the metablog

The Unseen Anaesthetist

Mon, 30 Dec 2024 04:35:00 +0000

A grim discontent with healthcare in many Western countries is intensifying, exposing cracks in a strained system.

The recent murder of a US health insurance CEO, along with the dark wave of public sympathy for the assailant, warns us that health system inequity and failure may culminate in extreme ways.

Australia faces its own challenges: escalating medical costs and burdened public and private hospitals, even as international healthcare corporations post record profits. The growing corporatisation of healthcare, driven by insurance companies and hospital conglomerates, is a concerning glimpse of one possible future for medical care. A significant portion of Australian healthcare funding now leaves our shores for these international corporations and their shareholders.

Yet media coverage presents an unbalanced narrative. While corporate healthcare profits receive measured reporting, medical practitioners face scrutiny and criticism, frequently without evidence. I wrote the piece below in response to a two-year media campaign suggesting widespread billing fraud among Australian doctors, particularly anaesthetists and surgeons. Much of this reporting revealed misunderstandings of the health system and medical billing while ignoring how such stories serve corporate healthcare interests, even as the same corporations encourage attacks on doctors from the sidelines.

I submitted this op-ed to several Australian media outlets, but it remains unpublished. I'm sharing it here to contribute to a balanced understanding of the role of medical professionals in Australian healthcare.

Trust is the foundation of anaesthetic care

In our first five minutes together, I must become the most trusted stranger in your life. It was 3 AM, and I was the on-call anaesthetist covering two private maternity hospitals in one of Australia's capitals, meeting a first-time mother who needed an emergency caesarean section. Despite the early hour and my tiredness, this young family's day had been longer. A mix of excitement, exhaustion, fear and hope – and now this couple must trust a stranger at one of life's most vulnerable and significant moments.

Despite her anxiety, we quickly built rapport: kind words, gentle reassurance, and a joke with her nervous partner about how he, too, will need a catheter once we get started. Despite the connected leads, the rhythm of monitors and my spinal anaesthetic, we transformed an emergency into something approaching "normal", even celebratory, a testament to the efficient work of our team. What was routine for us is a singular, life-changing moment for this young couple. Our team worked hard to maintain the balance of safety while delivering a positive, memorable experience.

One of the paradoxes of our work is that anaesthetists practice in a unique space where excellence frequently means invisibility. I often tell patients that the best anaesthetic is the one they don't remember having. While this is neither always desirable nor even possible, the look of disbelief when a patient smoothly wakes up to be told surgery is already complete, can be the greatest reward. Yet this excellence — this practised invisibility — makes our contribution hard to value or understand.

The value of this invisible excellence is substantial. In Australia, 39% of babies are delivered by caesarean section – and all of these require the careful care of an anaesthetist. Over 4 million anaesthetics are given annually in Australia and New Zealand by 8,000 ANZCA anaesthetists, three-quarters of whom are specialists who have completed over 10 years of medical and specialist training. Many anaesthetists hold multiple postgraduate degrees beyond specialty training, some even PhDs, further driving the quality and excellence of anaesthesia forward.

Australia's anaesthesia safety record ranks among the world's best, built on this demanding training, rigorous standards and peer accountability – excellence that underpins the community confidence in our care. When threats to the reputation and trust of anaesthetists occur, the profession acts decisively. The recent case of a senior anaesthetist's resignation demonstrates not whistleblower suppression but rather our profession actively protecting its integrity and reputation. Similar peer pressure occurs in the rare situation of exploitative billing – we point out and chastise unacceptable professional behaviours when seen.

For our young couple welcoming their first child, the emergency caesarean section proceeded quickly. With practised skill, the obstetrician gently delivered a stunned, floppy baby. The paediatrician, hiding any stress, quickly transformed this flat infant into a squawking, flailing bundle, lifting every heart in the room. In this private medicine setting, the anaesthetist and paediatrician (both on their third emergency caesarean of the night) work independently of the hospital. We navigate the complex decisions about billing for emergency care and balancing patient access with financially sustainable practice, especially given today's cost-of-living pressures.

The recent allegations of widespread Medicare fraud in The Age and ABC News show a fundamental misunderstanding of anaesthetic billing practices. Like many anaesthetists, I accept the insurer's payment as the full fee for many patients (though not all) – what we call 'no gap'. Some anaesthetists deliver all their care as 'no gap'. Others set their fees independently of insurer rebates, resulting in routine out-of-pocket charges. All anaesthetists prioritise transparency: we discuss fees before surgery whenever possible, provide written estimates, and ensure patients understand their likely out-of-pocket costs. This transparency ensures patients are fully informed and involved in their care.

