Maintaining safe lung cancer surgery during the COVID-19 pandemic in a global city.

BACKGROUND: SARS-CoV-2 has challenged health service provision worldwide. This work evaluates safe surgical pathways and standard operating procedures implemented in the high volume, global city of London during the first wave of SARS-CoV-2 infection. We also assess the safety of minimally invasive surgery(MIS) for anatomical lung resection. METHODS: This multicentre cohort study was conducted across all London thoracic surgical units, covering a catchment area of approximately 14.8 Million. A Pan-London Collaborative was created for data sharing and dissemination of protocols. All patients undergoing anatomical lung resection 1st March-1st June 2020 were included. Primary outcomes were SARS-CoV-2 infection, access to minimally invasive surgery, post-operative complication, length of intensive care and hospital stay (LOS), and death during follow up. FINDINGS: 352 patients underwent anatomical lung resection with a median age of 69 (IQR: 35-86) years. Self-isolation and pre-operative screening were implemented following the UK national lockdown. Pre-operative SARS-CoV-2 swabs were performed in 63.1% and CT imaging in 54.8%. 61.7% of cases were performed minimally invasively (MIS), compared to 59.9% pre pandemic. Median LOS was 6 days with a 30-day survival of 98.3% (comparable to a median LOS of 6 days and 30-day survival of 98.4% pre-pandemic). Significant complications developed in 7.3% of patients (Clavien-Dindo Grade 3-4) and 12 there were re-admissions(3.4%). Seven patients(2.0%) were diagnosed with SARS-CoV-2 infection, two of whom died (28.5%). INTERPRETATION: SARS-CoV-2 infection significantly increases morbidity and mortality in patients undergoing elective anatomical pulmonary resection. However, surgery can be safely undertaken via open and MIS approaches at the peak of a viral pandemic if precautionary measures are implemented. High volume surgery should continue during further viral peaks to minimise health service burden and potential harm to cancer patients. FUNDING: This work did not receive funding.

The Cardiac Surgery Advanced Life Support Course (CALS): delivering significant improvements in emergency cardiothoracic care.

BACKGROUND: A 3-day cardiac surgery advanced life support course was designed with a series of protocols to manage critically ill cardiac surgical patients and patients who suffer a cardiac arrest. We sought to determine the effect of this course on the management of simulated critically ill and cardiac arrest patients. METHODS: Twenty-four candidates participated in the course. Critically ill patients were simulated using intubated mannikins, with lines and drains in situ, and a laptop with an intensive care unit monitor simulation program. Candidates were tested before and after the course with rigidly predesigned clinical situations. Candidates were split into groups of 6, and cardiac arrests were simulated in the same fashion, with all required surgical equipment immediately available. All scenarios were videotaped, and after blinding, an independent surgeon assessed the times to achieve predetermined clinical endpoints. RESULTS: The time to successful definitive treatment was significantly faster postcourse for the critically ill patient scenarios: (565 secs [SD 27 secs] precourse, compared with 303 secs [SD 24 secs] postcourse; p < 0.0005). In addition, the times taken to achieve a wide range of predetermined objectives, including airway check, assessing breathing, circulation assessment, treating with oxygen, appropriate treatment of the circulation, and requesting blood gases, chest radiographs, and electrocardiograms, were also significantly faster in the postcourse scenarios. Times to successful chest reopening and internal cardiac massage were also significantly improved in cardiac arrest patients: (451 secs [SD 39 secs] precourse and 228 secs [SD 17 secs] postcourse; p = 0.011). CONCLUSIONS: Structured training and practice in the management of critically ill cardiac surgical patients and patients suffering a cardiac arrest leads to significant improvements in the speed and quality of care for these patients.

Liver blood flow during cardiac surgery.

OBJECTIVE: Impairment of liver blood flow and, therefore, potentially liver function, has important short-term consequences because of the liver's key metabolic importance and role in drug metabolism. The objective of this study was to quantify the effect of cardiac surgery on liver blood flow from before the induction of anaesthesia to 24 hours postoperatively. METHOD: Ten patients with no history of liver impairment, moderate or good left ventricular function, and undergoing routine hypothermic coronary artery bypass graft surgery, were entered into the study. Liver blood flow was determined by the clearance of indocyanine green (ICG), expressed as a percentage disappearance rate (PDR). RESULTS: The mean baseline percentage disappearence rate (PDR) of indocyanine green (ICG) was 19.84 +/- 4.47%/min. This increased marginally to 20.42 +/- 6.67%/min following the induction of anaesthesia, but after 15 min of cardiopulmonary bypass, the PDR fell to 13.51 +/- 3.69%/min; this was significantly lower than all other PDRs measured throughout the study. Prior to extubation, the PDR increased again to 20.01 +/- 3.72%/ min, and this level was maintained at 12 hours (PDR 20.32 +/- 3.53%min) and 24 hours (PDR 20.51 +/- 2.27%/min). CONCLUSION: The induction of anaesthesia and positive pressure ventilation do not affect liver blood flow. Cardiopulmonary bypass at 30 degrees C is associated with a significant reduction in liver blood flow, which returns to normal within 4-6 hours of surgery and remains normal for up to 24 hours after surgery.