key: cord-1009983-69pux7og
authors: Athanassoglou, Vassilis; Zhong, Haoyan; Poeran, Jashvant; Liu, Jiabin; Cozowicz, Crispiana; Illescas, Alex; Memtsoudis, Stavros G.
title: Anaesthesia practice in the first wave of the COVID-19 outbreak in the United States: a population-based cohort study
date: 2022-04-15
journal: Br J Anaesth
DOI: 10.1016/j.bja.2022.04.003
sha: c3194c304ce3863e38ec1da5b3b6b0759e69b59b
doc_id: 1009983
cord_uid: 69pux7og

nan

anaesthesia Editor -The COVID-19 pandemic has profoundly impacted daily clinical practice. Numerous clinical practice recommendations were published during the first wave focusing on guidance to maximise patient and healthcare worker safety. [1] [2] [3] However, many of these recommendations were not backed by rigorous evidence, 4-6a sometimes leading to confusion. For example, some experts suggested that use of tracheal intubation was preferable to supraglottic airway devices to create a closed system and minimise aerosolisation and environmental contamination, while others cautioned that airway instrumentation itself was aerosol generating. [7] [8] It is unclear to what extent these, at times contradicting, recommendations impacted anaesthesia practice in the early stage of the pandemic. We therefore utilised a large national dataset to describe potential changes in practice in the USA, with a specific focus on anaesthesia practice in orthopaedic surgery. We deliberately set out to first pursue descriptive data in order to understand potential changes in patients served and anaesthesia practice. We hypothesised that in elective orthopaedic surgery during the first wave of the COVID-19 outbreak, use of anaesthetic techniques would differ compared to the year prior. Even though it generally takes years for practice changes to occur, we believe that the extraordinary nature of the pandemic may have warranted an exception to this general wisdom.

After Institutional Review Board approval (IRB#2016-436), we retrospectively analysed patients captured in the Premier Healthcare database (Premier Healthcare Solutions, Inc., Charlotte, NC, USA) who underwent elective total knee or hip arthroplasty (TKA/THA) in the USA. We selected patients admitted during the initial surge of COVID-19 from 1

March to 30 June 2020, as these were the most recent data available to us at the time of J o u r n a l P r e -p r o o f analysis. In order to compare this cohort to controls, we selected patients admitted during the same time frame the year prior. TKA was defined based on International Classification of Diseases 9th Revision (ICD-9) procedure code 81.54 or 10th Revision (ICD-10) procedure codes 0SRC0xx, 0SRD0xx. THA was defined based on ICD-9 procedures codes 81.51 or ICD-10 procedure codes 0SR90xx, 0SRB0xx. Exclusion criteria were: unknown sex (n=3), unknown discharge status (n=15), and outpatient procedures (n=7918).

The main outcome of interest was type of anaesthesia on the day of surgery, which was identified from billing codes as described 9 ; this was as by general anaesthesia only, regional anaesthesia + general anaesthesia, or regional anaesthesia only. In addition to anaesthesia type, anaesthesia practice was also characterized by perioperative use of nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 (COX-2) inhibitors, and benzodiazepines. We compared anaesthesia practice before and during the first wave of the Table 1 ).

There was no clinically meaningful observable change of overall practice of anaesthesia between 2019 and 2020 in either the TKA or the THA cohort. Moreover, there were no meaningful changes in terms of perioperative NSAID and COX-2 inhibitor use;

benzodiazepine use was slightly lower during the COVID-19 period among TKA patients (from 77.7% to 72.3%; standardised difference 0.12) ( Table 1) . Despite a significant decrease in overall volume, characteristics of patients admitted for elective orthopaedic surgery during the COVID-19 pandemic were similar to the year prior.

These observations raise various questions, including those related to the risks of performing general anaesthesia and airway instrumentation rather than avoiding it during the COVID-19 pandemic. This is especially interesting as at the time practitioners did not know much about the pathogen, its mode of transmission, and the morbidities and mortality associated with infection. There were also no meaningful differences in use of simple J o u r n a l P r e -p r o o f analgesics during the pandemic. While the number of patients undergoing TKA or THA surgery dropped by almost 70%, the characteristics of patients undergoing either procedure was stable during the two years, signifying that for those orthopaedists who continued to operate in the USA, patient selection did not change. However, perioperative care might have changed. Zhong and co-workers 11 found a higher readmission risk during the pandemic, and suggested that patients were discharged home earlier to mitigate the risk of COVID-19 transmission during institutionalised care, possibly compromising rehabilitation. In this context, it is concerning that we saw reduced use of regional anaesthetic techniques as they might be associated with poorer postoperative mobilisation and rehabilitation. Further, higher opioid use in the setting of no regional anaesthesia might be associated with increased airway compromise necessitating emergent airway management.

Our analysis is limited by various factors. First, potential confounding in terms of a change in patient characteristics in 2020 (compared to 2019), although we did not observe meaningful group differences that could have explained differences in anaesthesia practice.

Second, we did not have access to data beyond those reported here and therefore cannot make any further comparisons to observe whether a longer term change of practice occurred. Third, we studied select aspects of anaesthetic practice. There may have been changes in anaesthetic practice that were not covered by the scope of this study. Fourth, we used a database covering a broad spectrum of hospitals; some inter-institutional differences in reporting and coding for anaesthetic practice cannot be excluded with certainty.

In conclusion, despite the recommendations from worldwide airway experts to avoid airway instrumentation during the period of the COVID-19 pandemic, our data showed that anaesthetic practice in the USA did not change with regards to the conduct of general and regional anaesthesia. In conjunction with previous studies showing worse patient outcomes, this questions the decision to favour general over regional anaesthesia. Further research is needed to investigate if these recommendations had lasting consequences beyond the initial pandemic period. J o u r n a l P r e -p r o o f 

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