Private specialists decide their billing rates to sustain their practice, not to exploit or profiteer. Fee decisions are grounded in ensuring the financial sustainability of private practices, enabling ongoing access to quality specialist care 24/7. It is relevant that one of the forces driving the surging closure of private maternity units around the country is difficulty accessing emergency anaesthetic and paediatric specialists.

The more significant problem with private medical fees lies not in unsubstantiated allegations of widespread fraud, but in complex and often contradictory Medicare rules combined with indexation that has lagged inflation for over 30 years, impoverishing our health system and undermining patient access. When billing mistakes happen, they are almost always unintentional and just as often to the doctor's disadvantage as benefit.

Yet rather than addressing these system-wide challenges, recent coverage has focused on unfounded allegations of widespread fraud, striking at the heart of the patient-anaesthetist relationship. Casually making accusations of systematic exploitation risks eroding the trust that modern anaesthesia relies upon.

In anaesthesia, we ask patients to surrender their autonomy to a near stranger. We do not demand or take this profound trust - we must earn, protect, and honour it. When misconduct allegations arise, we act decisively because trust, once broken, is nearly impossible to rebuild. And just as oxygen is essential to breathing, trust remains the foundation of safe anaesthetic care.

Opioid-free, AF anaesthesia and LMA atelectasis

Thu, 14 Nov 2024 10:37:00 +0000

Three interesting recent studies looking at specific choices around anaesthetic technique. In the Canadian Journal of Anesthesia, da Silveira reviews the benefits of opioid-free laparoscopic surgery; in the Journal of Cardiothoracic and Vascular Anesthesia, Ford goes deep on the pros and cons of different anaesthetic techniques for AF ablation procedures; and finally in the JCA, Liu reports on a single-centre RCT investigating the beneficial effects of LMAs on atelectasis.

Opioid-Free Laparoscopic Surgery: Less Nausea, Similar Pain Control

An interesting meta-analysis from da Silveira et al. explores whether we can effectively manage minimally invasive abdominal surgery without using opioids - an important question given how common opioid-related side effects are.

This was a comprehensive systematic review and meta-analysis of 26 randomised controlled trials, including 2,025 patients. The researchers specifically compared opioid-free versus opioid-containing anesthesia in minimally invasive abdominal surgeries. They were particularly interested in looking at side effects like PONV and bradycardia, as well as pain control and recovery times.

The results were quite interesting. The authors found that opioid-free anaesthesia:

Reduced PONV by 45% (from 24% to 13% / RR CI 0.40 to 0.74).
Led to slightly lower immediate postoperative pain scores (though not clinically significant).
Required less postoperative opioid use in the first 2 hours.
Showed no difference in recovery room length of stay.
Showed no increase in bradycardia, a previously noted concern when using intraoperative dexmedetomidine.

These findings are consistent with previous meta-analysis, but unique to this study, focus only on laparoscopic surgery, excluding orthopaedics and head & neck surgery included in past analyses.

"Opioid-free anesthesia showed a significant reduction in PONV and a decrease in opioid consumption during the first 2 hr postoperatively, suggesting it can be an alternative to opioid anesthesia in minimally invasive abdominal surgeries."

The (small) reduction in postop pain scores and opioid consumption is particularly notable, supporting the idea that intraoperative opioid may induce acute tolerance postoperatively. (We know this happens with remifentanil above a certain dose)

"A multimodal analgesic approach avoiding opioids with the use of lidocaine, magnesium, and ketamine suppresses impulses from injured nerve fibres and transmission of nociceptive stimuli, and may be able to promote analgesia in the first 24 hr after surgery, while reducing opioid consumption in the early postoperative period. ... Additionally, a2-agonists such as dexmedetomidine may replace opioids in terms of sympathetic stabilization, especially during major surgeries."

While the study captured a large sample size and robust statistical analysis, the authors acknowledge limitations related to study heterogeneity, "the included RCTs used different opioid-free anesthesia strategies and medication regimens".

Da Silveira and team make a strong argument for the possible superiority of opioid-free anaesthesia for laparoscopic surgery, it's worth noting that successful use of the technique requires expertise in using alternative agents like dexmedetomidine, ketamine, and regional techniques. The benefits, particularly in reducing post-operative nausea and vomiting, may be worth the learning curve.

