Science bites back

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

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

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

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

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

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

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

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

Mike Charlesworth and Andrew Klein

Kicking on while it’s kicking off

This month, we are beginning to see what many think may be the second surge of COVID-19 across Europe and elsewhere. Although some of the papers in this month’s issue were written and published during the first surge, they are now arguably more important than ever. First, Cook and Harrop-Griffiths discuss the many challenges of planned surgery, which includes time-critical and wholly elective procedures, in the context of the many issues affecting hospitals and the services they offer. We need to: manage the increased ICU activity associated with COVID-19; make hospitals safe places for staff, patients and relatives; ensure all patients are treated fairly; and look after our most important resource, our staff. Again, the challenges back in May are the same as those we face now and there are no easy answers. Professor Pandit suggests modelling might play a role when efforts are made to match demand and capacity (Fig. 1). Key questions include: how to set capacity; how to fund increased capacity; how to manage COVID-19 pathways; and how to manage demand. The current situation has forced us to increase capacity in the NHS and encouraged us to ask difficult questions about how we manage demand. As anaesthetists, we are well placed to influence the national agenda, which is what is needed to help us to learn to live with COVID-19.

Figure 1 Demand (which can be measured variously; horizontal black line) is constant over time so optimal capacity (red line 1) is easy to estimate. For varying demands shown, although mean demand is identical to the horizontal black line, the optimal capacities required to meet all the demand all the time increase (from dotted red line 2 to solid red line 3) as variation increases. However, this results in wasted capacity when demand falls to less than the peak. 

Should we routinely use hyperoxgenation in adult surgical patients whose tracheas are intubated? Weenink et al. argue that we should, and cite beneficial effects including: less surgical site infections; reduced postoperative nausea and vomiting; improved safety margins; and the use of hyperbaric oxygenation. These, they argue, outweigh any adverse effects, and they recommend the intra-operative administration of 0.80 fraction of inspired oxygen to non-critically ill adults whose tracheas are intubated. On the other hand, Sperna Weiland et al. go into more detail on the potential harms of hyperoxia, and argue its use to prevent surgical site infections is not supported by existing evidence. Where do you stand? Let us know over on Twitter!

This new randomised, crossover, simulation study from Schumacher et al. is the first to compare the use of modern respirators and powered respirators during advanced airway management procedures (Fig. 2). They found that videolaryngoscopy proved to have certain advantages whilst wearing respiratory protection, regardless of the type of protection used. When flexible bronchoscopic intubation was attempted, the use of protection did not significantly prolong attempts. Participants rated heat and vision significantly higher in the powered respirator group; however, noise levels were perceived to be significantly lower than in the standard respirator group.

Figure 2 Powered air‐purifying respirator with hood (left) and Standard air‐purifying respirator (right).

This systematic review and meta-analysis of observational studies from Armstrong et al. has an Altmetric score of 1148, which makes it our second most popular paper on social media, ever! It provides a message of hope for all of us facing a potential second wave, and shows how we have been able to adapt and improve outcomes for critically unwell patients with COVID-19 as our experience grows and learning accelerates. It is essential reading for all. Important also is this review of resilience strategies to manage psychological distress among healthcare workers during the COVID-19 pandemic, which builds on experiences from the SARS-CoV-1 and Ebola outbreaks. This new review from Sidebotham is a thought-provoking piece for many reasons, as it challenges everything we think we know about evidence-based medicine in peri-operative medicine and critical care. He concludes that, with the use of Bayes’ theorem, small underpowered randomised trials reporting weakly significant p values have a false positive risk of at least 50%. Likewise, large multicentre trials in critical care appear to have a high false negative risk. Is most of the evidence that underpins our clinical practice wrong? Charlesworth and Pandit outline some possible explanations and solutions, though the thought that every trial ever performed might need to be continuously repeated might be too much for some. Although such statistics may seem complex and inaccessible for most, they argue the way in which clinicians treat patients (and interpret clinical trials) is in fact Bayesian (Fig 3). 

Figure 3 The relationship between prior knowledge, clinical evidence and posterior knowledge from Bayes’ theorem are shown, for an example where the trial result (clinical evidence) shifts our final belief (posterior) towards accepting the intervention. Note that the precision (reflected in the width of the bell curves) of the posterior knowledge is tighter than prior knowledge and clinical evidence. The trial result (clinical evidence) may indicate a high probability of success of intervention, but our final belief will be tempered in a Bayesian framework: we do not accept this blindly. The distance between the distributions, their position and their precision arguably tell us more about the probability of success of an intervention than simply setting out to prove that something is true or false.

