Anaesthesia
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Over 1.5 million major surgical procedures take place in the UK NHS each year and approximately 25% of patients develop at least one complication. The most widely used risk-adjustment model for postoperative morbidity in the UK is the physiological and operative severity score for the enumeration of mortality and morbidity. However, this model was derived more than 30 years ago and now overestimates the risk of morbidity. ⋯ Our model provides parsimonious case-mix adjustment to quantify risk of morbidity on postoperative day 7 for a UK population of patients undergoing major colorectal surgery. Despite the C-statistic of < 0.7, our model outperformed existing risk-models in widespread use. We therefore recommend application in case-mix adjustment, where incorporation into a continuous monitoring tool such as the variable life adjusted display or exponentially-weighted moving average-chart could support high-level monitoring and quality improvement of risk-adjusted outcome at the population level.
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During the COVID-19 pandemic, ICU bed shortages sparked a discussion about resource allocation. We aimed to analyse the value of ICU treatment of COVID-19 from a patient-centred health economic perspective. We prospectively included 49 patients with severe COVID-19 and calculated direct medical treatment costs. ⋯ Compared with non-treatment (costs per lost life year, £106,085), ICU treatment (costs per quality-adjusted life-year, £7511) was economically preferable, even with a pessimistic interpretation of patient preferences for survival (sensitivity analysis of the value of statistical life year, £48,848). Length of ICU stay was a positive and extracorporeal membrane oxygenation a negative predictor for quality of life, whereas costs per day were a positive predictor for mortality. These data suggest that despite high costs, ICU treatment for severe COVID-19 may be cost-effective for quality-adjusted life-years gained.
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Across multiple disciplines undertaking airway management globally, preventable episodes of unrecognised oesophageal intubation result in profound hypoxaemia, brain injury and death. These events occur in the hands of both inexperienced and experienced practitioners. Current evidence shows that unrecognised oesophageal intubation occurs sufficiently frequently to be a major concern and to merit a co-ordinated approach to address it. ⋯ The tube should be removed if timely restoration of sustained exhaled carbon dioxide cannot be achieved. In addition to technical interventions, strategies are required to address cognitive biases and the deterioration of individual and team performance in stressful situations, to which all practitioners are vulnerable. These guidelines provide recommendations for preventing unrecognised oesophageal intubation that are relevant to all airway practitioners independent of geography, clinical location, discipline or patient type.