Cook and Harrop-Griffiths survey the damage of a health system stretched to its limits in response to the UK's COVID-19 crisis, and how elective surgery could be carefully recommenced – particularly considering that the pandemic is far from over.
"....this has been achieved ‘by the skin of our teeth’ and until very recently, the threat of insufficient ICU beds, ventilators, and the need for triage were all anticipated: a few hospitals were overcome by the surge of critically ill patents."
They highlight several priorities as the NHS looks to return to a 'new normal' of healthcare provision:
- Support ICU needs of those with COVID.
- Make hospitals safe for patients both with and without COVID.
- Returning staff and services to pre-pandemic areas as possible.
- Protect staff with adequate personal protective equipment.
- Appropriate surgical case triage.
"Having weathered the COVID‐19 storm, we are now being asked to assess the damage done, pick up the pieces and rebuild. However, this storm will rage for many months. Flattening the epidemic curve does not reduce the total number of cases but spread their burden over a longer period of time..."
Of particularly note is the challenge of ensuring COVID positive patients do not undergo non-essential surgery, known to be associated with a high post-operative mortality. They explore the complexities of pre-operative isolation and testing (PCR or CT), and the inherent limitations of these.
"The move from a health service focused on one single disease to one that continues that challenge while also addressing all the other health needs of the population may be even harder than that the crisis phase that preceded it."
Related editorial in Anaesthesia (May 2020) from Cook & Harrop-Griffiths:
Post-operative mortality in patients with SARS-CoV-2 infection having surgery is extremely high, even among low-risk patient or surgical groups, or those initially asymptomatic.
This massively-multicenter (235 hospitals, 24 countries; mainly Europe & N. America) cohort study investigated post-operative morbidity and mortality in those with confirmed SARS-CoV-2 infection.
Why is this significant?
Early data suggested that COVID-19 patients who underwent even minor elective surgery suffered worse post-operative outcomes, particularly higher mortality.
This large cohort study confirms these concerns and will assist decision making around the timing of surgery for COVID-19 patients and the process for re-commencing elective surgery in communities hardest hit by the pandemic.
What did they do?
Over a 3 month period in early 2020 the researchers analysed 1,128 patients who underwent emergency (74%) or elective (25%) surgery across 24 countries. Patients diagnosed with COVID seven days pre-op or 30 days post-op were included, although the majority of patients (74%) had SARS-CoV-2 infection diagnosed post-operatively.
And they found?
30-day mortality was extremely high (24%).
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.
Other interesting observations...
- Nonetheless 'lower-risk' groups still suffered significant 30-day mortality rates, eg. 30-49 year olds (6%), women (18%), ASA 1-2 (12%), no-comorbidities (7%).
- Being asymptomatic at admission did not have a significant protective effect (22% vs 27% mortality).
- Dyspnoea and/or sputum on admission were the only symptoms associated with worse outcomes.
- 20% of patients suffered ARDS, with a 63% mortality rate.
- Although emergency surgery was higher risk, elective surgery still carried a 19% mortality rate. Even minor surgery resulted in a 16% mortality rate!
- Even obstetrics (2% mortality) and gynaecology (5%) demonstrated orders of magnitude-higher mortality than expected.
- There was no statistically significant difference between local, regional or general anaesthesia.
- Pulmonary embolus was only seen in 2% at 30 days and when present did not appear to impact mortality.
Why such high post-operative COVID mortality?
The authors suggest this could be due to the combination of pro-inflammatory cytokine and immunosuppressive responses to surgery, and/or mechanical ventilation associated with general anaesthesia (although the later was not significantly associated with higher mortality).
Surgery for those with known or suspected COVID-19 should be avoided or delayed until after recovery from infection, as allowed by the underlying surgical pathology. When surgery cannot be delayed less-invasive surgery is preferable, and post-operative recovery should be closely monitored.
Keep in mind
Although RT-PCR testing was the main diagnostic test, in some settings clinical criteria (6%) and/or chest CT (7%) were instead used for diagnosis. Additionally, hospital data collection during a pandemic emergency carries higher risk of error, although this should not effect the broad validity of the research conclusions.