Modern Anaesthesia and AF Ablation: What's Best?

This narrative review by Ford et al. examines the impact of anaesthetic technique on the success of catheter ablation for atrial fibrillation (AF), particularly ventilation strategies. It has relevance given that AF's is the most common arrhythmia, leading to a surge in ablation procedures.

The authors examine three key areas: general anaesthesia (GA) vs conscious sedation, high-frequency jet ventilation (HFJV), and high-frequency low tidal volume ventilation (HFLTV).

They show that GA appears superior to conscious sedation, with one study showing 88% vs 69% arrhythmia-free rates at 17 months. The GA group also experience a lower rate of pulmonary vein reconnection and shorter procedural and fluoroscopy times.

Both HFJV and HFLTV show promise in improving catheter stability and procedural outcomes. The authors note:

"GA has been shown to decrease the movement of catheter tips compared to conscious sedation, enabling better stability and lesion formation."

Though they acknowledge that HFJV faces practical challenges:

"While HFJV is known for its positive impact on catheter stability, its implementation faces challenges such as high costs, the need for additional training to use the ventilator, and the inability to measure end-tidal CO2."

HFLTV might thus offer a practical middle ground between conventional ventilation and HFJV, potentially providing similar benefits without the extra cost and training demands.

The benefits of GA, HFJV and HFLTV arise from reduced respiratory variability, leading to:

Minimising left atrial movement.
Better catheter stability, improving procedural accuracy.
More effective lesion formation.

The main weakness of the review is the lack of direct comparative data between the different ventilation strategies, which the authors acknowledge, calling out the need for randomised controlled trials comparing these strategies.

Nevertheless, the review makes a compelling argument for the use of an anaesthetic technique that avoids ventilation variability – and the less variability, the better.

Less is more: Do laryngeal masks reduce atelectasis compared to endotracheal tubes?

Liu and colleagues investigated whether laryngeal mask airway (LMA) use reduces atelectasis formation during general anaesthesia, compared to endotracheal tubes (ETT) – relevant given that ~90% of patients develop some degree of atelectasis after induction.

This was a single-centre, double-blind RCT of 180 patients undergoing non-laparoscopic surgery under 2 hours, with intention-to-treat analysis. They used lung ultrasound (LUS) scoring to assess atelectasis at various timepoints (15 min post-induction, pre-emergence and 30 min after extubation) along with oxygenation. All patients were induced with sufentanil, propofol and rocuronium, and maintained with propofol/remifentanil TIVA. Ventilation was volume controlled with TV 6-8 mL/kg and PEEP 5 cmH2O, I:E 1:1.5, RR 12-20 and FiO2 40%.

Surprisingly the LMA group showed significantly lower LUS scores at all three timepoints, along with better oxygenation and fewer postoperative pulmonary complications.

The authors propose several mechanisms to explain the superiority of LMAs:

Faster Airway Insertion

Shorter apnea time during airway placement (41 vs 95 seconds).
Less time for oxygen absorption in preoxygenated alveoli to cause absorptive atelectasis.
As they note: "Prolonged ventilation pause during this period can easily lead to excessive absorption of oxygen in the alveoli, causing absorptive atelectasis".

Reduced Airway Irritation

Less manipulation of the throat.
Reduced stimulation of airway reflexes.
Lower risk of bronchospasm and secretions.
Less risk of small airway obstruction.
Better preserved mucociliary clearance rates.

Lower Muscle Relaxant Requirements

"After anesthesia induction and administration of muscle relaxants, the weakening of inspiratory muscle tension in patients leads to a relative increase in intra-abdominal pressure. The relaxed diaphragm moves cephalad, reducing the cross-sectional area of the chest, thereby altering the geometry of the thoracic cavity and increasing chest wall pressure, subsequently compressing lung tissue and causing compressive atelectasis."

Reduced Anaesthetic Requirements

Lower doses of sufentanil and rocuronium for induction.
Lower maintenance doses of propofol and remifentanil.
Better preserved respiratory function.

Particularly relevant in this study, "the majority of surgeries in both groups being endoscopic procedures, resulting in minimal demand for anesthetic drugs. Therefore, the increase in the required dose of anesthetic drugs to attenuate cough reflex during endotracheal intubation becomes more significant." Thus the effect could be more about depth of anaesthesia and muscle relaxation than airway choice per se.