Elsewhere this month we have: a mixed methods analysis of factors influencing change in clinical behaviours of non-physician anaesthetists in Kenya following obstetric anaesthesia training; a study of surgical cancellation rates due to peri-operative hypertension; a study of the clinical validation of bioreactance for the measurement of cardiac output in pregnancy; a review of neuraxial anaesthesia and peripheral nerve blocks during the COVID-19 pandemic; and a qualitative systematic review of the role of serratus anterior plane and pectoral nerve blocks in cardiac surgery, thoracic surgery and trauma. Over in Anaesthesia Reports, we have a report of extraconal orbital emphysema secondary to barotrauma in a ventilated patient with COVID-19 and a persistent left superior vena cava with partial anomalous venous return in a liver transplant patient. We are delighted to have appointed four new Editors to the Anaesthesia and three new Assistant Editors to Anaesthesia Reports. They are: Ed Mariano; Louise Savic; Iain Moppett; Ben Morton; Maryann Turner; Rose Kearsley; and Lachlan Miles. In addition, we are delighted to announce that our new trainee fellow for 20/21 will be Craig Lyons from Dublin. Congratulations!

Finally, make sure you join us for our webinar on Saturday morning to find out who has won paper of the year together with some excellent presentations on the best peri-operative medicine research around in 2020

See you on Saturday!

Mike Charlesworth and Andrew Klein

The gift of life

Earlier this year, the law in England changed to an ‘opt-out’ system for organ donation. This means that if you are not in an excluded group and have not confirmed whether you want to be an organ donor, it will be considered that you agree to donate your organs when you die. This month’s issue provides several brand new clinically-relevant updates in the field of solid organ transplantation from experts from around the world. 

Wales moved to an ‘opt-out’ system in 2015, whereas the rest of the UK maintained the ‘opt-in’ approach. This analysis from Madden et al. examines the effect of this legislative change on consent rates for deceased organ donation in Wales from 2015 to present. They found there was a significant increase as compared with England, although the impact was not immediate and took several years to take effect. There has been little coverage in the literature on risk factors in the donor for poor post-transplant organ quality and the role of donor management before organ retrieval. Bera et al. argue prevention of injury and promotion of repair before organ retrieval, by targeting specific pathological pathways, offers novel mechanisms for donor management beyond just physiological stabilisation

Organ donation after brain death (DBD) remains the deceased organ donation pathway of choice (Fig. 1). Manara et al. argue that increasing DBD donors in the UK can be achieved primarily by increasing consent rates to those comparable with the rest of Europe. Their work is simply everything you need to know about the current status of DBD organ donation in the UK. Donation after circulatory death (DCD) in the UK has increased over the last decade, due partly to cultural changes in end-of-life practices, as well as overcoming various ethical, legal and professional barriers. Gardiner et al. tell the story of the rise of DCD, and use data derived from publicly available sources to do so (Fig. 2). The question of how to define ‘death’ is an age-old ethical dilemma that continues to cause confusion and controversy. Some might suggest it can be defined as either circulatory-respiratory or neurological. Gardiner et al. argue there are not two different types of death, and it is not true that ‘irreversible’ means ‘permanent’ only when applied to the cessation of circulatory and respiratory functions. In their review article, they set out arguments for why permanent brain arrest is the true and sole criterion for the death of human beings. Finally, Cooper et al. set out the reasons that the ethical and practical ‘problem’ of consent for interventional research in deceased organ donors is far from resolved. They argue a failure to appreciate this may have serious implications for all, such as the prolongation of research processes or the loss of public trust in medical research generally and organ donation specifically. 

Figure 1 Schematic overview of the process of deceased organ donation.

Figure 2 Number of UK DCD cases and contribution as a percent of total deceased donations over time. Columns – number of DCD cases; Line – percent contribution of DCD (compared with total DBD and DCD).

Deep neuromuscular blockade during laparoscopic surgery might facilitate lower intra-abdominal pressure and provide adequate operating conditions, and has been proposed to have a number of other benefits. This new randomised controlled trial from Boggett et al. finds that deep neuromuscular blockade did not improve cognitive recovery or other recovery domains, and did not facilitate a reduction in intra-abdominal pressure. Many have long advocated the use of objective neuromuscular monitoring to avoid residual neuromuscular blockade (NMB). This new retrospective observational study of 30,340 cases from six Danish hospitals finds that acceleromyography was used in 88% of cases in six Danish hospitals where a non‐depolarising NMB drug was used, and in 30% of cases where succinylcholine was the sole NMB drug. These are amongst the highest rates of NMB monitoring reported. Bowdle and Jelacic urge us all to use routine quantitative twitch monitoring, and argue the trachea should not be extubated until the train-of-four ratio reaches a normalised value of at least 0.9 (Fig. 3).

Figure 3 Last recorded TOF values in 13,562 cases. A TOF value of 100 depicts the scenario where no fade is seen and the ratio is 1.0. The vertical line represents the median at 97, while the mean (SD) is 97.4 (24). 

