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Skip to 0 minutes and 9 seconds I think it’s obvious that we need to do it. There’s a massive backlog of several million people who would normally have had surgery, who need surgery. Some people who need surgery for life-saving reasons, life-extending reasons, others who need it because of pain, with these conditions people don’t enter surgery or the surgical pathway lightly. So it’s absolutely clear that we need to get the non-COVID part of the NHS and the elective part of the NHS up and running. But there are major challenges to it. So for the first surge, a lot of non-emergency work, almost all the non-emergency work, was put on hold. And that’s quite all right.

Skip to 1 minute and 0 seconds It was necessary in order for the NHS, the country, to cope with the surge. But in this next phase, we will have, effectively, a triple whammy. So it’s likely that we’ll have a resurgence of COVID activity in some manner. The extent of that is unknown. And whether these are rebounds of the first wave or whether they’re a new wave will be uncertain. We don’t know. It’s quite likely we’ll get a second wave. With that, we’ll have to manage the non-COVID activity, both emergency and elective. It’s quite all right that we do, otherwise the excess deaths associated with non-COVID health care needs will exceed those associated with COVID. Then, of course, we have the winter.

Skip to 1 minute and 47 seconds We have further challenges in terms of the winter pressures, but we also have, in September and October, the young folk returning to school and then to university. And then, of course, this year, perhaps more than ever returning to university. So those are the challenges that we normally have. Those of us who are old enough to have snot-eating kids and kids coming back to the university and the exposure to new viruses and new illnesses. And just distinguishing between people who are sick from COVID and people who are sick from run-of-the-mill adenoviruses and other illnesses. It’s going to create multiple challenges. And so, as with all pandemics, the greatest thing is uncertainty. But you can’t stand still.

Skip to 2 minutes and 46 seconds We have to move forward, and we have to grapple with these challenges and move forward towards them.

Skip to 3 minutes and 0 seconds I think, at the moment, some people have described it’s half time in the pandemic. We had a period in August, particularly where I am in the southwest, where there was a relatively low incidence of sick patients with COVID. There was a low prevalence of the disease in the community. And it’s likely that that will increase. And already, we’ve had outbreaks in hospitals. We’ve had outbreaks in communities and outbreaks in whole cities. We’ve had necessary closures of hospitals, or lockdowns, or reimposing lockdown in towns and other centres. And it’s likely that that will occur again. So we have to track the epidemic locally. We have to test and test and test to understand what’s going on.

Skip to 3 minutes and 55 seconds So if patients are– we’ve known from COVIDsurg and I think COVIDsurg is just one paper. So COVIDsurg was a cohort of about 1,800 patients who had COVID perioperatively. The majority developing it post developing symptoms postoperatively. And there’s close to 30% mortality in those patients.

Skip to 4 minutes and 20 seconds It did mostly– so the risk factors were high ASA, high ASA, and high age, so over 70, males and emergency patients. But it wasn’t predominantly– it didn’t have a massive effect whether surgery was major or minor. And it had no impact on the type of anesthesias used. And so, on the basis of the knowledge we have at the moment– there’s a Chinese paper that supports this– we know that surgery where patients have COVID is extremely high-risk. We need more information to confirm whether it’s quite as high-risk as COVID studies suggest, but we must try and seek to avoid surgery when patients have COVID or are in the process of getting it.

Skip to 5 minutes and 2 seconds And of course, in order to keep other patients and staff safe, we need to control the epidemic within the hospital. And so, as well as testing within the community to understand how the epidemic is happening, whether we’re in a phase where the epidemic is rising, where R zero is above zero, what the absolute numbers are. For many regions, we simply don’t get enough information. We also need to test within hospitals. So we need to test patients who are coming in. We also need to test patients who are symptomatic and we also need to have an idea of how many staff are infected or impacted. So we need to understand the epidemic within the hospitals, as well as within the community.

Skip to 5 minutes and 44 seconds And I think that is one of the challenges. And I think, sadly, one of the slightly unmet challenges. So, until about two weeks ago, the standard of care was that patients expecting to have surgery would have to self-isolate for two weeks. And NICE has recommended that’s no longer necessary. Patients only need to self-isolate for the period of time after they’ve had a antigen test, a PCR test. I have to say, I struggle with that as a recommendation, because the two or three day self-isolation provides no value in confirming or reassuring us that the patient is not developing COVID. And that’s not very reassuring for the staff. And it’s not very sure reassuring for the patient.

Skip to 6 minutes and 37 seconds The 14 days equates to five days of incubation, and then a nine-day period where patients can be secreting, whether or not they’re symptomatic. And that 14 days provides, I think, quite a lot with reassurance. I understand the pressures to get rid of it. But I find the decision difficult. And I think it means that we, in hospitals, are going to be stuck with our inefficient systems because we’re going to have to assume that patients may still be brewing COVID for a longer period of time. So those are very significant challenges. And those are really without a major resurgence of COVID.

Skip to 7 minutes and 23 seconds So I think, because we’re not requiring patients to self-isolate, the idea that patients who are more vulnerable should self-isolate make some sense because they are potentially at a higher risk if they get COVID. But in terms of spreading it within the hospital, I’m not sure it makes a whole lot of sense. So, in terms of keeping patients and staff safe, I think we have to test in the community. We have to test in the hospitals. We have to maintain our guard. And I avoid saying stay alert, but we have to maintain our guard up so that staff are protected.

Skip to 8 minutes and 4 seconds And the inconvenience of wearing airborne PPE for anaesthetists and droplet PPE for most surgical procedures, I think it’s likely to need to continue for some time. And particularly, in the winter, if we get a resurgence of COVID, then I think that’s going to need to be emphasised. I fully understand the desire to drop away from it, to reduce the amount of PPE people are wearing. And I think if we knew that the levels in September, October, November were going to stay low, then I think we’d probably be at about the right time where that would be sensible. But unfortunately, I think we don’t. We’re going to rely on research.

