Evaluation of electronic screening in the preoperative process.

STUDY OBJECTIVE: Rising patient numbers, with increasing complexity, challenge the sustainability of the current preoperative process. We evaluated whether an electronic screening application can distinguish patients that need a preoperative consultation from low-risk patients that can be first seen on the day of surgery. DESIGN: Prospective cohort study. SETTING: Preoperative clinic of a tertiary academic hospital. PATIENTS: 1395 adult patients scheduled for surgery or procedural sedation. INTERVENTIONS: We assessed a novel electronic preoperative screening application which consists of a questionnaire with a maximum of 185 questions regarding the patient's medical history and current state of health. The application provides an extensive health report, including an American Society of Anesthesiologists physical status (ASA-PS) classification and a recommendation for either consultation by an anesthesiologist at the preoperative clinic or approval for screening on the day of surgery. MEASUREMENTS: The recommendation of the electronic screening system was compared with the regular preoperative assessment using measures of diagnostic accuracy and agreement. Secondary outcomes included ASA-PS classification, patient satisfaction, and the anesthesiologists' opinion on the completeness and quality of the screening report. RESULTS: Sensitivity to detect patients who needed additional consultation was 97.5% (95%CI 91.2-99.7) and the negative likelihood ratio was 0.08 (95%CI 0.02-0.32). 407 (29.2%) patients were approved for surgery by both electronic screening and anesthesiologist. In 909 (65.2%) cases, the electronic screening system recommended further consultation while the anesthesiologist approved the patient (specificity 30.9% (95%CI 28.4-33.5); poor level of agreement (ĸ = 0.04)). Agreement regarding ASA-PS classification scores was weak (ĸ = 0.48). The majority of patients (78.0%) felt positive about electronic screening replacing the regular preoperative assessment. CONCLUSIONS: Electronic screening can reliably identify patients who can have their first contact with an anesthesiologist on the day of surgery, potentially allowing a major proportion of patients to safely bypass the preoperative clinic.

Operational experience of the Dutch helicopter emergency medical services (HEMS) during the initial phase of the COVID-19 pandemic: jeopardy on the prehospital care system?

PURPOSE: The SARS-CoV-2 virus has disrupted global and local medical supply chains. To combat the spread of the virus and prevent an uncontrolled outbreak with limited resources, national lockdown protocols have taken effect in the Netherlands since March 13th, 2020. The aim of this study was to describe the incidence, type and characteristics of HEMS and HEMS-ambulance 'Lifeliner 1' dispatches during the initial phase of the COVID-19 pandemic compared to the same period one year prior. METHODS: A retrospective review of all HEMS and HEMS-ambulance 'Lifeliner 1' dispatches was performed from the start of Dutch nationwide lockdown orders from March 13th until May 13th, 2020 and the corresponding period one year prior. Dispatch-, operational-, patient-, injury-, and on-site treatment characteristics were extracted for analysis. In addition, the rate of COVID-19 positively tested HEMS personnel and the time physicians were unable to take call was described. RESULTS: During the initial phase of the COVID-19 pandemic, the HEMS and HEMS-ambulance was requested in 528 cases. One year prior, a total of 620 requests were received. The HEMS (helicopter and ambulance) was cancelled after deployment in 56.4% of the COVID-19 cohort and 50.7% of the historical cohort (P = 0.05). Incident location type did not differ between the two cohorts, specifically, there was no significant difference in the number of injuries that occurred at home in pandemic versus non-pandemic circumstances. Besides a decrease in the number of falls, the distribution of mechanisms of injury remained similar during the COVID-19 study period. There was no difference in self-inflicted injuries observed. Prehospital interventions remained similar during the COVID-19 pandemic compared to one year prior. Specifically, prehospital intubation did not differ between the two cohorts. The rate of COVID-19 positively tested HEMS personnel was 23.1%. Physicians who tested positive were unable to take call for a mean of 25 days (range 8-53). CONCLUSION: A decrease in the number of deployments and increase in the number of cancelled missions was observed during the COVID-19 study period. No major differences in operational- and injury characteristics were found for HEMS and HEMS-ambulance dispatches between the initial phase of the COVID-19 pandemic in the Netherlands and the same period one year prior. These findings highlight the importance of continued operability of the HEMS, even during pandemic circumstances. LEVEL OF EVIDENCE: III, retrospective comparative study.

