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The COVID-19 Pandemic and Perioperative Neuroscience.

“As we look to the opportunities and challenges that a new year will bring”—so began my Editorial in the January 2020 issue of JNA.1 Little did I know when I wrote these words exactly how great those challenges would be. The COVID-19 pandemic has impacted personal and professional lives across the globe. Neuroanesthesiologists and neurointensivists have been on the front line of the pandemic response, and this issue of the Journal includes a series of Short Reports outlining the experiences of colleagues as they rose to the challenges posed by the pandemic. The first report describes changes in neuroanesthesia practice in the largest neurosurgery center in China very early in the pandemic.2 The development of a 3-level system of COVID-19 risk, and separation of COVID and non-COVID cases to minimize nosocomial transmission, allowed some neurosurgical and neurointerventional services to continue while maintaining a safe environment for health care worker and patients. Similar arrangements are now integrated into most health care systems worldwide, but it is these early lessons from China and elsewhere that allowed others to be better prepared as the first wave of the pandemic spread across the globe. As health care systems struggled to cope with the surge in COVID-19 cases, nonessential activity, including elective neurosurgery, was cancelled, and diverse clinical areas repurposed and staffed to manage critically ill COVID-19 patients.3 In a retrospective process analysis, Rath et al4 report their experience of repurposing a dedicated neurocritical care unit as part of the UK pandemic response plan. By increasing surge capacity, reducing intensive care unit demand, and redeploying and retraining staff, this unit was able to maintain sufficient critical care capacity to manage all urgent neuroscience cases while load-sharing the management of (non-neurological) critically ill COVID-19 patients as general critical care networks became overwhelmed. Resources, equipment, and real estate availability were obvious challenges, but the authors report that it was the adaptability and resilience of staff that was crucial to their successful pandemic response. Long working hours (sometimes in unfamiliar environments), access to and use of personal protective equipment, and the need to rapidly review and implement continually evolving guidelines all contribute to the high levels of stress and fear reported by health care workers during the pandemic.5 Staff wellness, both physical and psychological wellness, is crucial to a successful pandemic response, and tailored interventions to enhance resilience and support staff are essential components of a response plan.6 Although most aspects of health care have been impacted by the COVID-19 pandemic, the management of acute ischemic stroke patients undergoing endovascular treatment (EVT) presents particular challenges given the time imperative for intervention and risks associated with aerosol transmission of coronavirus during EVT.7 Chowdhury et al8 report clinical practices and associated safety issues for health care teams in 114 tertiary stroke centers in 25 countries. In this crosssectional survey, all responding centers had revised local acute stroke protocols in response to the COVID-19 pandemic, although half reported no changes to anesthetic management during EVT. Unsurprisingly, additional measures to minimize risk to health care teams resulted in delays at various stages of treatment in many centers; any adverse outcome impacts of these delays were not quantified. Substantial practice variability was reported in several areas, including testing for COVID-19 and use of personal protective equipment by health care teams during EVT. These findings are concerning given the potential risks to health care providers associated with the transfer of acute ischemic stroke patients between several hospital locations over a short period of time, limited or no opportunity for COVID-19 testing before EVT, and the potential for aerosolization and higher transmission rates if urgent intubation is required during EVT.7 In addition to impacts on health care, the COVID-19 pandemic has adversely affected clinical training. Cancellation of elective neurosurgery, redeployment of trainees, cessation of in-person learning and cancellation of examinations have resulted in unprecedented disruption to neuroanesthesiology training programs. In an email-based survey, Rajan et al9 found that neuroanesthesiology fellowship training program directors had responded quickly to the changed environment by the introduction of innovative approaches to training, including a switch to web-based education and initiatives to support trainee well-being. Residents and fellows were positive about online teaching, although they did not believe that this was an adequate substitute for “hands-on” training. While it seems certain that the apprentice-based approach to neuroanesthesiology training, with in-person tuition in the operating room, will remain an essential component of training, experiences during the pandemic suggest that distance-based learning options, including high fidelity telesimulation, may be effective and flexible supplements to traditional learning methods.10 Just as the world will be irreversibly changed by the pandemic, many aspects of health care will also be different in the postpandemic era. The next challenge for neuroanesthesiologists and neurointensivists will be to incorporate lessons learned during the pandemic to improve clinical care and outcomes for patients, and to sustain high-quality education for neuroanesthesiology training in the new normal.