The authors note: "Compared to endotracheal intubation, laryngeal masks effectively reduce atelectasis formation and progression in gynecological, urological non-laparoscopic, and orthopedic limb surgeries."

The study is mainly limited by the lack of neuromuscular monitoring and the restriction to relatively healthy patients having shorter (mainly endoscopic!) procedures – arguably the group that atelectasis is least clinically important for!

Nonetheless, the results suggest that when appropriate, using an LMA rather than ETT may reduce atelectasis formation. The authors acknowledge this may not apply to longer procedures, laparoscopic surgery, or higher-risk patients; and naturally the risk-benefit balance of an unprotected airway versus an ETT needs to be considered.

"Rapid insertion and less airway irritation are key factors contributing to the LMA's ability to decrease the formation of absorptive atelectasis."

Mentioned studies:

CAB da Silveira, ACD Rasador, HJS Medeiros et al. Opioid-free anesthesia for minimally invasive abdominal surgery: a systematic review, meta-analysis, and trial sequential analysis. Can J Anaesth. 2024 Nov 5.
Ford P, Cheung AR, Khan MS et al. Anesthetic Techniques for Ablation in Atrial Fibrillation: A Comparative Review. J. Cardiothorac. Vasc. Anesth. 2024 Nov 1; 38 (11): 275427602754-2760.
Liu B, Wang Y, Li L et al. The effects of laryngeal mask versus endotracheal tube on atelectasis after general anesthesia induction assessed by lung ultrasound: A randomized controlled trial. J Clin Anesth. 2024 Nov 1; 98: 111564111564.

Anaesthesia and Compounding Marginal Gains

Fri, 01 Nov 2024 04:25:00 +0000

The British Cycling Revolution: A Lesson in Marginal Gains

When Dave Brailsford was appointed Performance Director of British Cycling in 2003, he inherited a program defined by failure. The national team hadn't won Olympic gold since 1908, and no British cyclist had ever claimed victory in the Tour de France's 110-year-long history. The 39-year-old cyclist-turned-performance consultant would transform British cycling and our approach to improvement through an unexpectedly simple philosophy: the aggregation of marginal gains.

Growing up in one of the few English families in North Wales, Brailsford developed a perpetual drive to prove himself. "Somehow I always felt I did not quite fit in," he reflected. "So I always thought I must try harder than the others to be accepted, to be successful." This outsider mentality would fuel his pursuit of excellence.

At twenty, Brailsford abandoned his job to pursue cycling in France as a sponsored amateur. In between training sessions, he devoured exercise physiology and sports psychology texts and later earned a degree in sports science and psychology that laid the foundation for his revolutionary approach to British cycling.

Brailsford's approach was revolutionary in precision and scope, implementing rigorous systems for measuring cyclist performance, from power output to recovery metrics. However, the true uniqueness of his methodology was its holistic nature, relentlessly pursuing tiny, cumulative advantages across all performance domains: physical conditioning, technological innovation, psychological preparation, and even the minutiae of daily life.

Rather than pursuing dramatic overhauls, Brailsford focused on finding one percent improvements across every aspect of cycling performance. His team painted truck floors white to spot dust that might undermine bike maintenance. They had a surgeon teach hand-washing techniques to prevent illness and transported custom mattresses and bedding between hotels to ensure sleep quality. They scrutinised every detail, from wind tunnel testing for minor aerodynamic advantage to athlete nutrition and the perfect pillow for optimal recovery.

"It struck me that we should think small, not big, and adopt a philosophy of continuous improvement through the aggregation of marginal gains. Forget about perfection; focus on progression, and compound the improvements." - Sir Dave Brailsford.

The results were extraordinary. British cyclists dominated the Tour de France within the decade and amassed 16 Olympic gold medals across the 2008 Beijing and 2012 London Games, setting seven world records. By 2016, they had won two-thirds of the Olympic cycling gold in Rio. While British Cycling's success was enabled by substantial funding, the power of a marginal gains strategy transformed both the sport and our understanding of how excellence can be achieved.

The Transformative Power of Marginal Gains in Anaesthesia

Every component of anaesthetic practice is tightly coupled. Every aspect of care – from preoperative assessment to emergence and recovery, from team cohesion to workflow and handovers – influences all others. While this coupling can amplify errors, it also means improvements do not merely add up – they compound. A refined preoperative assessment enhances intraoperative management, enabling smoother emergence and better recovery. These improvements compound both vertically within each patient's care journey and horizontally across all patients. In anaesthesia, marginal gains compound geometrically.