Chemical irritant crowd control, such as with tear gas and pepper spray, can often cause injuries, sometimes severe or permanently disabling, and rarely even death.
Kinetic impact projectiles used for crowd control frequently cause injuries, often severe (70%), permanently disabling (15%), or even causing death (3%).
This systematic review out of Berkeley investigated data on death, injury and disability resulting from crowd control projectiles:
- Rubber and plastic bullets
- Beanbag rounds
- Shot pellets
- Baton rounds
The researchers looked at published data from a 27 year period in the US, UK/N Ireland, Israel, Palestine, Switzerland, Turkey, Kashmir and Nepal.
The study was part of a larger effort from Physicians for Human Rights and the International Network of Civil Liberties Organizations.
What did they find?
Analysing 26 articles (mainly cohort studies) including 1,984 injured people, they identified 53 (3%) deaths and 300 (15%) permanently disabled. Half of total deaths and 83% of disabilities were due to head or neck strikes.
More than half (56%) of the deaths were from penetrative injuries, and 27% from chest or abdominal trauma.
The majority of permanent disability was vision loss, or abdominal injuries resulting in splenectomy or colostomy.
71% of survived injuries were severe, mostly to skin or extremities.
"Given their inherent inaccuracy, potential for misuse and associated health consequences of severe injury, disability and death, KIPs do not appear to be appropriate weapons for use in crowd-control settings."
Although colloquially called 'non-lethal weapons', it would be more accurate to label kinetic impact projectiles (KIPs) as less-lethal weapons given the high risk of severe injury, permanent disability or even death.
"We identified only two basic contexts in which CCWs should be used in crowd-control settings:
- Arrest of individuals engaged in unlawful behaviour, such as throwing rocks and;
- Crowd dispersal in riot situations that threaten public safety."
Several articles highlighted the effect on morbidity of delays in accessing medical care due to police action and civil unrest.
"There is an urgent need to establish international guidelines on the use of CCWs to prevent unnecessary injury, disability and death, particularly in the use of operational models that avoid the use of weapons."
This important WHO-funded review and meta-analysis from Canada's COVID-19 SURGE group (Systematic Urgent Review Group Effort) looked at the effect of three non-pharmacological interventions on coronavirus transmission:
- Physical distancing
- Face masks
- Eye protection
Why is this important?
The speed of both the global spread of SARS-CoV-2 and national responses has lead to a bundled-approach to public health interventions for which the evidence-base is still catching up. This review provides reassurance that the core recommendations are likely beneficial.
What did they do?
Reflecting the lack of data, the review group analysed research covering not just SARS-CoV-2, but also SARS and MERS, capturing 172 observational studies with over 25,000 patients in both community and healthcare settings.
What did they find?
Perhaps unsurprisingly (though reassuring!) physical distancing > 1 meter was associated with lower transmission risk (risk difference 95% CI -11.5 to -7.5%) with increasing protection as distance increased beyond 2 meters.
Face-masks were also associated with reduced transmission (risk difference 95% CI -14.3% to -15.9%, though with low certainty), as was eye protection (risk difference 95% CI -12.5% to -7.7%).
N95 masks were even more strongly associated with risk reduction, as was mask use in a health-care setting vs non-health-care. Both N95 and multi-layer surgical masks were more protective than single-layer masks.
Simple protective behavioural changes, namely physical distancing, face-mask use and eye protection, are associated with a significant risk reduction in coronavirus transmission.
“...recognize, as an aspect of health worker safety, the precautionary principle that reasonable action to reduce risk, such as the use of a fitted N95 respirator, need not await scientific certainty”.
Campbell (2006) SARS Commission final report
Keep in mind...
Most of the 172 studies reported on bundled interventions (ie. PPE and distancing) so multi-factor analysis was required to tease out the individual contributions to risk reduction. Randomised trials are still pending...
Simple protective behavioural changes, namely physical distancing, face-mask use & eye protection, are associated with a significant risk reduction in coronavirus transmission.
Withdrawn by the authors because of their inability to confirm validity of data from Surgisphere used as the basis for this study:
“Because all the authors were not granted access to the raw data and the raw data could not be made available to a third-party auditor, we are unable to validate the primary data sources underlying our article.”