiological variables and fluids for transfer of brain-injured patients. Of note, there is little high-quality evidence to support particular values and this table is the product of discussion and consensus between members of the Working Party. Where possible, the BP targets reflect the recommendations of the European Trauma Course.
Figure 1 Global social media activities relating to tracheostomies. A video of a three‐year‐old girl singing through her tracheostomy tube was posted on social media by her mother and was later reported by a newspaper (*). A television documentary about a synthetic organ surgeon, who was accused of falsifying his research on synthetic trachea transplantation, was broadcast (#). The news of a baby born without a nose dying at age two was posted on social media and was later reported by a multimedia news channel. He received a tracheostomy at five days old ($). An imprisoned Nobel Peace Prize laureate Liu Xiaobo’s was reported as being in a ‘life threatening’ state. His family opted against receiving a tracheostomy (^).
Figure 2 Black curves represent predicted probability of the physiological variable given the other predictors being controlled for logistic Early Warning Score (EWS). Horizontal red lines represent individual parameter dividing bins used by National EWS (NEWS, right axis).
Elsewhere (and not disguised with a fig leaf!), Webb et al. discuss their pilot study, which aimed to assess the feasibility and effectiveness of an offer of a free five-week supply of nicotine replacement patches provided to smokers at the time of listing for surgery, and to determine the effect on sustained abstinence for four weeks before surgery. Whilst the offer stimulated more cessation attempts before surgery, with many more in the intervention group either quitting or making attempts to quit, a large proportion (59%) had relapsed at six months.
For those of you with an interest in intensive care medicine and ultrasound, this new study from Dransart‐Rayé might be right up your street. Given that pulmonary complications have a significant impact on morbidity and mortality after major surgery, the authors conducted a prospective study in 109 patients to evaluate whether lung ultrasound could be used as a predictive marker for postoperative ventilatory support in high‐risk surgical patients. Using an easy‐to‐implement method, it was demonstrated that lung ultrasound abnormalities were indeed associated with postoperative pulmonary complications, and as such they conclude that the use of ultrasound could allow for earlier interventions and thus improve clinical outcomes.
Figure 3 Ability of lung ultrasound (LUS) score to predict requirement for postoperative ventilatory support (a) Receiver operating characteristic curve (b) inconclusive limits of LUS score (grey area).
Figure 2 Box-and-whisker plots showing the numerical translation of verbal probability expressions by anaesthetists (white columns) and surgeons (grey checked columns). The solid line within the box represents the median, the limits of the box the interquartile range (IQR) and the whiskers represent the range. Outliers were defined as 1.5 9 IQR and are shown by ○.
Figure 4 Challenges in optimising pathways in emergency laparotomy.
Proponents of total intravenous anaesthesia (TIVA) cite the anti-oxidant, anti-inflammatory and immunomodulatory effects of propofol as compared with volatile inhalational anaesthesia. This new narrative review from Irwin et al. is a must read for all! They discuss effects on postoperative nausea and vomiting, free radical scavenging, organ protection, pain, and immunity. Will TIVA one day be the technique of choice for all patients undergoing general anaesthesia? Find out more by reading the free full text! Some of our most popular papers have described advances in regional anaesthesia. This review from Albrecht and Chin brings them all together for the first time. Find out all about advances in: safety and performance; fascial plane blocks; and extending block duration, as well as what the future might hold for regional anaesthesia.
Welcome to the first issue of Anaesthesia for 2020, which is open access for all to read and download. Thankfully, modern anaesthesia is extremely safe, and reports of death due to anaesthetic-related complications are extremely rare. Some complications can be predicted, and it is sometimes even possible to employ strategies to mitigate the associated risk. This new paper from Ramalingam et al. prospectively examines the risk of transoesophageal echocardiography (TOE)-related complications in anaesthetised patients, and the results are alarming. Firstly, the incidence of complications was 1:1300, and the risk of death following a complication was ~40%, which is higher than previously thought. Secondly, complications occurred in patients without known risk factors. Ashworth and Greenhalgh provide some important commentary and context. It seems the benefits of peri-operative TOE continue to outweigh the risks for most cardiac surgical patients, but we can now provide patients with more precise estimates of the incidence of complications, which remain lower than the incidence of major surgical complications. One important recommendation is that insertion aids, such as a laryngoscope (or videolaryngoscope), are used.
Figure 1 Receiver operating characteristic curves for each risk score and the primary outcome of any cardiovascular event (defined as myocardial injury after non‐cardiac surgery (MINS), heart failure, stroke, resuscitated cardiac arrest or cardiovascular death) within 30 days of surgery in patients with a history of atrial fibrillation. Revised cardiac risk index (c‐index 0.60) is denoted by the black line, CHADS2 (c‐index 0.62) is denoted by the blue line, CHA2DS2‐VASc (c‐index 0.63) denoted by the red line and R2CHADS2 (c‐index 0.65) denoted by the green line.
There is still time to register for the Association of Anaesthetists Winter Scientific Meeting in London, and our journal session will be on Friday the 10th of January. Speakers include Dr Rosie Hogg, Dr Eric Albrecht and Dr John Carlisle. Finally, we will soon be publishing our 2020 supplement in collaboration with the British Journal of Surgery, which will cover all aspects of advances in peri-operative care. As ever, there will be a great blog, some useful infographics and lots of clinical take-home messages.