The benefits extend beyond patient outcomes. Small improvements create ripple effects throughout the perioperative environment. When anaesthesiologists enhance even minor aspects of their practice, team dynamics improve. Better communication protocols reduce stress; streamlined workflows improve efficiency and job satisfaction; more effective patient interactions enhance professional relationships. These improvements boost anaesthetist well-being, producing a positive feedback loop where personal satisfaction can drive further advances in care quality.

There is another crucial reason to embrace continuous improvement: stagnation in anaesthetic practice is not neutral – it is regression. Medical knowledge, technology, and best practices evolve constantly. The moment we stop improving, we begin falling behind. As for a patient in intensive care, stability is not enough; we must see progress. Our clinical environment becomes more complex each year, with new therapies, devices, drugs, techniques, and patient safety requirements. Rising patient expectations and evolving healthcare standards demand continuous adaptation. Yesterday's gold standard becomes tomorrow's minimum requirement. Anything less than improvement represents decline.

Kaizen: Empowering Small Steps in Large Organisations

The Japanese concept of Kaizen, or continuous improvement, perfectly captures the marginal gains philosophy. Kaizen is not about dramatic overhaul or revolutionary change but instead empowers individuals to make small, meaningful improvements in their daily work. When consistently applied, these incremental changes drive both personal excellence and institutional advancement.

In hospitals that embrace Kaizen, every staff member – from porters to doctors – is empowered to identify and implement improvements to their daily work. This democratisation of improvement has profound effects: it raises morale by giving staff agency over their work, creates a culture where questioning current practice becomes the norm rather than the exception, and, most importantly, it recognises that those who do the work are best placed to improve the work. The beauty of Kaizen is its sustainability. Unlike grand transformation projects that may get bogged down by politicking and implementation frictions, small daily improvements become woven into the fabric of everyday practice.

Implementing Marginal Gains in Your Practice

Begin by examining the unexplored corners of your practice – these often hide the most significant potential for improvement. The seemingly minor aspects of your daily routine, experienced by you, your team, and your patients, involve large patient surface areas. In their sheer frequency, these delightfully ordinary moments become critical targets because small things scale.

Small improvements create significant cumulative impact when consistently applied across hundreds of cases. Each enhancement, however minor, multiplies these benefits across every patient you treat.

Technical skills

Start with fundamental technical skills: consider how you might enhance even the most routine procedures. Could routine subcutaneous local anaesthetic before cannulation improve your patients' experience? When applied consistently, such minor refinements in technique can strengthen the quality of routine procedures.

Communication

Non-technical skills offer another rich opportunity for marginal gains. Implementing structured handover tools like SBAR might appear modest, yet it demonstrably improves communication clarity and patient safety. Refining preoperative patient communications can significantly reduce anxiety and improve satisfaction. Regular preoperative team meetings and post-operative debriefings create opportunities for continuous performance enhancement.

Patient experience

The patient journey offers numerous opportunities for marginal gains. Regular post-operative visits improve patient satisfaction and provide valuable feedback for improvement. Systematic patient surveys can reveal patterns indicating where small changes yield significant impact.

Personal well-being

Personal development deserves equal attention when pursuing marginal gains. Establish regular reflection time through journaling or collegiate discussion. Commit to reading one new journal article weekly, focusing on areas for growth. Simple mindfulness practices or brief exercise routines contribute to performance and well-being – even five minutes of focused breathing before starting your list can enhance both.

Remember that improvement does not require perfect conditions. On challenging days, focus on maintaining established gains. Every small step forward contributes to long-term progress.

Begin by identifying the smallest areas that you can improve. Managing your practice without seeking improvement is like wearing the same underwear for a week – technically possible, increasingly uncomfortable, and eventually, someone will notice and call you out on it. It's better to make small, regular changes before things get embarrassing.

Summing it up

Excellence in anaesthesia emerges not from revolutionary breakthroughs but from consistent, small improvements compounding over time. Each enhancement — in knowledge, technical skill, communication, or patient interaction — builds toward better patient outcomes: reduced complications, improved recovery times, enhanced patient experience, and more robust team performance.