Back in May, we were delighted to publish a new PROSPECT guideline for oncological breast surgery. This month, McCartney and Abdallah provide the context, and conclude the guidelines are an important addition to our knowledge. The next challenge, which is the same for any other new guideline, will be to see if they can be implemented with the help of our surgical and other peri-operative colleagues. Direct oral anticoagulant prescriptions now exceed those of warfarin and are increasing annually. Mayor and White call for a more pragmatic approach to these agents in the peri-operative period for patients undergoing hip fracture surgery, by focussing more on the risks associated with delay. Their editorial is essential reading for all anaesthetists, and new guidance for those caring for these patients is eagerly awaited. Lastly, Agarwal and Laycock provide their thoughts on the utility of point-of-care testing and fibrinogen concentrate in postpartum haemorrhage

Elsewhere we have: a randomised controlled trial of the effect of 6% hydroxyethyl starch 130/0.4 on kidney and haemostatic function in cardiac surgical patientsa database analysis of spinal versus general anaesthesia for surgical repair of hip fracture and subsequent risk of morbidity and mortalitya systematic review and meta-analysis of peri-articular infiltration analgesia for should surgery; and a celebration of the achievements and challenges in systematic reviews of evidence in peri-operative care as the Cochrane Anaesthesia Review Group turns 20. Over in Anaesthesia Reportsa report of the use of rocuronium ‘priming’ for tracheal intubation in COVID-19 patients has received a lot of attention on Twitter, as did a report of recurrent massive pulmonary emboli in a critically ill patient with COVID-19 and awake tracheostomy in a child with respiratory distress due to a retropharyngeal abscess

Last week, we held a TweetChat with Professor Tim Cook about his new paper on risks to health from COVID-19 for anaesthetists and intensivists. The paper was received extremely well on social media and generated much debate about the use of risk assessments for all staff members, which he argues should include environmental risk and mitigation strategies as well as personal risk. You may have seen also this new paper from Bampoe et al. about immune seroconversion to SARS-CoV-2 in frontline maternity health professionals, which was featured all over the mainstream media. 

Finally, we hope you can join us for our presentation of ‘Paper of the Year’ on the 26th of September, which also includes presentations on top airway and subspecialty papers, as well as the pitfalls and perils of publishing. 

Mike Charlesworth and Andrew Klein

Surviving the COVID-19 information pandemic

The COVID-19 pandemic has affected all aspects of life in many different ways, and one clear theme is the saturation of our inboxes, newspapers, televisions and medical journals with COVID-19-related content. As a journal, we handled and made decisions on a record number of submissions over recent months, and we have: carefully selected 74 COVID-19 papers for publication, which are free to access forever; registered over 1,000,000 full text downloads; and reached over 2 million users on Twitter. However, the sheer volume of information may have, at times, resulted in cognitive overload, more so at times of escalated clinical activity. Kearsley and Duffy discuss all this and more and ask, have we managed the information surge? There are many lessons we can and must learn for the future.

The death of healthcare workers infected with SARS-CoV-2 has received much attention in the media, but there exists no central registry for such deaths. Kursumovic et al. argue the need for robust data and analysis, as the current and future NHS workforce need to feel safe and confident that they will be protected at work. A brand new review from Professor Cook describes in more detail the occupational risk associated with COVID-19 for anaesthetists and intensivists, and is essential reading for all. Patients with severe respiratory failure due to COVID-19 might be referred to a specialist centre for venovenous extracorporeal membrane oxygenation, but how are decisions about acceptance to such centres made? This editorial from Zochios et al. provides a sample decision algorithm, which can be adapted as pressure on resources changes over time (Fig. 1).

Figure 1 Proposed decision algorithm for initiation of venovenous extracorporeal membrane oxygenation (ECMO) in COVID‐19–associated respiratory failure. RESP, respiratory ECMO survival prediction; PaO2, partial pressure of oxygen in arterial blood; FiO2, fraction of inspired oxygen.

The ‘aerosol box’ is a novel device typically consisting of a plastic cube covering a patient’s head and shoulders. At the beginning of the pandemic, inventors of the box were praised by many for their ingenuity. There was, however, no published research demonstrating safety and/or efficacy. This paper by Begley et al. now has five citations and an Altmetric score approaching 400! In it, they report data suggesting aerosol boxes significantly slow intubation times and may even cause damage to personal protective equipment. Another recent paper by Simpson et al. supports this conclusion and goes further by suggesting the risk of aerosol exposure may even be increased. The question is, should we be more cautious about the widespread introduction of novel devices such as this in the future, or is practice before evidence sometimes justified? Other COVID-19 papers this month include narrative reviews of: airborne transmission of SARS-CoV-2 to healthcare workerspoint-of-care lung ultrasound; and patient blood management

