key: cord-0682444-4a7rx35x
authors: Charbonneau, Hélène; Mrozek, Ségolène; Pradere, Benjamin; Cornu, Jean-Nicolas; Misrai, Vincent
title: How to resume elective surgery in light of COVID-19 post-pandemic propofol shortage: An anaesthetist and surgeon indivisible concern
date: 2020-07-09
journal: Anaesth Crit Care Pain Med
DOI: 10.1016/j.accpm.2020.07.007
sha: 8d7c9d76e069e4b2a8d1c7ec055f8aed11dfdb13
doc_id: 682444
cord_uid: 4a7rx35x

nan

J o u r n a l P r e -p r o o f and neuromuscular blocking drugs that are better known for their use in the operating theatre. The supplies of routine intravenous anaesthetic drugs (curare, propofol and midazolam) administered at a far higher rate than usual become at critically low levels in Europe and in the United States in a ripple effect and led to the placement of several medications on the shortage list.

To care for COVID-19 patients, referral healthcare centres have restructured their medical and surgical services. Prioritisation and patient triage were based on disease risk stratification and safetydriven algorithms according to the advice of expert committees. Hence, difficult ethical decisions regarding patients' care have been made according to the available resources. Non-urgent (elective) surgical procedures have been curtailed and postponed preventing nosocomial transmission of COVID-19 and to reallocate health care workers to specialise COVID-19 units. The impacts of these restrictions and prioritisation were not solely limited to "low-priority" or benign diseases but also affected oncological procedures. Therefore, major concerns regarding the potential impact of these measures on patient health and prognosis have been raised. Exact worldwide cancellations in elective surgery are currently unknown but a recent projection estimated that 28 millions of operations would have been cancelled or postponed over the 3-month COVID-19 crisis. [2] 

The shortage of some medications has become a routine international concern despite being underreported and has impacted patient care over the last two decades. Among the drugs most frequently affected by shortages, sterile injectable propofol is of the utmost concern. The reasons for propofol shortage are not only a straightforward consequence of the increasing number of patients requiring mechanical ventilation but the result of multilevel disruptions of the drug supply chain due to lockdown, plants closure and travel restrictions.

As an illustration of the seriousness of the situation, the French government decided on the 27 th of J o u r n a l P r e -p r o o f (Official Journal n° 2020-466 Art 12-4-1) of critical importance for ICUs and general anaesthesia: midazolam, propofol, atracurium, cisatracurium, and rocuronium.

How to reboot elective surgery in this context of propofol shortage: Make loco-regional anaesthesia great again

The recent work of NIHR Global Health Research Unit outlined that if the global healthcare system increased routine surgical volume by 20% post-pandemic, it would take a median 45 weeks to clear the backlog of operations resulting from COVID-19 disruption [2] . From a surgical perspective, beyond prioritisation of patients based on emergency status, we need not only to reconsider the techniques and the approaches that should be used, but to work upstream on the quality of medical care and secure the surgical indications, accounting that more than one-tenth of procedures in yearly overall medical care would not be needed [3] .

The breaking news about anaesthetic drug shortages and the need for regulation should alert anaesthesiologists to reconsider and balance all anaesthetic alternatives. Although epidemiological data are scarce, loco-regional anaesthesia remains globally underutilised despite its benefit [4] .

However, the use of loco-regional anaesthesia should be prioritised in this post-pandemic era to counterweight propofol shortage and delays in surgical interventions, as local anaesthetics were much less prone to be in short supply. Propofol-based total intravenous anaesthesia has been reported to be particularly adjusted to ambulatory surgery setting, but loco-regional anaesthesia should be used as much as possible as an optimised technique [5] . Compared to general anaesthesia, regional anaesthesia limits airway manipulations and could reduce the risk of nosocomial transmission from an asymptomatic undiagnosed COVID-19 patient to the surgical operating theatre team via aerosolised viral particles.

Emerging COVID-19 surgical and anaesthesiology guidelines were undoubtedly necessary but written under pressure with very limited cross considerations between specialties. They are intended to identify patients who absolutely need to be treated within a given time frame, those who can tolerate Page 4 of 4 J o u r n a l P r e -p r o o f delayed treatment, and those whose treatment can be postponed until the situation has normalised. Unfortunately, the situation seems much more complex and further, more in-depth work is needed to modify our approach in the following months, especially with regard to functional diseases [2] . Rather than a binary approach, we likely need to analyse treatment options within the spectrum of their "consumption rate" in terms of perioperative drugs, intraoperative time, workforce, visits to the hospital, exposure/need for COVID-19 testing and settings, home-based, office-based, outpatient or inpatient surgery, regardless of the cost.

Implementing clinical pharmacy services in France: One of the key points to minimise the effect of the shortage of pharmaceutical products in anaesthesia or intensive care units?

Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans: Elective surgery during the SARS-CoV-2 pandemic

Overtreatment in the United States

Epidemiology, trends, and disparities in regional anaesthesia for orthopaedic surgery

Propofol vs. inhalational agents to maintain general anaesthesia in ambulatory and in-patient surgery: a systematic review and meta-analysis