Management of Trauma in COVID-19 Patients: An Adaptation of Practice

Over the past two and a half years, the world has been living in the shadow of the COVID-19 pandemic. Malaysia has been similarly affected, reporting a total of 4,575,809 cases and 35,784 deaths till 5th July 2022.1 During this time, the medical field has learned to fight this virus and its complications. Public health measures such as mass vaccinations and infection control precautions were implemented to reduce the spread of COVID-19. Despite this, the COVID-19 virus continued to evolve, with no clear end in sight until today. Therefore, healthcare practitioners must remain constantly vigilant in the management of COVID-19 patients, regardless of whether infection rates spike or wane. This review aims to demonstrate the principles of management of COVID-19 patients presenting with trauma

Psychological distress among healthcare professionals at the frontlines: anaesthesiologists’ perspective

The COVID-19 pandemic raging in Malaysia has been one of the greatest challenges so far since its formation, and standing at the forefront of this “war” are Malaysian healthcare practitioners. We sought to capture a snapshot of the psychological distress encountered by those in the medical profession standing at the frontlines of the fight against COVID-19, by carrying out a cross-sectional study to investigate the prevalence of burnout and depression risk among anaesthesiology clinicians in a nationally designated exclusive COVID-19 hospital. We utilised validated questionnaires and included all the clinicians (n=88) in the Anaesthesiology and Intensive Care Department. This study was conducted throughout the month of May 2020, which corresponded to the end of the first Malaysian Government Movement Control Order (from 18th March to 3rd May 2020). Results showed that more than half of anaesthesiologists managing COVID-19 patients suffered from burnout, and up to 67% had a high risk of depression. Both burnout and depression are significantly associated with one another. The findings are discussed, followed by recommendations for preventative strategies to increase the mental fortitude of healthcare practitioners in Malaysia

Psychological distress among healthcare professionals at the frontlines: anaesthesiologists’ perspective

The COVID-19 pandemic raging in Malaysia has been one of the greatest challenges so far since its formation, and standing at the forefront of this “war” are Malaysian healthcare practitioners. We sought to capture a snapshot of the psychological distress encountered by those in the medical profession standing at the frontlines of the fight against COVID-19, by carrying out a cross-sectional study to investigate the prevalence of burnout and depression risk among anaesthesiology clinicians in a nationally designated exclusive COVID-19 hospital. We utilised validated questionnaires and included all the clinicians (n=88) in the Anaesthesiology and Intensive Care Department. This study was conducted throughout the month of May 2020, which corresponded to the end of the first Malaysian Government Movement Control Order (from 18th March to 3rd May 2020). Results showed that more than half of anaesthesiologists managing COVID-19 patients suffered from burnout, and up to 67% had a high risk of depression. Both burnout and depression are significantly associated with one another. The findings are discussed, followed by recommendations for preventative strategies to increase the mental fortitude of healthcare practitioners in Malaysia

A comparison of ramping position and sniffing position during endotracheal intubation: a systematic review and meta-analysis

Objectives: Positioning during endotracheal intubation (ETI) is critical to ensure its success. We aimed to determine if the ramping position improved laryngeal exposure and first attempt success at intubation when compared to the sniffing position. Methods: PubMed, EMBASE, and Cochrane CENTRAL databases were searched systematically from inception until January 2020. Our primary outcomes included laryngeal exposure as measured by Cormack-Lehane Grade 1 or 2 (CLG 1/2), CLG 3 or 4 (CLG 3/4), and first attempt success at intubation. Secondary outcomes were intubation time, use of airway adjuncts, ancillary maneuvers, and complications during ETI. Results: Seven studies met our inclusion criteria, of which 4 were RCTs and 3 were cohort studies. The meta-analysis was conducted by pooling the effect estimates for all 4 included RCTs (n = 632). There were no differences found between ramping and sniffing positions for odds of CLG 1/2, CLG 3/4, first attempt success at intubation, intubation time, use of ancillary airway maneuvers, and use of airway adjuncts, with evidence of high heterogeneity across studies. However, the ramping position in surgical patients is associated with increased likelihood of CLG 1/2 (OR = 2.05, 95% CI 1.26 to 3.32, p = 0.004) and lower likelihood of CLG 3/4 (OR = 0.49, 95% CI 0.30 to 0.79, p = 0.004), moderate quality of evidence.Conclusion: Our meta-analysis demonstrated that the ramping position may benefit surgical patients undergoing ETI by improving laryngeal exposure. Large scale well designed multicentre RCTs should be carried out to further elucidate the benefits of the ramping position in the surgical and intensive care unit patients. © 2020 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/bync-nd/4.0/)