The impact of marginal gains cascades beyond individual improvements. Like British cycling's transformation under Brailsford, our collective commitment to continuous enhancement can elevate both our individual practice and the entire field of anaesthesia. The question is not whether to pursue improvement — the question is which small enhancement you will tackle today.

References

Healthcare Kaizen: Continuous Improvement article collection
Subcutaneous local anaesthetic before cannulation article collection
Chadband, I (4 April 2013). Sir Dave Brailsford and the story behind his amazing ride from Bangor to Buck House. The Telegraph. Retrieved Nov 2024.
Lewis, T (20 Oct 2019) Golden aura around marginal gains is beginning to look a little tarnished The Guardian. Retrieved Nov 2024.

The Power of Kindness in Anaesthesia

Sun, 06 Oct 2024 09:15:00 +0000

Kindness is the foundation of positive human relationships. Kindness is also the foundation of quality anaesthesia, framing not just the goals of care but the paths we tread to reach them: kindness to our patients, kindness to one's team, and kindness to oneself. Kindness is the oxygen that sustains our practice.

"[Kindness is] helpfulness towards someone in need, not in return for anything, nor for the advantage of the helper himself, but for that of the person helped." – Aristotle, Book II of Rhetoric

Like many anaesthetists, I often fixate on outcomes. Yet, the journey usually matters as much for patients as the destination. While modern medicine makes successful outcomes the lowest bar, the hospital experience shapes the patient's entire perception of care, sometimes turning a medical success into a perceived failure. When we centre our practice on kindness, we elevate both process and outcome, giving them equal weight.

Too often, we equate quality anaesthesia with technical excellence: precise techniques, rapid turnover, stable vitals, and adherence to best practices. We audit hard markers like pain scores and discharge times. Yet this reductionist approach misses the cornerstone of healthcare: kindness.

When we view our practice through the lens of kindness – not empathy, for it helps no one for the anaesthetist to experience the same pains and fears as their patient – we reorient our decisions around "how can I help this person?" with a clarity of purpose unburdened by personal gain. This perspective expands our care to embrace the whole person under our care. For instance, taking a few extra minutes to explain the procedure to an anxious patient or keeping a family informed and reassured are acts of kindness that impact a patient's experience.

Patient fears before anaesthesia and surgery become just as essential to address as the technical aspects of care. Technique choices are no longer made for the convenience of the anaesthetist or hospital but rather for the needs of the patient. Perioperative care rooted in kindness recognises the interconnection between patient experience and patient outcomes – the two factors that truly matter to those under our care.

This practice of kindness extends beyond the patient. It reshapes and reorients our engagement with our team and ourselves. Kindness is a glue that binds a team together, encouraging a sense of unity and shared purpose.

Kindness to our team means fostering a culture of supportive communication: listening to concerns, acknowledging contributions, and responding to mistakes with constructive compassion. How often do you thank your assistant and surgical team at the end of a list?

Kindness becomes even more critical in moments of crisis. Everyone in the room likely shares your stress and looks to you for professional and emotional leadership. Maintaining calm, staying composed, and offering reassurance transform a team's performance under pressure. In a crisis, anger is a poison that corrodes collective resilience. Kindness, on the other hand, is a powerful tool that can reassure and instil confidence in the team, transforming both the atmosphere and the outcome of the crisis.

Kindness to oneself may be the most challenging form of kindness to practice. In a field where expectations are high, self-compassion is essential as we struggle to accept imperfect outcomes or personal errors. We must see mistakes not as failures but as opportunities for growth. The long hours, the high-intensity work, a sometimes-capricious health system, and the unpredictability of anaesthesia all contribute to burnout. Getting lost in our vocation can be easy and insidious, but we must recognise that life cannot be all work. Our families, our friendships, and our health must take priority. Kindness to ourselves is not indulgence; it is self-preservation. By practising self-kindness, we acknowledge our own value and well-being, prevent burnout and ensure we can continue providing the best care to our patients and team.

In our demanding profession, perhaps the best advice is simple:

"Be a little kinder than you have to." – Emily Jenkins.

When we practice kindness – to our patients, our team, and ourselves – we create an environment where care is more than just a technical exercise. We cultivate a virtuous cycle: supported team members provide better patient care, and well-cared-for patients make our work more fulfilling. Kindness in anaesthesia can lead to improved patient outcomes, enhanced team dynamics, and a more satisfying professional experience for all involved.

