Summary
Healthcare workers involved in aerosol‐generating procedures, such as tracheal intubation, may be at elevated risk of acquiring COVID‐19. However, the magnitude of this risk is unknown. We ...conducted a prospective international multicentre cohort study recruiting healthcare workers participating in tracheal intubation of patients with suspected or confirmed COVID‐19. Information on tracheal intubation episodes, personal protective equipment use and subsequent provider health status was collected via self‐reporting. The primary endpoint was the incidence of laboratory‐confirmed COVID‐19 diagnosis or new symptoms requiring self‐isolation or hospitalisation after a tracheal intubation episode. Cox regression analysis examined associations between the primary endpoint and healthcare worker characteristics, procedure‐related factors and personal protective equipment use. Between 23 March and 2 June 2020, 1718 healthcare workers from 503 hospitals in 17 countries reported 5148 tracheal intubation episodes. The overall incidence of the primary endpoint was 10.7% over a median (IQR range) follow‐up of 32 (18–48 0–116) days. The cumulative incidence within 7, 14 and 21 days of the first tracheal intubation episode was 3.6%, 6.1% and 8.5%, respectively. The risk of the primary endpoint varied by country and was higher in women, but was not associated with other factors. Around 1 in 10 healthcare workers involved in tracheal intubation of patients with suspected or confirmed COVID‐19 subsequently reported a COVID‐19 outcome. This has human resource implications for institutional capacity to deliver essential healthcare services, and wider societal implications for COVID‐19 transmission.
There is a need for high quality research to improve perioperative patient care in Africa. The aim of this study was to understand the particular barriers to clinical research in this environment.
We ...conducted an electronic survey of African Surgical Outcomes Study (ASOS) investigators, including 29 quantitative Likert scale questions and eight qualitative questions with subsequent thematic analysis. Protocol compliant and non-compliant countries were compared according to WHO statistics for research and development, health workforce data, and world internet statistics.
Responses were received from 134/418 of invited researchers in 24/25 (96%) of participating countries, and three non-participating countries. Barriers included lack of a dedicated research team (47.7%), reliable internet access (32.6%), staff skilled in research (31.8%), and team commitment (23.8%). Protocol compliant countries had significantly more physicians per 1000 population (4 vs 0.9, P<0.01), internet penetration (38% vs 28%, P=0.01) and published clinical trials (1461 vs 208, P<0.01) compared with non-compliant countries. Facilitators of research included establishing a research culture (86.9%), simple data collection tools (80%), and ASOS team interaction (77.9%). Most participants are interested in future research (93.8%). Qualitative data reiterated human resource, financial resource, and regulatory barriers. However, the desire to contribute to an African collaboration producing relevant data to improve patient outcomes was expressed strongly by ASOS investigators.
Barriers to successful participation in ASOS related to resource limitations and not motivation of the clinician investigators. Practical solutions to individual barriers may increase the success of multi-centre perioperative research in Africa.
Low- and middle-income countries have a critical shortage of specialist anaesthetists. Most patients arriving for surgery are of low perioperative risk. Without immediate access to preoperative ...specialist care, an appropriate interim strategy may be to ensure that only high-risk patients are seen preoperatively by a specialist. Matching human resources to the burden of disease with a nurse-administered pre-operative screening tool to identify high-risk patients who might benefit from specialist review prior to the day of surgery may be an effective strategy.
To develop a nurse-administered preoperative anaesthesia screening tool to identify patients who would most likely benefit from a specialist review before the day of surgery, and those patients who could safely be seen by the anaesthetist on the day of surgery. This would ensure adequate time for optimisation of high-risk patients preoperatively and limit avoidable day-of-surgery cancellations.
A systematic review was conducted to identify preoperative screening questions for use in a three-round Delphi consensus process. A panel of 16 experienced full-time clinical anaesthetists representing all university-affiliated anaesthesia departments in South Africa participated to define a nurses' screening tool for preoperative assessment.
Ninety-eight studies were identified, which generated 79 questions. An additional 14 items identified by the facilitators were added to create a list of 93 questions for the first round. The final screening tool consisted of 81 questions, of which 37 were deemed critical to identify patients who should be seen by a specialist prior to the day of surgery.
A structured nurse-administered preoperative screening tool is proposed to identify high-risk patients who are likely to benefit from a timely preoperative specialist anaesthetist review to avoid cancellation on the day of surgery.
