gasexchange

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...

Metajournal now has a dedicated index of peer-reviewed COVID-19 articles published in critical care, anesthesia, emergency medicine and resuscitation journals, along with relevant coronavirus articles from major general medical publications, including Lancet, BMJ, NEJM, JAMA, MJA & CMAJ – plus 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. 😷

Three papers from the first BJA of the new decade highlight the importance of non-inferiority: protective ventilation strategies, dexamethasone for prolonging interscalene blocks, and high inspired oxygen and surgical site infections.

Although none investigated new questions, they all represent studies into areas of ongoing uncertainty. They are each a useful reminder that most perioperative interventions do not significantly improve outcomes, although the majority of these probably do not ever make it to publication.

Lung-protection and atelectasis

Généreux et al. investigated the atelectasis-preventing benefit of a common protective ventilation strategy (PEEP and regular recruitment manoeuvres). Notable not just because there was no difference in atelectasis after extubation, but because the use of ultrasound to measure atelectasis helped to better track the intraoperative and post-extubation changes between the intervention and control groups. [→ article summary]

Read more...

Three interesting articles that appeared in the past few months, all following a common theme of ‘protection with small changes’. Although only one is itself practice changing, together they challenge us to continue to look to how small practice changes may have significant protective and preventative effects in the lives of our patients.

Antihypertensives evening dosing

Hermida et al. (2019) published impressive results from the massive, 10-year Hygia Project, which randomised almost 20,000 patients to take anti-hypertensive medications at bedtime or awakening.

Not only did patients who took antihypertensives (of any class) in the evenings have better blood pressure control, they also received a 45% reduction in major cardiovascular outcomes, including CVD death, infarct, coronary revascularisation, heart failure and stroke!

Given that many critical care doctors briefly touch on the medications their patients are taking, a simple “you should ask your primary physician about when its best to take your blood pressure tablets” could have a disproportionately large impact on patient health.

Read on for protection with intravenous lidocaine and ischaemic conditioning...

As I read articles this week, three very different papers created a nexus of interest and push-back against mildly dogmatic thinking in the critical care specialities. Two challenge existing anaesthesia dogma, while the third highlights the potential for missteps when incorporating new media into our practice and education.

Although critical care specialties like anaesthesia and emergency medicine are often seen from the outside as embracing change and being unafraid of dipping our collective toes into the rivers of progress, there are still many strongly held views that persist even in the face of contrary evidence.

Ketamine and persistent pain

Chumbley, Thompson, Swatman and Urch report in the European Journal of Pain the results of their double-blind, randomised, placebo-controlled trial of a 96-hour perioperative ketamine infusion to reduce persistent post-surgical pain after thoracotomy. Notably they found that this significant-duration ketamine infusion did not reduce post-thoracotomy chronic pain.

This paper is the first quality RCT to follow thoracotomy patients for a year after surgery in the setting of perioperative ketamine. It adds to existing evidence suggesting a lack of effect of ketamine for mitigating persistent surgical pain – even though this has been a popular opinion (hope?) among anaesthetists and pain specialists in the past. The results of the ROCKet trial will provide us with more confidence in answering this question.¹

Read on for anaesthesia checklists and FOAMed mistakes...