Article Notes
- Small study size; note the wide confidence interval in absolute difference of percentage COVID infection, ranging from 50% relative decrease to 15% increase in infection rate.
- Self-reporting by subjects.
- Poor-compliance with hydroxychloroquine; around 1 in 5 did not complete course.
As of February 28th 2023, pholcodine has FINALLY been banned in Australia by the Therapeutic Goods Administration (TGA).
Press release here: TGA - Pholcodine
It's very sad that it took 14 years after Florvaag & Johansson's landmark 2009 paper describing the connection between pholcodine and NMBD anaphylaxis, for this problem to be addressed.
How many patients were exposed to avoidable harm?
Videira identified that in addition to the interval since last NMBD, anesthetists commonly used the adequacy of spontaneous minute ventilation as a decision heuristic for deciding on the need for reversal.
“The adequacy of the breathing pattern was also cited heavily … This visual cue may be erroneously interpreted as a sufficient sign for tracheal extubation, instead of a necessary one. This heuristic assesses function of the diaphragm, not of the upper airway muscles.”
Although the findings are broadly consistent with existing low-quality observational and randomised trials, once again there are trial issues that cast uncertainty:
It is unfortunate that, perhaps in their haste, the researchers did not design a more robust trial.
Following their important 2020 study of the risk of surgery for COVID patients, the COVIDSurg Collaborative reports on their prospective cohort study aiming to determine the optimal delay for planned surgery after COVID infection.
Once again this was an international (116 countries), multicentre, prospective cohort study including all surgery types, over 140,000 patients, and 3,127 post-COVID. Once again the 30-day postoperative mortality was sobering: even in the 5-6 week post-COVID group, 30-day mortality was dramatically higher (OR 3.6, 2.0-5.2) compared to those without a COVID diagnosis. Worryingly the risk was consistent among both low-risk and high-risk surgical groups.
Although after the 7-week mark postoperative mortality was similar to non-post-COVID patients (OR 1.5, 0.9–2.1), those with persisting COVID symptoms still suffered a 6.0% 30-day mortality (3.2–8.7). (30-day mortality among non-COVID patients was 1.5% (1.4-1.5).
Post-COVID surgical timing takeaway:
Surgery should be delayed for at least 7 weeks after COVID, although those with persistent COVID symptoms will still have more than twice the 30-day mortality than those without.