FRAILTY, PERIOPERATIVE RISK & CARDIAC ARREST

Frailty in NAP7 a 🧵

Frailty (ie clinical frailty scale score >4) was a big issue in the aetiology of perioperative cardiac arrest

TL/DR

-a high proportion of cases
-frail patients’ more likely
*to be emergency surgery
*to be major surgery
-increased complications
-insufficient illogical monitoring (IMO)
-low rates of DNACPR recommendations
-insufficient risk assessment & communication
-these patients account for a substantial proportion of cardiac arrests
-risk assessment (& communication) poor
-drug dosing an issue in many
-periop cardiac arrest rate ≈8-fold higher than the young & fit
-successful ROSC rate notably lower
-overall early mortality after periop cardiac arrest 40-fold higher then in the young & fit

Frailty arguably a bigger issue than older age

It is a topic relevant t to
-all anaesthetists,
-all perioperative physicians
-orthogeriatricians
- those planning services
& many more





@NAPs_RCoA @jas_soar @IainMoppett @AgeAnaesthesia @RCoANews @drrichstrong @emirakur @adk300 @CPOC_News

1/n…-publications.onlinelibrary.wiley.com/doi/10.1111/an…
rcoa.ac.uk/sites/default/… Activity Survey
-26% (1,676/6,466) of patients aged >65 yrs were frail

-15% of those aged 66-75 yr
-29% of those aged 76-85 yr
-62% of those aged >85 yr

2/n

NAPs and TIVA and pEEG monitoring

Quick summary 🧵 for amongst others
@JulianCorbettF

NAP5
Awareness
-TIVA was associated with a doubling in frequency of accidental awareness (during general anaesthesia (AAGA)
-what a lot of people missed was that when TIVA was used correctly in a TCI mode there was no signal
-most AAGA during TIVA was due to syringe/delivery errors, programming errors, erroneous use of manual infusions especially when converting from volatile to TIVA (eg to transfer sick pt to ICU or radiology)
-6% of GAs were TIVA. 90% of these in theatre were TCI. Outside theatre 18% were TCI.


-pEEG (BIS) use was low at 2.8%
-much higher with TIVA:
*8% without NMB
*23% with NMB
-report recommended universal use of BIS when TIVA used with paralysis


1/5rcoa.ac.uk/sites/default/…
rcoa.ac.uk/sites/default/… In NAP6 (anaphylaxis) we took stock of all drugs used during anaesthesia

-use of TIVA rose to 8%
-pEEG monitoring was used in 12%
*rising to 32% with TIVA
*38% with TIVA + NMB
-with variation by specialty, anaesthetist seniority & BMI



2/5 rcoa.ac.uk/sites/default/…

CARDIAC ARREST DURING OR AFTER SURGERY IN UK PRIVATE HOSPITALS

This is a timely reminder that all healthcare has risks & safety is at the heart of everything we should be doing.

Timely also as I was speaking today to the Independent Healthcare Providers Network (IHPN) about Perioperative Cardiac Arrest in the Independent healthcare sector -based on the findings of the @RCoANews NAP7 report.



A thread on what we found. Not all of which is comfortable. But it is an important discussion.
@bbchealth
@BBCPanorama
@RCoANews



1/15rcoa.ac.uk/research/resea…

https://x.com/bbchealth/status/1777200152849064332

TLDR NAP7: Perioperative cardiac arrest in private hospitals

To be clear much work takes place in all sectors to promote safety. The vast majority of anaesthesia and surgery is very safe and outcomes good. But anaesthesia and surgery has risk, some of which is unpredictable.

Being safe and preparing for unusual events is difficult and it is likely harder in settings that are smaller and more remote than in a large NHS hospital.

The purpose of the NAP7 study was to examine the data on cardiac arrest in or after surgery and to explore areas where care may be improved.

2/15

Amidst the gloom at the NHS crisis its easy to forget one factor: sociomedical success

In the last 30 yrs UK health has been transformed.The predictable consequences required long term planning which appears absent

A 🧵 of old slides (2017) but they still make the point

1/n Wealth creates health & longevity (& population surge).