Background. In high-income countries, preoperative anaemia has been associated with poor postoperative outcomes. To date, no large study has investigated this association in South Africa (SA). The ...demographics of SA surgical patients differ from those of surgical patients in the European and Northern American settings from which the preoperative anaemia data were derived. These associations between preoperative anaemia and postoperative outcomes are therefore not necessarily transferable to SA surgical patients.Objectives. The primary objective was to determine the association between preoperative anaemia and in-hospital mortality in SA adult non-cardiac, non-obstetric patients. The secondary objectives were to describe the association between preoperative anaemia and (i) critical care admission and (ii) length of hospital stay, and the prevalence of preoperative anaemia in adult SA surgical patients.Methods. We performed a secondary analysis of the South African Surgical Outcomes Study (SASOS), a large prospective observational study of patients undergoing inpatient non-cardiac, non-obstetric surgery at 50 hospitals across SA over a 1-week period. To determine whether preoperative anaemia is independently associated with mortality or admission to critical care following surgery, we conducted a multivariate logistic regression analysis that included all the independent predictors of mortality and admission to critical care identified in the original SASOS model.Results. The prevalence of preoperative anaemia was 1 727/3 610 (47.8%). Preoperative anaemia was independently associated with in-hospital mortality (odds ratio (OR) 1.657, 95% confidence interval (CI) 1.055 - 2.602; p=0.028) and admission to critical care (OR 1.487, 95% CI 1.081 - 2.046; p=0.015).Conclusions. Almost 50% of patients undergoing surgery at government-funded hospitals in SA had preoperative anaemia, which was independently associated with postoperative mortality and critical care admission. These numbers indicate a significant perioperative risk, with a clear need for quality improvement programmes that may improve surgical outcomes. Long waiting lists for elective surgery allow time for assessment and correction of anaemia preoperatively. With a high proportion of patients presenting for urgent or emergency surgery, perioperative clinicians in all specialties should educate themselves in the principles of patient blood management.
Priorities for peri‐operative research in Africa Biccard, B.M.; Biccard, BM; Torborg, AM ...
Anaesthesia,
January 2020, 2020-Jan, 2020-01-00, 20200101, Letnik:
75, Številka:
S1
Journal Article
Recenzirano
Odprti dostop
Summary
Deaths following surgery are the third largest contributor to deaths globally, and in Africa are twice the global average. There is a need for a peri‐operative research agenda to ensure ...co‐ordinated, collaborative research efforts across Africa in order to decrease peri‐operative mortality. The objective was to determine the top 10 research priorities for peri‐operative research in Africa. A Delphi technique was used to establish consensus on the top research priorities. The top 10 research priorities identified were (1) Develop training standards for peri‐operative healthcare providers (surgical, anaesthesia and nursing) in Africa; (2) Develop minimum provision of care standards for peri‐operative healthcare providers (surgical, anaesthesia and nursing) in Africa; (3) Early identification and management of mothers at risk from peripartum haemorrhage in the peri‐operative period; (4) The role of communication and teamwork between surgical, anaesthetic, nursing and other teams involved in peri‐operative care; (5) A facility audit/African World Health Organization situational analysis tool audit to assess emergency and essential surgical care, which includes anaesthetic equipment available and level of training and knowledge of peri‐operative healthcare providers (surgeons, anaesthetists and nurses); (6) Establishing evidence‐based practice guidelines for peri‐operative physicians in Africa; (7) Economic analysis of strategies to finance access to surgery in Africa; (8) Establishment of a minimum dataset surgical registry; (9) A quality improvement programme to improve implementation of the surgical safety checklist; and (10) Peri‐operative outcomes associated with emergency surgery. These peri‐operative research priorities provide the structure for an intermediate‐term research agenda to improve peri‐operative outcomes across Africa.
Summary
Functional capacity is an integral component of the pre‐operative evaluation of the cardiac patient for non‐cardiac surgery. Stair climbing capacity has peri‐operative prognostic importance. ...It may predict survival after lung resection and complications after major non‐cardiac surgery. However, stair climbing cannot determine the aerobic metabolic capacity necessary to survive the peri‐operative stress response. The potential benefits and current limitations of cardiopulmonary exercise testing to determine peri‐operative aerobic capacity are discussed. Principles for the selection of an appropriate screening test of aerobic function are put forward.
