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Posts tagged Covid-19.

Why were Anaesthetists so early on COVID?

On a Monday morning in March, anaesthetist Dr Rob Hackett stood outside his children's inner Sydney school as a solitary protestor, asking parents to keep their children home if they could.

In the heady early days of the coronavirus pandemic, alarm was raised by a disparate mix of professionals: virologists and epidemiologists, journalists and technologists, and a range of frontline and critical care medical specialists exposed to the first COVID patients.

But as concern spread from the earliest hit countries to those threatened by their own surge, one specialty group was over-represented in public calls for early action: anaesthesia.

In Australia, medical anaesthetists from all states and territories spoke-up, not for health authorities and legislators, but for their communities. For a specialty most comfortable when not spoken of, suddenly anaesthetists were appearing in national newspapers, on radio, television, and even (very small) picket lines.

In Victoria, Dr Pieter Peach was a prominent early voice pushing for cancellation of Melbourne's Grand Prix. The Australian Society of Anaesthetist's fearless president Dr Suzi Nou guided the society's careful campaigns to prepare for the pandemic, pause elective surgery and then cautiously restart. In NSW, Dr Tanya Selak's advocacy was celebrated on Telstra's #saythanks billboard, while Rob picketed outside his children's school.

Like a warning telegram from 1940s London, the message scrawled on Rob's chest captured the zeitgeist of our specialty at the time:

"Lives depend on it. Government too slow to act."

Read on for why…

The Paradox of Avoidance

The cries of 'over-reaction' are as predictable as they are simplistic. Epidemiologists and pubic health experts knew they were coming, because avoiding a disaster brings little thanks.

As Australia emerges unevenly from its soft lockdown, anxious and still responding to COVID flares, it is the envy of much of the world. Alongside success achieved in places as varied as New Zealand, Vietnam, Taiwan, South Korea, Iceland and even austerity-inflicted Greece – the contrast with those that have suffered disastrous outcomes is obvious.

And yet the naysayers still question the painful necessity of the lockdowns, even as study after study demonstrates how the measures have avoided or delayed hundreds of millions of infections.

The United Kingdom, uniquely and even justifiably proud of its National Health System, first chose instead to ignore expert advice and offer up its venerated NHS as a funeral-pyre sacrifice to COVID and the gods of conservatism. Today more than 43,000 British are dead. (You know what would help NHS healthcare workers more than clapping? Earlier border closure and adequate access to PPE!)

Sweden pursued a Claytons lockdown founded on an ideological mix of misplaced intellectual-exceptionalism and responsibility-abdicating libertarianism (my eyes are rolling...). It has not gone well.

Despite making up less than 40% of the Nordic population, Sweden now accounts for five out of of six Nordic COVID deaths. Sweden has twice the population of neighbouring Norway but twenty-times the COVID mortality.

And then there is the Land of the Free, the United States. The wealthiest country on the planet, now the epicentre of the pandemic with well over 2 million infected and 120,000 deaths. A disaster due to a failure to act either early or decisively, a dash of magical thinking and an embarrassing absence of leadership.

It is disappointing that the main contribution the United States is currently making to the global COVID response is to serve as a warning to other nations.

The common theme among these failures is the inability to develop a rational response guided by expert advice. A virus does not care for your wishful thinking. A virus does not care for your political posturing, your dog-whistling or your belief in national uniqueness. A virus is the honey-badger of microbiology.

Which leads us back to the braying calls of 'over-reaction'. Whether former politicians, conservative economists, or performance artists playing opinion writers, they are all making the same mistake: misattributing causality and misunderstanding the purpose of modelling.

Read more on the paradox of avoidance...

Flattening the curve of pandemic research

The wave of COVID research continues, much of it low-quality and hurriedly published. This is apparently the norm for academic publishing during a pandemic: fast, furious and haphazard.

However, two very significant reviews appeared in The Lancet this week that impact and inform anaesthetists and other critical care specialists.

Post-operative mortality, COVID & surgery

Early pandemic data suggested that COVID-19 patients having even minor elective surgery suffered worse post-operative outcomes, particularly high post-operative mortality. The COVIDSurg Collaborative has confirmed this after a multicenter trial across 24 countries.

Across the entire 1,128 patient cohort, 30-day mortality was a jaw-dropping 24%. Yes, 1 in 4 died within 30 days of surgery.

Pulmonary complications (pneumonia, ARDS or unexpected post-op ventilation) were very common (51%) and were associated with an even higher mortality (38%; and 83% of all deaths). Mortality was unsurprisingly associated with older age ≥ 70 years, male sex, ASA ≥ 3, emergency surgery, major surgery, and malignancy.

But even among low-risk groups, post-operative mortality was shockingly high: 30-49 year olds (6%), women (18%), ASA 1-2 patients (12%), and even those without comorbidities (7%). Being asymptomatic at admission did not have a significant protective effect (22% vs 27% mortality).

Elective surgery still carried a 19% mortality rate, and even for minor surgery mortality was 16%! Anaesthesia modality (local, regional or GA) did not have a significant impact.

Click through to read the summary or full-text, though the obvious take-away is that non-essential surgery should be avoided as much as is possible in those with confirmed or suspected COVID.

This will have huge implications for recommencement of elective surgery in many pandemic-hit countries. (Cook & Harrop-Griffiths explore this very topic in an NHS-context in their recent editorial.)

Read on for physical distancing, face-mask and HCQ research...

Thoughts on PPE

Amidst the medical anxiety surrounding COVID-19, no issue appears more emotive than the use and access to personal protective equipment (PPE).

Whether anaesthesia, intensive care or those poor bastards on the front-line in emergency departments and ambulances, adequate PPE has never been simultaneously so important across the entire planet. To outsiders the emotion and fear may seem excessive, but for healthcare workers fear is protective.

It was recently said that for anaesthesia this is our first modern "pilot goes down with the plane" safety issue. While we might be stretching that metaphor too far, it does help to frame our collective anxiety. It reveals both the shared hazard of a contagion, and also the foundation for the anxiety many feel.

Read more on PPE and COVID...

Peer-reviewed COVID-19 articles on metajournal

Metajournal now has a dedicated index of peer-reviewed COVID-19 articles published in critical care, anaesthesia, emergency medicine and resuscitation journals, along with relevant coronavirus articles from major general medical publications, including Lancet, BMJ, NEJM, JAMA, MJA & CMAJplus specialist articles from infectious disease, epidemiology and immunology journals.

metajournal.com/covid

This shows the latest covid and pandemic articles as they are indexed, or click on the 'Best' tab to see the highest quality and most important articles – many of which have metajournal summaries.

If you want to stay up to date with the latest COVID-19 articles, make sure to follow the relevant coronavirus topics by clicking on the red topic tags at the top of the page. Relevant articles will then be included in your weekly metajournal email if you are a metajournal subscriber.

There are already over 1,000 peer-reviewed covid articles indexed.

If you are looking specifically for articles covering Personal Protective Equipment (PPE) in the time of covid, the PPE article index along with the "Anaesthesiology, Personal Protective Equipment (PPE) and COVID" collection, has you covered. 😷

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