A survey on burnout and depression risk among anaesthetists during COVID-19: the tip of an iceberg?

The recent article by Heath et al. [1] is a timely one, which addresses the need for solutions to minimise the adverse psychological impact of the COVID-19 pandemic. In the midst of this public health crisis, anaesthetists are at the frontline of the ‘war’ against the virus, and hence at great risk of suffering from mental and emotional harm, akin to a ‘parallel pandemic’ [2]. Due to the nature of the work of anaesthetists in managing patients in acute and critical care, with special emphasis on airway management and ventilatory support, their work-load worldwide has increased during the pandemic, predisposing to burnout. Also, as the clinicians responsible for airway management, anaesthetists are among those at greatest risk of contracting COVID-19 [3], and with this risk comes worry and anxiety, contributing to further psychological distress. In view of the multiple psychological challenges faced by anaesthetists worldwide, we sought to define the problem by investigating the prevalence of burnout and depression risk among anaesthetists in a nationally designated exclusive COVID-19 hospital

Comparison of bed-up-head-elevated intubation position with Glidescope assisted tracheal intubation: a randomised, controlled, non-inferiority trial

Proper positioning during intubation is critical in order to increase the likelihood of success. The bed-up-headelevated (BUHE) intubation position has been shown to improve laryngeal view, reduce airway complications and prolong safe apneic time during intubation. Concurrently in the last decade, there has been an exponential increase in the use of video laryngoscopy (VL) devices, especially for difficult airway patients, as it has been shown to improve laryngeal exposure. The use of VL will increase, and may replace traditional laryngoscopy one day. In this study, we sought to determine if the BUHE intubation position is non-inferior to Glidescope-assisted intubation with regards to laryngeal exposure. In addition, we aimed to determine the differences in time required for intubation (TRI) in the two groups

Comparison of Macintosh Laryngoscopy in Bed-up-Head–Elevated Position With GlideScope Laryngoscopy: A Randomized, Controlled, Noninferiority Trial

BACKGROUND: Approximately half of all difficult tracheal intubations (DTIs) are unanticipated; hence, proper positioning during intubation is critical to increase the likelihood of success. The bed-up-head–elevated (BUHE) intubation position has been shown to improve laryngeal view, reduce airway complications, and prolong safe apneic time during intubation. In this study, we sought to determine whether the BUHE intubation position is noninferior to Glidescope (GLSC)- assisted intubation with regard to laryngeal exposure. METHODS: A total of 138 American Society of Anesthesiologists (ASA) I to III patients were randomly assigned into 2 groups and underwent baseline laryngoscopy in the sniffing position. Group BUHE patients (n = 69) were then intubated in the BUHE position, while group GLSC patients (n = 69) were intubated using GLSC laryngoscopy. Laryngeal exposure was measured using Percentage of Glottic Opening (POGO) score and Cormack–Lehane (CL) grading, and noninferiority will be declared if the difference in mean POGO scores between both groups do not exceed −15% at the lower limit of a 98% confidence interval (CI). Secondary outcomes measured included time required for intubation (TRI), number of intubation attempts, use of airway adjuncts, effort during laryngoscopy, and complications during intubation. RESULTS: Mean POGO score in group BUHE was 80.14% ± 22.03%, while in group GLSC it was 86.45% ± 18.83%, with a mean difference of −6.3% (98% CI, −13.2% to 0.6%). In both groups, there was a significant improvement in mean POGO scores when compared to baseline laryngoscopy in the sniffing position (group BUHE, 25.8% ± 4.7%; group GLSC, 30.7% ± 6.8%) (P < .0001). The mean TRI was 36.23 ± 14.41 seconds in group BUHE, while group GLSC had a mean TRI of 44.33 ± 11.53 seconds (P < .0001). In patients with baseline CL 3 grading, there was no significant difference between mean POGO scores in both groups (group BUHE, 49.2% ± 19.6% versus group GLSC, 70.5% ± 29.7%; P = .054). CONCLUSIONS: In the general population, BUHE intubation position provides a noninferior laryngeal view to GLSC intubation. The laryngeal views obtained in both approaches were superior to the laryngeal view obtained in the sniffing position. In view of the many advantages of the BUHE position for intubation, the lack of proven adverse effects, the simplicity, and the costeffectiveness, we propose that clinicians should consider the BUHE position as the standard intubation position for the general population. (Anesth Analg 2020;131:210–9