Over the last century life expectancy has dramatically increased, as has the population

This creates numerous problem only one of which is health costs

2/n

Controversially, I’ve been chatting about population TRIAGE today

A short 🧵& some polls at the end

Early in the pandemic the risk of healthcare being ‘overwhelmed’ was high on the agenda with population triage a logical consequence. Lockdown was to prevent this.

1/11 I now consider triage to be of three types

Triage by prognosis Normal decision-making led by prognosis (& patient’s goals)

Triage by resource
- by individual
- at population level

The latter is not normal

2/11

The pandemic & ICU

There is questionable value of conversation with an individual who is either misinformed or intentionally misrepresenting recent history

However a thread to correct the record/explain apparent inconsistency in data that may lead others to honest error

1/n March 2020 was a time of uncertainty & fear.

The evidence from Wuhan & northern Italy is that we would be engulfed by an unprecedented number of sick patients many needing ICU

Doing nothing was never an option

2/n

A short thread on the revised list of AGPs

The AGP list has changed in England

The following are no longer considered to be AGPs

@TonyPi314 @_andyshrimp @drjulesbrown @NWilson247 @EuanTovey

1/6 These changes are laid out in the new NHS National IPC manual (14 April 2022)

england.nhs.uk/wp-content/upl…

2/6

A thread on the (topical) high rate of COVID identified or acquired in hospital

The fact that this is up to 30% is being highlighted by some as indicating that hospitalisation numbers are inaccurate

1/ First I agree that it leads to confusion & it would be much better to report -those admitted due to COVID
- those admitted ‘while infected’ (likely same as community rate ≈2-3% cases)
-those who acquire it in hospital

2/

OXIMETRY and SKIN COLOUR
Is it a major factor?

Lots of interest today
bbc.co.uk/news/uk-593635…
@bbchealth
@guardiannews
@HSJnews
@Telegraph
All covering it

I've had a look & this thread explores

1/ The technology is not ancient - I recall first oximeter arriving coming Gateshead 1988 in my first year of anaesthetic practice

Oximetry calculates differences in light absorption between oxygenated (light) & deoxygenated (dark) blood

No surprise that pigments affect readings.

@ICNARC report 19 Nov

shows us a system
-under sustained pressure
-dramatically impacted by the unvaccinated
-with pressures preventing care of many vaccinated patients

For staff and patients alike seemingly unending & miserable.

icnarc.org/our-audit/audi…

1/ ICU UNDER SUTAINED PRESSURE

About 1000 patients in ICU with COVID through last several months

Equivalent to 1/3 of all UK ICU beds
So the rest of UK health is running on 2/3 of required ICU capacity
ICUs have expanded, taking staff from other locations

It's unsustainable

2/

PREVENTING UNDETECTED OESOPHAGEAL INTUBATION. A thread @RCoANews @dasairway @ICS_updates @FICMNews @CollegeODP @SaferSurgeryUK @BACCNUK @MartinBromiley

It is rare
It is fatal
It is avoidable
Sadly it still happens

1/16

rcoa.ac.uk/news/rcoa-das-… Glenda's was not a difficult airway case.

Please DO READ this judiciary.uk/publications/g…

2/16

Important paper illustrating how changing to FFP3 masks on wards reduces risk of healthcare worker infection

Hugely important for policy
Massive for counties with low vaccination rates
Important still in those with high vaccination rates

authorea.com/users/421653/a…

1/9 I don't follow all the inferences (especially that all staff cases on 'green wards' (ie those without known COVID patients) were community acquired) but I do agree with their finding that a change to FFPs dramatically reduced staff infections on 'red wards' (COVID wards)

2/9

A thread on what studying "AGPs" tells us about 'aerosols and droplets'

Focus on this paper
…-publications.onlinelibrary.wiley.com/doi/10.1111/an…

Done in Sydney
Hats off to @NWilson247 @EuanTovey
My role was microscopic

First: discussion should be 'what is the proportion of each in disease risk: not A vs B The study builds on work by others esp Bristol AERATOR study which has examined designated 'aerosol generating procedures' in a laminar flow theatre

