Anaesthesia
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Editorial
Kicking on while it's still kicking off - getting surgery and anaesthesia restarted after COVID-19.
Cook and Harrop-Griffiths survey the damage of a health system stretched to its limits in response to the UK's COVID-19 crisis, and how elective surgery could be carefully recommenced – particularly considering that the pandemic is far from over.
"....this has been achieved ‘by the skin of our teeth’ and until very recently, the threat of insufficient ICU beds, ventilators, and the need for triage were all anticipated: a few hospitals were overcome by the surge of critically ill patents."
They highlight several priorities as the NHS looks to return to a 'new normal' of healthcare provision:
- Support ICU needs of those with COVID.
- Make hospitals safe for patients both with and without COVID.
- Returning staff and services to pre-pandemic areas as possible.
- Protect staff with adequate personal protective equipment.
- Appropriate surgical case triage.
"Having weathered the COVID‐19 storm, we are now being asked to assess the damage done, pick up the pieces and rebuild. However, this storm will rage for many months. Flattening the epidemic curve does not reduce the total number of cases but spread their burden over a longer period of time..."
Of particularly note is the challenge of ensuring COVID positive patients do not undergo non-essential surgery, known to be associated with a high post-operative mortality. They explore the complexities of pre-operative isolation and testing (PCR or CT), and the inherent limitations of these.
summary"The move from a health service focused on one single disease to one that continues that challenge while also addressing all the other health needs of the population may be even harder than that the crisis phase that preceded it."
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Review Meta Analysis
The role of serratus anterior plane and pectoral nerves blocks in cardiac surgery, thoracic surgery and trauma: a qualitative systematic review.
Serratus anterior plane and pectoral nerves blocks are recently described alternatives to established regional anaesthesia techniques in cardiac surgery, thoracic surgery and trauma. We performed a systematic review to establish the current state of evidence for the analgesic role of these fascial plane blocks in these clinical settings. We identified relevant studies by searching multiple databases and trial registries from inception to June 2019. ⋯ Block duration may be prolonged by a continuous catheter technique with potentially similar results to thoracic epidural analgesia. There were no reported complications and the risk of haemodynamic instability appears to be low. The current evidence, though limited, supports the efficacy and safety of serratus anterior plane and the pectoral nerves blocks as analgesic options in cardiothoracic surgery.
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Review
Are most randomised trials in anaesthesia and critical care wrong? An analysis using Bayes' theorem.
False findings are an inevitable consequence of statistical testing. In this article, I use Bayes' theorem to estimate the false positive and false negative risks for randomised controlled trials related to our speciality. ⋯ By contrast, large, multicentre trials in critical care appear to have a high false negative risk. These findings suggest much of the evidence that underpins our clinical practice is likely to be wrong.
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Multicenter Study
Surgical cancellation rates due to peri-operative hypertension: implementation of multidisciplinary guidelines across primary and secondary care.
Patients with uncontrolled hypertension are at increased risk of complications during general anaesthesia but the number of patients whose surgery is delayed or cancelled due to hypertension remains unknown. Prospective, regional multicentre service evaluations were performed on consecutive patients undergoing elective surgery before and after the publication of new guidelines from the Association of Anaesthetists and the British Hypertensive Society. The aim was to quantify the number of operations cancelled due to hypertension alone and to assess impact of the guidelines on cancellation rates. ⋯ Our data suggest achievement of three major outcomes: reduced surgical cancellations due to hypertension alone; improved detection of significant hypertension before elective surgery; and reduced referral back to primary care from hospital for hypertension management. To the best of our knowledge, this is the first time the successful implementation of guidelines from the Association of Anaesthetists has been assessed on such a broad scale. Our data indicate that these guidelines have been effectively implemented in both primary and secondary care, which is likely to have made a positive psychosocial, physical and economic impact on patients and the NHS.
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Maternal mortality rates in low-middle income countries remain high, with sub-Saharan Africa accounting for two-thirds of global maternal deaths. Inadequate staff training is one of the main contributors to anaesthesia-related deaths and the Association of Anaesthetists developed the Safe Anaesthesia from Education course in collaboration with the World Federation of Societies of Anaesthesiologists to address this training gap. We aimed to evaluate the impact of this course among Kenyan participants. ⋯ Eighty-four of the 103 participants were observed in their workplace and capability, opportunity and motivation-behaviour framework was used to study the barriers and facilitators to practice change. Psychological capability and reflective motivation were the main factors enabling positive behaviour change such as team communication and pre-operative assessment, whereas physical and social opportunity accounted for the main barriers to behaviours such as performing the surgical safety checklist. Our study demonstrates that the Safe Anaesthesia from Education obstetric course is relevant in the low-resource setting and may lead to knowledge translation in clinical practice.