Anaesthesia Digested - October issue
October 2020
Outcomes from intensive care in patients with COVID-19: a systematic review
and meta-analysis of observational studies
Armstrong RA, Kane AD, Cook TM.
Demand-capacity modelling and COVID-19 disease: identifying themes for
future NHS planning
Pandit JJ.
Kicking on while it’s still kicking off - getting surgery and anaesthesia restarted
after COVID-19
Cook TM, Harrop-Griffiths W.
The October issue contains a number of papers relevant
to where we are with COVID-19, and where we need to
go. Cook et al. address the problem that the literature
surrounding outcomes after ICU admission is largely
composed of small case series and cohort studies.
Additionally ‘headline’ survival rates have had variable
follow-up periods, some studies included patients who were
still receiving ICU support, and heterogeneity across studies
was high. The authors sought to generate a point-estimate
of mortality after completed ICU episodes. Outcome data
for 10,150 patients from 11 countries were analysed, with
the largest contribution from UK ICNARC data. All studies
were observational cohort studies. ICU mortality across all
studies was 41.6 (34.0–49.7%), I2 93.2% and was broadly
consistent globally. This is higher than the 22% for other
viral pneumonias (so not ‘just a little flu’). The question is
whether this high death rate was from the disease process, or
the difficulty in providing ‘normal’ intensive care during the
pandemic. Mortality decreased over time, perhaps reflecting
learning.
This leads into the editorial by Pandit focussing on how we
should model ICU requirements in the future. Capacity is
more than just bed numbers: functional capacity includes
staff numbers and how long they are contracted to, or
prepared to, work; demand is patient numbers but also
length of stay. It is crucial to understand that variations in
demand are more significant than average demand in setting
optimal capacity, in order to account for surges. As we have
seen, the NHS has historically ignored this in favour of ‘flow’to gain considerable staff and infrastructure cost savings, a
so-called ‘lean’ approach. This has been brutally exposed
by the pandemic, and it is not hyperbole to say that the
Government shut down the economy to the tune of billions
of pounds because of a lack of ICU capacity and fear of
critical care being overwhelmed. However, is it rational to
set capacity at the height of what is needed during a surge,
inevitably meaning periods of underutilisation? How should
we fund it? Or should we consider reducing demand through
overt or covert rationing, something the NHS has done up
to the present time? Where does COVID-19 and the need
for multiple pathways fit into this? We need to tackle these
difficult questions urgently to help influence the national
agenda.
Finally, what of those patients who have been denied
essential surgery as a result of the pandemic? Harrop-
Griffiths and Cook opine how we can restart elective surgery
urgently during a time of massive uncertainty, with the risk
of ‘second waves’ and with an exhausted workforce. They
explore how to keep staff and patients safe by developing
and testing pathways, rational and proportionate use of
PPE, and how to return operating theatres and equipment
to their original use. This needs attention to be paid to rest,
recuperation and therapy for our workforce, a consistent
priority of the Association of Anaesthetists, and without which
the grand plans of our managers and surgeons will fail - the
entire peri-operative team need vision, skills, experience and
compassion to continue to do the best for all our patients.
André E. Vercueil, Editor, Anaesthesia
N.B. the articles referred to can be found in either the latest issue of Anaesthesia or on Early View (ePub ahead of print)