-intubation/extubation
-NIV/HFNO
-tracheostomy

& largely identified a LACK of aerosol

More to come on other designated AGPs

I am interested (as an anaesthetist/intensivist) in the claims that N95/FFP masks could
-raise CO2
-decreased oxygen uptake in pregnant patients

It is not a trivial claim
aricjournal.biomedcentral.com/articles/10.11…
& is stated here by a WHO IPC expert group

..among a long list of downsides

1/15 The paper quoted regarding CO2 elevation is this one
ajicjournal.org/article/S0196-…

It studied
10 nurses
All white
9 female
9 elevated BMI, 5 BMI >30 kg/m2

2x 12 hour shifts
N95 +/- surgical mask over it
Unclear whether expiratory valve

Assessed
compliance comfort & physiology

2/15

A longish thread on RESTARTING ELECTIVE SURGERY for a Saturday morning

First up it is very clear we need to do it

Some patients have life threatening or painful conditions that need addressing.

Provision of healthcare is a must for any civilised society

1/n The volume of missed surgery is huge

We've probably lost at least 2 million cases in 2020 and we now have a waiting list of about 5 million

Different sources have broadly similar numbers between 2 and 3 million additional cases on the waiting list

2/n

Strong article @By_CJewett on AEROSOLS, COUGH, the complex discussion around risk for HEALTHCARE WORKERS and FFP3/N95 masks

With @drjulesbrown me and others

Here's a bit of the evidence behind it
1/19

theguardian.com/us-news/2021/m… First the archetypal metanalysis by Tran which seemingly underpins the early approach by many public health organisations

Evidence base...
"We identified 5 case-control and 5 retrospective cohort studies which evaluated transmission of SARS to HCWs"
2/19

ncbi.nlm.nih.gov/pmc/articles/P…

A thread on why a slower lockdown release makes sense for the wide and younger community (& so for all)

ICU pressures will not fall for up to 8 weeks after similar falls in deaths
@john_actuary
1/n

…-publications.onlinelibrary.wiley.com/doi/full/10.11… The reasons can be illustrated by the median ages of patients in the 3 groups affected by COVID
-patients who died (median age 83) @ONS
-hospital admissions (age 73) @ISARIC1
-ICU admissions (age 61) @ICNARC

Impact of vaccination is much slower in the younger groups

2/n

Nice to see this published
Working with @john_actuary from @COVID19actuary we’ve modelled impact of vaccination on
-deaths
-hospital admissions
-ICU admissions

…-publications.onlinelibrary.wiley.com/doi/full/10.11… Vaccinating just by age would have this impact on the three measures

The lag in the last two is because the groups differ.

Median ages
-deaths 83
-hospitalised 73
-ICU 61

So the cohort who might get to ICU have to wait for vaccination

Round 3 of ACCC TRACK. Exploring impact of COVID on anaesthetic departments and surgical activity out now
@emirakur @jas_soar @HSRCNews @RCoANews

nationalauditprojects.org.uk/downloads/ACCC… Only about a third of anaesthetic departments operating well in December- worse then October and before the new year surge hit

@nico111111 @rupert_pearse @JeremyFarrar An important piece by an excellent communicator laying out what it means when the NHS is 'overwhelmed'
@chrischirp

-first more difficult to provide care
-then standards of care reduce
-finally inability to provide even that care to some needing it

theguardian.com/commentisfree/… Important to remember that pressure on NHS will last longer than high rates of mortality

https://twitter.com/doctimcook/status/1348266400624898052?s=20

An important piece by an excellent communicator laying out what it means when the NHS is 'overwhelmed'
@chrischirp

-first more difficult to provide care
-then standards of care reduce
-finally inability to provide even that care to some needing it

theguardian.com/commentisfree/… Important to remember that pressure on NHS will last longer than high rates of mortality

https://twitter.com/doctimcook/status/1348266400624898052?s=20