The use of high-flow apnoeic oxygenation during laryngeal surgery is something most of us are familiar with, either through clinical practice or the rapid increase in associated publications describing its use. This new prospective observational study from O’Loughlin et al. finds that the use of low-flow tracheal apnoeic oxygenation with a narrow-bore catheter to oxygenate non-obese patients for short duration laryngeal surgery is supported, as it provides adequate operating conditions and without excessive accumulation of carbon dioxide (Fig. 2). Patel and El-Boghdadly remind us that apnoeic oxygenation is nothing new, and was first described 350 years ago. They highlight various limitations of the study by O’Loughlin, and the lack of novelty regarding the study findings. There remain many unanswered questions, such as: ideal flow rates for nasal high-flow apnoeic oxygenation; the potential benefits of lower concentrations of oxygen delivered with low flows; and the prediction of safe apnoea times for individual patients. All in all, the lower you go, the lower the flow; the higher the flow, the longer you go (Fig. 3). 

Figure 2 Microlaryngoscopy view showing a 10‐French oxygen catheter in‐situ.

Figure 3 The underlying principles of per‐oxygenation, which includes pre‐oxygenation and apnoeic oxygenation and ventilation. Pre‐oxygenation ends when apnoea starts due to induction of anaesthesia and administration of neuromuscular blocking drugs. Thereafter, apnoeic oxygenation and ventilation and, in the setting of high‐flow nasal oxygen, transnasal humidified, rapid‐insufflation ventilatory exchange. This may continue until desaturation commences. Efficacy describes the time during which pre‐oxygenation achieves a pre‐determined end‐tidal oxygen concentration before apnoea commences. The apnoea time is the time between commencement of apnoea and arterial oxygen desaturation. Efficiency is the combination of pre‐oxygenation with apnoeic oxygenation and ventilation.

We all know we should consider using point-of-care viscoelastic testing during certain clinical scenarios, but many may not be confident to interpret the outputs of such tests. This is more so the case for trainees rotating between hospitals where different tests and systems are used. Rössler et al. developed the ‘Visual Clot’ as an alternative mode of presentation, and this paper describes its use amongst 60 clinicians. They conclude the 3D Visual Clot improves therapeutic decisions based on viscoelastic testing, as pathologies can be recognised more accurately, faster, with greater confidence and reduced perceived work‐load (Fig. 4). Ahmed and Agarwal ask whether or not an old dog can be taught a new trick in the context of visual spatialisation of viscoelastic testing and artificial intelligence. They argue that any system that can help a clinician to interpret complex variables effectively and rapidly, allowing them to initiate interventions accurately, is always going to be welcome. Finally, the recently published international multidisciplinary consensus statement on fasting before procedural sedation in adults and children was has attracted much attention, and this new editorial from McCracken and Smith provides some clinical context. They describe the many strengths and limitations of consensus statements, and the implications for clinical practice. Is it time to disassociate fasting before procedural sedation from fasting before general anaesthesia? There are no doubt strong arguments for and against, in an area where the evidence will always be far from perfect. 

Figure 4 Example scenario of a rotational thromboelastometry with a corresponding Visual Clot. The scenario displays a plasmatic factor deficiency, as shown by the prolonged clotting time (CT ) in the (a) rotational thromboelastometry EXTEM and INTEM channel or the missing plasmatic factors in the (b) Visual Clot. This scenario would be answered correctly by selecting ‘plasmatic factors’ as a treatment and nothing else.

Elsewhere we have: a study outlining how a reusable elastomeric respirator may be adapted to address N95 shortages during this and other respiratory pandemicsa quality improvement initiative examining the impact of a risk-stratified thromboprophylaxis protocola randomised controlled trial of the efficacy of quadruple treatment on different types of pre-operative anaemiaa prospective cohort study of tranexamic acid before lower limb arthroplasty; and a case series of pneumomediastinum following tracheal intubation in COVID-19 patients

Over in Anaesthesia Reports, the Assistant Editors have prepared two new editorials. The first by Charlesworth et al. summarises all reports published in the first half of 2020, including their key clinical messages. Bailey and Shelton discuss indexing, metrics and social media, which is a truly fascinating read with something for everyone. Recent reports include: acute recurrent bradycardia with evoked potential loss during transforaminal lumbar interbody fusionfailure of standard tracheostomy decannulation criteria to detect suprastomal pathologycomputed tomography scanning in the prone position; and the use of separate-level neuraxial anaesthesia for caesarean delivery in a patient with a history of spinal tuberculosis

Would you like to join us either as an Editor for Anaesthesia or as an Assistant Editor for Anaesthesia Reports? We are advertising these posts now, and we would be delighted to hear from you!

Mike Charlesworth and Andrew Klein

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