Thinking Out-of-the-Box: A Non-Standard Application of Standard Pulse-Oximetry and Standard Near-Infrared Spectroscopy in a COVID-19 Patient.

PURPOSE: Purpose of this report is to describe the feasibility of lingual pulse oximetry and lingual near-infrared spectroscopy (NIRS) in a COVID-19 patient to assess lingual tissue viability after several days of mechanical ventilation in the prone position. MATERIALS & METHODS: In a COVID-19 ICU-patient, the tongue became grotesquely swollen, hardened and protruding from the oral cavity after 20 h of mechanical ventilation uninterrupted in the prone position. To assess the doubtful viability of the tongue, pulse-oximetric hemoglobin O2-saturation (SpO2; Nellcor, OxiMax MAX-NI, Covidien, MA, USA) and NIRS-based, regional tissue O2-saturation measurements (rSO2; SenSmart, Nonin, MN, USA) were performed at the tongue. RESULTS: At the tongue, regular pulse-oximetric waveforms with a pulse-oximetric hemoglobin O2-saturation (SpO2) of 88% were recorded, i.e. only slightly lower than the SpO2 reading at the extremities at that time (90%). Lingual NIRS-based rSO2 measurements yielded stable tissue rSO2-values of 76-78%, i.e. values expected also in other adequately perfused and oxygenated (muscle-) tissues. CONCLUSION: Despite the alarming, clinical finding of a grotesquely swollen, rubber-hard tongue and clinical concerns on the adequacy of the tongue perfusion and oxygenation, our measurements of both arterial pulsatility (SpO2) and NIRS-based tissue oxygenation (rSO2) suggested adequate perfusion and oxygenation of the tongue, rendering non-vitality of the tongue, e.g. by lingual venous thrombosis, unlikely. To our knowledge, this is the first clinical report of lingual rSO2 measurement.

First, do no harm: bilateral radial artery occlusion in a COVID-19 patient.

OBJECTIVE: Objective of this case report is to draw attention to a less known thrombotic complication associated with COVID-19, i.e., thrombosis of both radial arteries, with possible (long-term) consequences. THE CASE: In our COVID-19 ICU a 49-year-old male patient was admitted, with past medical history of obesity, smoking and diabetes, but no reported atherosclerotic complications. The patient had been admitted with severe hypoxemia and multiple pulmonary emboli were CT-confirmed. ICU-treatment included mechanical ventilation and therapeutic anticoagulation. Preparing the insertion of a new radial artery catheter for invasive blood pressure measurement and blood sampling, we detected that both radial arteries were non-pulsating and occluded: (a) Sonography showed the typical anatomical localization of both radial and ulnar arteries. However, Doppler-derived flow-signals could only be obtained from the ulnar arteries. (b) To test collateral arterial supply of the hand, a pulse-oximeter was placed on the index finger. Thereafter, the ulnar artery at the wrist was compressed. This compression caused an immediate loss of the finger's pulse-oximetry perfusion signal. The effect was reversible upon release of the ulnar artery. (c) To test for collateral perfusion undetectable by pulse-oximetry, we measured regional oxygen saturation (rSO2) of the thenar muscle by near-infrared spectroscopy (NIRS). Confirming our findings above, ulnar arterial compression demonstrated that thenar rSO2 was dependent on ulnar artery flow. The described development of bilateral radial artery occlusion in a relatively young and therapeutically anticoagulated patient with no history of atherosclerosis was unexpected. CONCLUSIONS: Since COVID-19 patients are at increased risk for arterial occlusion, it appears advisable to meticulously check for adequacy of collateral (hand-) perfusion, avoiding the harm of hand ischemia if interventions (e.g., catheterizations) at the radial or ulnar artery are intended.