When we are kind to ourselves, we have the emotional resources to extend that kindness to others. In anaesthesia, as in life, kindness is not just a virtue – it's the vital sign reflecting our practice's health. Kindness is an act of compassion that elevates routine care, benefiting everyone involved.

COVID research mid-year round up

Thu, 07 Jul 2022 03:50:00 +0000

We are now two and a half years into the COVID pandemic, and just beginning to see yet another case surge with the arrival of the BA.5 Omicron sub-variant. The good news just keeps coming! 😉

Along with new variants, 30 months has also given us a lot of research and data. Metajournal alone has indexed almost 39,000 COVID-related publications relevant to anaesthesia, pain, critical care and emergency medicine.

Of course that's a crazy volume of research to manage, with a pretty low signal-to-noise ratio. Sifting through that for quality and relevant studies is exactly what metajournal was designed for.

Here's a quick round-up of interesting COVID-related research...

RAT tests & infectiousness

As good quality, locally validated RAT tests become increasingly available, we are also collecting more data showing they are a good indicator of individual infectiousness at the moment in time the test is performed.

The article collection 'Does a COVID RAT-negative result mean non-infectious?' explores several of these studies, suggesting that a negative RAT is likely a reliable indicator of being non-infectious.

The bottom line...

A correctly-performed adequately-validated RAT, is likely a sensitive indictor of individual infectiousness at that specific moment in time. The reliability of a negative RAT will be improved if using the same manufacturer and technique as a previously positive test, and more so if there are several subsequent negative RATs.

Return to exercise after COVID?

A recent J Sci Med Sport editorial (Hughes 2022) from Australian elite sport, exercise medicine and sports cardiology experts, provides reassuring encouragement when returning to exercise after COVID recovery.

The authors first note that:

"...with over 6 million cases recorded in Australia & NZ in the first 4 months of 2022, and few reports of serious adverse outcomes with exercise, the approach to return to exercise has become more pragmatic."

The authors' experience has been that most vaccinated elite athletes achieve pre-morbid fitness levels by day 7-14 post COVID recovery. Recreational athletes are recommended to pursue a more conservative course, but nonetheless they suggest:

"...a quick return to moderate exercise with a more cautious return to higher intensity exercise."

For those with no or minimal symptoms, the authors describe a graduated approach of exercise return over 6 days (days 1-3, 50% intensity for 15-30 min, then days 4-6, 75% intensity for 30 min), culminating in return to normal activity on day 7, if the graduation is well tolerated.

Interestingly these guidelines are very similar to Jewson's 2020 roadmap for return to activity after COVID infection, developed by the Australasian College of Sport and Exercise Physicians.

Jewson (2020) described three risk categories:

Low: Under 50 years with mild illness resolving within 7 days.
Intermediate: prolonged symptoms (>7d); persistent SOB or chest pain; pre-existing comorbidities; elite/endurance athletes.
High: hospitalised with COVID; SOB or chest pain at rest; cardiac abnormalities.

Jewson's graduated return to physical activity:

Begin after 10 days of rest and when 7 days symptom-free.
Begin with 15 minutes of light activity, with gradual increase guided by lack of fatigue with activity.
🚩 Red flag symptoms: chest pain, palpitations, severe dyspnoea. STOP & medical review.

Key takeaway

For those with mild or asymptomatic COVID infections, a careful graduated return to exercise can begin soon after recovery from COVID, while monitoring for excessive fatigue and cardiorespiratory symptoms.

Which N95/P2 respirators most often pass Fit Tests?

Ng and co. out of Australia's Royal Melbourne Hospital published excellent audit data answering this very question after Fit Testing 2,161 healthcare workers.

Why is this important?

Many healthcare workers and significantly, the general public, may not have access to formal Fit Testing. We also know that as face shape varies among individuals, so does the effectiveness of protection for different mask types – this is particularly significant for women who have more difficulty in finding suitably-fitting N95 respirators. (Notably 73% of Fit Tested staff in this study were women.)

The results of this study may allow individuals to make educated choices on suitable masks even when they do not have access to Fit Testing, as well as guiding institutional mask purchases.

What did they find?

Three-panel flat-fold N95 masks performed best (3M Aura 9320A+) both for fit test (96% pass) and wearer comfort and usability.

The other three tested designs were not as performant:

Semi-rigid cup type (3M 1860 or 1860S): 65% FT pass.
Duckbill type: (BSN ProShield or Halyard Fluidshield): 59% FT pass.
Flat-fold cup type: (BYD Care DE2322): 32% FT pass.

