From Joseph Cosgrove (thanks Judith!)
Busy on-call so a bit behind with this weekend’s latest outcome data re COVID-19 ICU admissions. I’ll endeavour to get some information out later but in the meantime here’s a piece about anaesthesia and surgery during the pandemic. The intention is (as ever) to inform and not to scaremonger. It’s when we know facts rather than political spin that we can put ourselves in a position to understand what is required, to plan and to understand what why we may not achieve. So, no false promises as we live in uncertain times. Another “bit of a long one” but hopefully it’ll explain the situation we’re facing.
The first infographic comes from an international collaborative (COVIDsurg) that have analysed cancelled surgeries in 60 countries worldwide and modelled the overall impact on Perioperative, Intensive Care and Surgical Services. They predict that 28.4 million operations will be cancelled or postponed, 2.3 million of which will be cancer operations. A Canadian model suggests the need for 20% extra capacity to ensure a 10.4 month turn-around. Canada has another socialised health care system, similar (but not the same) to the NHS. One way of getting an overview of what this means to the NHS could be to consider the following: 1. What’s the relative funding for healthcare in UK and Canada and how is that funding divided up? 2. What level of capacity were both systems working at before the pandemic took hold?
The next thing to consider when attempting to restore “business as usual” is that operations will take longer. Why? Well many cases (certainly all major abdominal and thoracic surgeries) will require patients to be intubated i.e. have a general anaesthetic and a breathing tube (endotracheal tube) placed in their wind-pipe (trachea). At the end of the operation the tube will be removed (extubation.) Both these procedures (especially extubation) are aerosol generating procedures (AGPs) and staff levels will need to be at a minimum (usually Anaesthetist and assistant (ODP or nurse in UK)) and full PPE should be worn.
Following intubation and extubation there has to be an air change to ensure that viral particles have been removed from the air. The efficiency of the filter system will determine the waiting time but for arguments sake let’s say it’s 10-minutes before it’s safe for other staff to enter. That equates to an extra 20-minutes per operation.
There’s more. While patients are being anaesthetised in the operating theatre or anaesthetic room the scrub staff could be preparing equipment needed for the surgery. Such equipment is kept in sterile containers and would previously be opened in anticipation of surgery in many cases. Risk of viral contamination means that this is no longer the case hence more time. Furthermore, with respect to waking the patient and extubation, previously the scrub staff could simultaneously begin to tidy (and more importantly) clean the operating theatre in preparation for the next case. The risk of viral contamination therefore delays this. So, the housekeeping can only begin after the post-extubation air-change.
In theory all patients presenting for surgery will have been self-isolating and will have tested negative for COVID-19, but as experiences all around the world are demonstrating there remains a risk of post-operative infection, which brings me onto the second infographic. This was shown via a Webinar on Friday held by the Lancet medical journal. It relates to a study looking at 30-day outcomes of 1128 patients (worldwide) that have undergone surgery during the pandemic. The UK recruited 43% of patients, with Italy and Spain (other badly hit countries) recruiting 16% of patients each. This final section therefore relates to “what had gone before” and what the initial findings of the study are.
What went before: 1. In 2012 the European Society of Anaesthesiology and European Society of Intensive Care Medicine published surgical outcomes of 46, 539 patients (accepting this is 46 times higher than the current COVID-19 surgical study a. The overall 60-DAY MORTALITY was 4% b. In UK it was 6.3% (the largest recruiter to the study with 10,630 patients) c. In Italy it was 7.5% (2,673 patients) d. In Spain it was 12.5% (5,433 patients) 2. In 2015 a Europe wide study demonstrated an incidence or 4.2% post-operative respiratory problems in 5,384 patients (Eur J Anaesthesiol. 2015; 32:458-70) 3. In 2017 a so-called meta-analysis which looks at multiple studies and collates data from them noted a 20% 30-DAY MORTALITY for surgical patients that developed post-operative respiratory problems compared to 0.2% if there were no such complications (British Journal of Anaesthesia 2017; 118: 317-334)
Current study (accepting 1,128 patients is not 46,539, albeit with UK again being the largest recruiter): 1. Not all patients were COVID-19 positive when they presented for surgery 2. A total of 51% of patients (as opposed to the 4.2% above) developed post-operative respiratory complications with a 30-DAY MORTALITY RATE= 38% 3. Overall mortality (whether infected pre-operatively or post-operatively) was approx. 28% (noting 4% 60-day mortality rate from 2012) 4. Mortality rates were higher in men, urgent and emergency major surgery and in the over 70s.
Finally, PLEASE DO NOT REGARD THE 70yo AS SOME SORT OF CUT OFF OR AGEIST. Rather than age being a direct factor IT IS MORE LIKELY THAT THE DEGREE OF SO-CALLED CLINICAL FRAILTY WAS AT PLAY HERE, it’s just the incidence of clinical frailty increases as we age (third infographic.) A 70-year-old who cycles 100 mile per week is more than likely to have a much better physiological reserve than a 40-year-old ravaged by decades of severe chronic disease who then falls acutely ill.
It is also important to reassure that CLINICAL FRAILTY APPLIES TO PREVIOUSLY PHYSICALLY ABLE ADULTS WHO HAVE BEEN IN PHYSICAL DECLINE FOR MONTHS OR YEARS. It doesn’t apply to anyone with learning difficulties or anyone with a stable physical disability.
As I said earlier the information is to inform not to scare. It can provide information for patients to consider what they regard as being best for them and it can enable health care professionals to better identify the risks and improve care. Together we can work together to individualise care.
This pandemic is a chronic slow burn and the smart money is on it taking at-least two years before perioperative and surgical services have caught up, assuming there is no severe significant second and third surge of infections.