Rationale and design of the PeriOperative ISchemic Evaluation-3 (POISE-3): a randomized controlled trial evaluating tranexamic acid and a strategy to minimize hypotension in noncardiac surgery

Background: For patients undergoing noncardiac surgery, bleeding and hypotension are frequent and associated with increased mortality and cardiovascular complications. Tranexamic acid (TXA) is an antifibrinolytic agent with the potential to reduce surgical bleeding; however, there is uncertainty about its efficacy and safety in noncardiac surgery. Although usual perioperative care is commonly consistent with a hypertension-avoidance strategy (i.e., most patients continue their antihypertensive medications throughout the perioperative period and intraoperative mean arterial pressures of 60 mmHg are commonly accepted), a hypotension-avoidance strategy may improve perioperative outcomes

Prophylactic Topical Tranexamic Acid Versus Placebo in Surgical Patients: A Systematic Review and Meta-Analysis

Objectives: Perioperative bleeding remains a major concern to all clinicians caring for perioperative patients. Due to the theoretical risk of thromboembolic events associated with tranexamic acid (TXA) when administered intravenously, topical route of TXA has been extensively studied, but its safety and efficacy profile remain unclear in the literature. The primary aim of this review was to assess the effect of topical TXA on incidence of blood transfusion and mortality in adults undergoing surgery. Data sources: EMBASE, MEDLINE, CENTRAL, and ISI Web of Science were systematically searched from their inception until May 31, 2019. Review methods: Parallel-arm randomized controlled trials were included. Results: Seventy-one trials (7539 participants: orthopedics 5450 vs nonorthopedics 1909) were included for quantitative meta-analysis. In comparison to placebo, topical TXA significantly reduced intraoperative blood loss [mean difference (MD) -36.83 mL, 95% confidence interval (CI) -54.77 to -18.88, P < 0.001], total blood loss (MD -319.55 mL, 95% CI -387.42 to -251.69, P < 0.001), and incidence of blood transfusion [odds ratio (OR) 0.30, 95% CI 0.26-0.34, P < 0.001]. Patients who received topical TXA were associated with a shorter length of hospital stay (MD -0.28 days, 95% CI -0.47 to -0.08, P = 0.006). No adverse events associated with the use of topical TXA were observed, namely mortality (OR 0.78, 95% CI 0.45-1.36, P = 0.39), pulmonary embolism (OR 0.73, 95% CI 0.27-1.93, P = 0.52), deep vein thrombosis (OR 1.07, 95% CI 0.65-1.77, P = 0.79), myocardial infarction (OR 0.79, 95% CI 0.21-2.99, P = 0.73), and stroke (OR 0.85, 95% CI 0.28-2.57, P = 0.77). Of all included studies, the risk of bias assessment was "low" for 20 studies, "unclear" for 26 studies and "high" for 25 studies. Conclusions: In the meta-analysis of 71 trials (7539 patients), topical TXA reduced the incidence of blood transfusion without any notable adverse events associated with TXA in adults undergoing surgery