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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. 😷

Biased thinking in a time of COVID

The 2020 coronavirus pandemic for all it's horror and challenge, has highlighted certain uncomfortable truths about the human condition. One of these has been the impact of our cognitive short-comings: our difficulty understanding the non-linear and non-binary, and our susceptibility to cognitive biases.

Many of these problems led to missteps at the beginning of the pandemic response, and now early in the fight continue to impede our decisions. By better understanding these cognitive traps we can at least be more alert to our blind spots and alter our actions in response.

As early data seeped out of China in January, quickly followed by cases appearing in global travel hubs, many national governments along with their populations refused to acknowledge the pandemic threat. Even as Northern Italy's health system first bent then broke, surpassing China's own COVID death count a mere 47 days after Italy's first confirmed case, world governments continued to water-down the threat.

Read on about exponential growth and biased thinking...

The importance of non-inferiority and equivalence

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...

Small Changes & Protection: antihypertensives, cognitive decline and ischaemic preconditioning

Metajournal on Small Changes & Protection: antihypertensives, cognitive decline and ischaemic preconditioning

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...

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