Skip to 8 minutes and 51 seconds We’re going to rely on the Office of National Statistics continuing to do the great job it does in informing, as apparently the pandemic is progressing. And then, within hospitals, for those patients who do come in, we’re going to need to maintain separate pathways for patients who do have COVID, who may have COVID, and who are unlikely to have COVID. And it’s going to be more of the same, I’m afraid. More rattle. And if COVID does return with a vengeance, we will have those further challenges of re-instituting expanded intensive cares. We don’t have enough intensive cares for a real second wave. Re-instituting the space that is required for those extra intensive critically ill patients.

Skip to 9 minutes and 39 seconds And redeploying staff and resources to those settings. And so, the challenge that has been set by the NHS, which is to increase surgical activity to 90% of normal in October, is a huge challenge. So I think it’s unlikely that we will return to the efficiencies we’ve had in the past this year. And returning to 90% of elective activity within the next two months, the next three months– one to two months, actually– is a mountain to climb, I think. I think we should take on the challenge. We should aim to do that.

Skip to 10 minutes and 23 seconds We should aim to be as efficient as we can so there is little inefficiencies that happen in theatre waiting too long between cases, doing everything in series rather than in parallel. We need to do everything we can to reduce those delays and try and be as efficient as we can on the day. But a lot of it is sort of controlled by things that happen before patients get to hospital.

Skip to 10 minutes and 56 seconds I think it’s an unknown known area at the moment. So people are talking about– one of the things that I think emerged in March and April was just how long an illness this is when you’re properly unwell. Several colleagues of mine in their 40s, 50s, who had a pretty bad dose of COVID, as it were, but didn’t end up in hospital varied in terms of how long though they were unwell, from one day to two weeks, to probably six or eight weeks. With persistent shortness of breath, that’s six to eight weeks. And so it’s a very variable event. We know that patients who end up in hospital in intensive care, it’s a really long illness.

Skip to 11 minutes and 47 seconds And it’s characterised– for instance, on intensive care, I think the biggest 20% of patients who visited critical care are still there in a month. And 9% are still there six weeks. And not only that, but they’re not in a simple weaning phase. They’re not pre-morbidly frail patients who take a long time to leave the ventilators. They’re often patients who still have new thrombosis and new events happening during that two to four, six, even eight weeks on ITU. We know some patients spend more than a hundred days on ITU. So there’s a very broad spectrum of illness.

Skip to 12 minutes and 27 seconds And I think if somebody is young and fit and has recovered completely from their COVID episode, then it probably– and that’s genuine– they probably don’t need a dramatic workup. But unless their surgery is particularly urgent, I wouldn’t be rushing into it. So again, as always, you’re balancing the urgency against benefits of quick surgery. But if someone’s been unwell for a month, or hospitalised, or even in intensive care, then I think it probably– I think it’s uncertain, but I think we will need to understand things in the coming months much better. So people talk about long COVID. They talk about an illness– and I think that’s ill-defined– but an illness which drags on, where the symptoms of COVID persist.

Skip to 13 minutes and 20 seconds And I think, in general practise, this term long COVID is probably more of a sort of chronic fatigue and chronic debility. But still, functioning illness. There’s another group of patients who have genuine chronic functional deterioration, shortness of breath, and inability to get going again. And some of those are likely to have ongoing cardio respiratory persistent illness. So there’s people who have looked at recovery from SARS. I know SARS is a very different illness, but patients who had survived SARS, most had been alive a year afterwards, their lung function had largely recovered. So it recovered 80%, 90%, a year on. The two areas that hadn’t recovered, that still a lot of recovery to do, were generalised weakness, muscle weakness.

Skip to 14 minutes and 19 seconds We know the degree of de-conditioning and muscle loss that happens with prolonged illness and psychological distress. So perhaps there’s something to learn from that. So we need to look at people’s overall physical conditioning in their nutrition and rehabilitation from that perspective, after COVID. But also, there will be patients who have permanent lung disease, changes in their transfer factor, and also lung function, particularly those with preexisting disease. And finally, a group where there’s emerging evidence that they have cardiac dysfunction and some form of post-COVID cardiomyopathy, which I think needs more explanation, and I’m no expert on it. But I think if a patient presents– in an outpatient clinic and says, I had nasty COVID, I’m still not quite back to normal.

Skip to 15 minutes and 17 seconds I think bells should ring. And for some major surgery, significant investigation to exclude significant debilitation and cardio respiratory disease do need to be acted on.

Professor Tim Cook on COVID-19

In August 2020, we interviewed Professor Tim Cook, Consultant in Anaesthesia and ICM, Royal United Hospitals Bath, RCoA Advisor on Airway and Director of National Audit Projects. Tim has worked very closely with the RCoA throughout the COVID-19 pandemic to provide evidence-based recommendations on keeping patients and staff safe throughout this period.

In this Zoom interview we ask him three questions:

  • What are the major challenges of offering surgical treatments now that COVID-19 is endemic?
  • How can we keep patients and staff safe?
  • How would you manage and risk assess a patient who has had COVID who presents for major elective surgery?

Click on the video above to hear his answers to these difficult questions.

In your workplace have you struggled to offer elective surgery whilst treating patients with COVID 19. What solutions have you found to improve flow? Have you cared for patients who have presented for surgery whilst still suffering from the symptoms of “Long COVID-19’? Do use the comments section to discuss these questions with your fellow learners.

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Perioperative Medicine in Action

UCL (University College London)