Final word?

Three-panel flat-fold N95 masks performed best for both fit test (96% pass) and wearer comfort and usability.

Novavax vs Omicron

Nuvaxoid (NVX-CoV2373), the protein-subunit COVID vaccine developed by Novavax, was already shown to be safe and 90% effective against the Alpha (B.1.1.7) SARS-CoV-2 variant – but now we have early release data showing similar efficacy against Omicron and it's various sub-variants (including the surging BA.5).

"...the data indicates a booster shot of Novavax’s vaccine generates neutralizing antibody responses to Omicron variants comparable to what was seen against the original strain of SARS-CoV-2 at the peak of its initial Phase 3 trial."

It is thought that Nuvaxoid's protein subunit structure provides much broader cross-neutralising antibodies than mRNA vaccines, such as from Moderna and Pfizer.

Interesting, animal studies show that the original Nuvaxoid vaccine results in similar neutralising titres to BA.5 as does a new, Omicron BA.1-specific formulation.

Bottom-line...

The current Nuvaxoid vaccine could make for a good booster option for populations where BA.5 is surging.

Pre-print hoopla: COVID-associated neurodegeneration & Risks of subsequent infections

Two pre-prints generated a lot of attention recently.

Outcomes of SARS-CoV-2 Reinfection (Al-Aly, Bowe, Xie)

A large cohort study using US Dep. of Veterans Affairs data looked at the mortality and morbidity associations between first infections, re-infections and the non-infected.

This data found that re-infection was associated with further increases in mortality, hospitalisation and morbidity, regardless of vaccination status.

While this was erroneously reported as 'subsequent infections are worse' it appears more accurately to show that there is (likely) a cumulative health burden to reinfection with COVID. This should not surprise us. However we should temper our concern by noting that this says nothing about the 219,000 study participants (85%) who did not suffer a reinfection, or about those who were unknowingly reinfected, but for whatever reason were not tested.

Retrospective cohort studies like this, even when very large, are acutely sensitive to confounders. Arguably this study selected those with re-infections and symptoms, as these were the group most likely to present for care. Additionally 90% of subjects were men - so take it all with a pinch of salt.

Regardless, you should try hard to avoid any COVID infection, whether it is your first or your third. There is no COVID infection that it better than non-infection!

COVID and neurodegenerative risk (Zarifkar)

The second pre-print to get us all hot & bothered was Danish data presented by Zarifkar at the recent European Academy of Neurology (EAN) Congress.

Among over 35,000 COVID-positive patients there was an associated increased relative risk for Alzheimer's (RR, 3.5, 95% CI 2.2-5.5), Parkinson's (RR 2.6, 95% CI 1.7-4.0), ischaemic stroke (RR 2.7, 95% CI, 2.3-3.2), and intracerebral haemorrhage (RR 4.8, 95% CI 1.8-12.9).

Buuuuut, and here's the problem, for all of those morbid end-points (except ischaemic stroke) a similar association was seen for influenza infection or "after other common respiratory tract infections".

Clearly COVID (or Influenza) is not causing Alzheimer's disease (a progressive chronic disease usually occuring over decades), but it is feasible that a systemic inflammatory insult could hasten progression of existing neurodegeneration. There may also be confounding factors, such that the same comorbidities associated with neurodegeneration are also associated with infection, severe COVID illness, or simple seeking out a test.

These large-population observational studies are clearly interesting, but we need to be careful to avoid rushing straight down the causation-highway. Remember that before falling in with the crazy COVID-minimiser crowd (🙄), legendary meta-researcher Dr John Ioannidis' published landmark research showing that 80% of conclusions from observational studies were later disproven.

Food for thought.

xkcd.com

Some more COVID reading...

Despite the 39,000 COVID-related publications indexed by metajournal, it's easy to drill down into more relevant research and seperate the signal from the noise.

Click on Search... and then Reviews to narrow the COVID results to only the Latest COVID Review Articles.

Case in point, the latest edition of Critical Care Clinics has a big COVID focus, including reviews of COVID critical illness post-sequalae, COVID and acute kidney injury, the role of thrombus in COVID-19, Multisystem inflammatory syndrome in children, and COVID in the critically ill pregnant patient.

Of course, don't worry, plenty more COVID research still to come...