Cardiovascular risk prediction using clinical risk factors is integral to both the European and the American algorithms for preoperative cardiac risk assessment and perioperative management for ...non-cardiac surgery. We have reviewed these risk factors and their ability to guide clinical decision making. We examine their limitations and attempt to identify factors which may improve their performance when used for clinical risk stratification. To improve the performance of the clinical risk factors, it is necessary to create uniformity in the definitions of both cardiovascular outcomes and the clinical risk factors. The risk factors selected should reflect the degree of organ dysfunction rather than a historical diagnosis. Parsimonious model design should be applied, making use of a minimal number of continuous variables rather than creating overfitted models. The inclusion of age in the model may assist partly in controlling for the duration of risk factor exposure. Risk assignment should occur throughout the perioperative period and the risk factors chosen for model inclusion should vary depending on when the assignment occurs (before operation, intraoperatively, or after operation).
Summary
The purpose of this meta‐analysis was to determine the efficacy of peri‐operative interventions in decreasing the incidence of postoperative delirium. An electronic search of four databases ...was conducted. The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines were adhered to. We included randomised controlled trials of non‐cardiac surgery with a peri‐operative intervention and that reported postoperative delirium, and identified 29 trials. Meta‐analysis revealed that peri‐operative geriatric consultation (OR 0.46, 95% CI 0.32–0.67) and lighter anaesthesia (OR 2.66, 95% CI 1.27–5.56) were associated with a decreased incidence of postoperative delirium. For the other interventions, the point estimate suggested possible protection with prophylactic haloperidol (OR 0.62, 95% CI 0.36–1.05), bright light therapy (OR 0.20, 95% CI 0.03–1.19) and general as opposed to regional anaesthesia (OR 0.76, 95% CI 0.47–1.23). This meta‐analysis has shown that peri‐operative geriatric consultations with multicomponent interventions and lighter anaesthesia are potentially effective in decreasing the incidence of postoperative delirium.
Summary
Identification of high‐risk patients admitted to intensive care with COVID‐19 may inform management strategies. The objective of this meta‐analysis was to determine factors associated with ...mortality among adults with COVID‐19 admitted to intensive care by searching databases for studies published between 1 January 2020 and 6 December 2020. Observational studies of COVID‐19 adults admitted to critical care were included. Studies of mixed cohorts and intensive care cohorts restricted to a specific patient sub‐group were excluded. Dichotomous variables were reported with pooled OR and 95%CI, and continuous variables with pooled standardised mean difference (SMD) and 95%CI. Fifty‐eight studies (44,305 patients) were included in the review. Increasing age (SMD 0.65, 95%CI 0.53–0.77); smoking (OR 1.40, 95%CI 1.03–1.90); hypertension (OR 1.54, 95%CI 1.29–1.85); diabetes (OR 1.41, 95%CI 1.22–1.63); cardiovascular disease (OR 1.91, 95%CI 1.52–2.38); respiratory disease (OR 1.75, 95%CI 1.33–2.31); renal disease (OR 2.39, 95%CI 1.68–3.40); and malignancy (OR 1.81, 95%CI 1.30–2.52) were associated with mortality. A higher sequential organ failure assessment score (SMD 0.86, 95%CI 0.63–1.10) and acute physiology and chronic health evaluation‐2 score (SMD 0.89, 95%CI 0.65–1.13); a lower PaO2:FIO2 (SMD −0.44, 95%CI −0.62 to −0.26) and the need for mechanical ventilation at admission (OR 2.53, 95%CI 1.90–3.37) were associated with mortality. Higher white cell counts (SMD 0.37, 95%CI 0.22–0.51); neutrophils (SMD 0.42, 95%CI 0.19–0.64); D‐dimers (SMD 0.56, 95%CI 0.43–0.69); ferritin (SMD 0.32, 95%CI 0.19–0.45); lower platelet (SMD −0.22, 95%CI −0.35 to −0.10); and lymphocyte counts (SMD −0.37, 95%CI −0.54 to −0.19) were all associated with mortality. In conclusion, increasing age, pre‐existing comorbidities, severity of illness based on validated scoring systems, and the host response to the disease were associated with mortality; while male sex and increasing BMI were not. These factors have prognostic relevance for patients admitted to intensive care with COVID‐19.
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