key: cord-0826116-3qe344sb authors: Schultz, Marcus J.; Roca, Oriol; Shrestha, Gentle S. title: Global lessons learned from COVID-19 mass casualty incidents date: 2021-11-15 journal: Br J Anaesth DOI: 10.1016/j.bja.2021.10.040 sha: a5fd8962129db211426352d494ee134ef32eaa67 doc_id: 826116 cord_uid: 3qe344sb With healthcare systems rapidly becoming overwhelmed and occupied by patients during a pandemic, effective and safe care for patients is easily compromised. During the course of the current pandemic, numerous treatment guidelines have been developed and published that have improved care for patients with COVID-19. Certain lessons have only been learned during the course of the outbreak, from which we can learn for future pandemics. This editorial aims to raise awareness about the importance of timely stockpiling of sufficient amounts of personal protection equipment and medications, adequate oxygen supplies, uninterrupted electricity, and fair locally adapted triage strategies. Healthcare systems worldwide are under pressure from a pandemic of a 'new' disease by a 'new' respiratory pathogen caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) 1 1a . It seems that there is no prospect of a near-term end as we are startled by new waves of patients in different parts of the world with each new month 2 . The disaster continuous to unfold in places where vaccinations are scarce, but also in places with higher vaccination rates where it mainly affects the unvaccinated or those who are unable to develop sufficient antibodies in response to vaccination. Every day, countless people around the world are admitted to hospitals or seek medical support, depending on how healthcare is organized locally. As in any pandemic we are in intense need of hospital beds, healthcare personnel, protective equipment, and medicines. But what makes this current pandemic 'special' is an increased, at times extreme, need for oxygen, and also, to a lesser extent, an increased need for ventilators. In most individuals infection with SARS-CoV-2 will pass unnoticed, and in those with symptoms COVID-19 usually presents as a common cold or flu. However, some individuals develop pulmonary infiltrates that alone or in combination with venous thromboembolism lead to acute (hypoxaemic) respiratory failure 1 . And in some of these patients, other organs are effected as well. COVID-19 is thus primarily a respiratory disease, and in its severe forms may end in multiorgan failure. In the earliest stages of the COVID-19 pandemic, the unknown nature of the 'new' respiratory pathogen meant that it posed a terrible threat to health professionals. We quickly realized that we could protect ourselves sufficiently. On a patient level, the focus shifted to testing nonspecific and specific treatments for the new disease. International partnership quickly arose, collaborating on the design and analysis of large classic clinical trials as well as platform trials combining initially separated clinical trials to obtain answers to clinical questions more rapidly than ever before, providing evidence that certain strategies like early administration of steroids 5 and other anti-inflammatory drugs 6 , as well as timely anticoagulant therapy, 7-9 are effective, while other treatments like antivirals, antimalarials 10 , and antiparasitic therapies 11 are not. Unfortunately we also faced shortages in these therapies, including 'affordable' treatments like steroids and anticoagulant therapy, especially in low-and middle-income countries 12 . Even highincome counties experienced medication shortages, for example, in the Netherlands, in October 2021 there was a shortage of tocilizumab, with a new national wave lurking. The pandemic was initially felt as major threat for critical care services, which in part is true since the number of expensive intensive care unit beds has always been limited, even in rich countries, and these units can easily be overwhelmed in a respiratory disease pandemic. In the first waves worldwide this had a major impact on normal processes, as many planned admissions had to be postponed, causing indirect harm to other patients that could not be admitted to the overcrowded intensive care J o u r n a l P r e -p r o o f units. 12a More important, it created a shortage of ventilators 13 , as many hospitals in many countries felt they needed to enlarge their critical care services, in particular ventilatory care, expanding beyond the physical boundaries of existing units, including recovery rooms, or even operation rooms. Then the concerns were that care, especially ventilatory care, could become inappropriate, as many extra nurses and doctors were needed at the bedside of the rapidly growing group of critically ill patients that needed invasive ventilation, with many of them having little or even no experience in invasive ventilation. Interestingly, we learned quickly that many patients may not have needed invasive ventilation after all 13, 14 , and many could be treated with noninvasive supplementary oxygen alone. An individualized approach for ventilatory support other than early intubation and invasive ventilation could be effective and potentially conserve resources. Meanwhile, we rapidly learned that ventilation characteristics in COVID-19 were not so different from those in patients with acute respiratory failure due to another causes, and that ventilation could be more 'lungprotective' than ever reported, especially with the use of lower tidal volumes 15 . The real challenge was the large number of patients needing oxygen therapy, even without the need for invasive ventilatory support, including continuous positive airway pressure or noninvasive ventilation. Indeed, only ~14% of patients with COVID-19 develop severe disease and only ~5% become so critically ill that they need admission to an intensive care unit for acute respiratory failure and other forms of organ dysfunction 16, 17 . Thus, the challenge turned from a 'fight for ventilators' into a 'cry for oxygen' 18 . within an optimal saturation range by decreasing the time spent above a safe target range 21 . Another important issue is that 'stand-alone' HFNO devices often lack batteries, meaning that in case of an electricity outage, the therapy is abruptly interrupted with serious consequences for the patient. It took time to understand these problems, and to take appropriate actions. In resource-limited settings, panic among the public led to hoarding of oxygen cylinders, 22 which was unanticipated. Oxygen plants were, and still are, limited to a few large healthcare centres, with some plants non-functional or not repaired. Also, piped oxygen systems are not usually maintained, leaving this hospital system with leakage from the pipelines and flowmeters, inadequate oxygen pressure, etc. Together with poor local healthcare policy, this magnified the oxygen shortages. Better anticipation, establishment of more oxygen plants and regular maintenance, together with a better J o u r n a l P r e -p r o o f healthcare system focused on basic healthcare needs could have mitigated these problems. In places hit hard by oxygen scarcity, the value of rational use of oxygen could not be overemphasized. These strategies range from oxygen sparing measures like forgoing the use of high oxygenation targets, avoiding oxygen wastage, use of oxygen checklists, and awake prone positioning 23, 24 . In COVID-19 patients treated with HFNO, awake prone positioning not only decreases the need for tracheal intubation but has an oxygen sparring effect 25 . For instance, if the fraction of inspired oxygen can be lowered from 80% to 60% with proning, at a flow rate of 60 L min -1 the total amount of oxygen needed drops from ~3000 to ~2000 L h -1 , a reduction of a third! Some However, when resources are insufficient, they should be allocated with the maximum equity while trying to preserve as many lives as possible. 26a What were the most important global lessons learned from COVID-19-related mass casualty incidents? In the places hit worst by the pandemic, the disease was underestimated and preparedness was suboptimal. The focus was on interventions like invasive ventilation, which would potentially benefit only a very limited number of patients with already a poor prognosis, rather than on simple interventions like consistent availability and appropriate use of medical oxygen by trained healthcare workers, and also sufficient stockpiling of PPE and medications. It is imperative to apply the lessons learnt from this pandemic and at the cost of millions of lives lost to be better prepared for future pandemics. The axiom to 'do less for more, not more for less' is relevant worldwide, facilitated by sufficient stockpiling of PPE and medications, uninterrupted oxygen and electricity supplies, and fair triaging, which are more important than ventilators overall. All authors jointly drafted the editorial and revised it critically for important intellectual content, gave final approval of the version to be submitted, and agreed to be accountable for all aspects of the work.. 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