Anaesthesia for vascular emergencies - a state of the art review.

In this state-of-the-art review, we discuss the presenting symptoms and management strategies for vascular emergencies. Although vascular emergencies are best treated at a vascular surgical centre, patients may present to any emergency department and may require both immediate management and safe transport to a vascular centre. We describe the surgical and anaesthetic considerations for management of aortic dissection, aortic rupture, carotid endarterectomy, acute limb ischaemia and mesenteric ischaemia. Important issues to consider in aortic dissection are extent of the dissection and surgical need for bypasses in addition to endovascular repair. From an anaesthetist's perspective, aortic dissection requires infrastructure for massive transfusion, smooth management should an endovascular procedure require conversion to an open procedure, haemodynamic manipulation during stent deployment and prevention of spinal cord ischaemia. Principles in management of aortic rupture, whether open or endovascular treatment is chosen, include immediate transfer to a vascular care centre; minimising haemodynamic changes to reduce aortic shear stress; permissive hypotension in the pre-operative period; and initiation of massive transfusion protocol. Carotid endarterectomy for carotid stenosis is managed with general or regional techniques, and anaesthetists must be prepared to manage haemodynamic, neurological and airway issues peri-operatively. Acute limb ischaemia is a result of embolism, thrombosis, dissection or trauma, and may be treated with open repair or embolectomy, under either general or local anaesthesia. Due to hypercoagulability, there may be higher numbers of acutely ischaemic limbs among patients with COVID-19, which is important to consider in the current pandemic. Mesenteric ischaemia is a rare vascular emergency, but it is challenging to diagnose and associated with high morbidity and mortality. Several peri-operative issues are common to all vascular emergencies: acute renal injury; management of transfusion; need for heparinisation and reversal; and challenging postoperative care. Finally, the important development of endovascular techniques for repair in many vascular emergencies has improved care, and the availability of transoesophageal echocardiography has improved monitoring as well as aids in surgical placement of endovascular grafts and for post-procedural evaluation.

Confronting a post-pandemic new-normal-threats and opportunities to trust-based relationships in natural resource science and management.

Natural resource governance is inherently complex owing to the socio-ecological systems in which it is embedded. Working arrangements have been fundamentally transformed throughout the COVID-19 pandemic with potential negative impacts on trust-based social networks foundational to resource management and transboundary governance. To inform development of a post-pandemic new-normal in resource management, we examined trust relationships using the Laurentian Great Lakes of North America as a case study. 82.9% (n = 97/117) of Great Lakes fishery managers and scientists surveyed indicated that virtual engagement was effective for maintaining well-established relationships during the pandemic; however, 76.7% (n = 89/116) of respondents indicated in-person engagement to be more effective than virtual engagement for building and maintaining trust. Despite some shortcomings, virtual or remote engagement presents opportunities, such as: (1) care and nurturing of well-established long-term relationships; (2) short-term (1-3 years) trust maintenance; (3) peer-peer or mentor-mentee coordination; (4) supplemental communications; (5) producer-push knowledge dissemination; and, if done thoughtfully, (6) enhancing diversity, equity, and inclusion. Without change, pre-pandemic trust-based relationships foundational to cooperative, multinational, resource management are under threat.

COVID-19 pandemic and its effect on supra-regional extracorporeal shock wave lithotripsy (ESWL) service

Introduction & Objective: The COVID-19 pandemic brought significant challenges to all healthcare systems around the world. We studied its impact on our supra-regional ESWL service. Methods: Patients who received ESWL using our onsite lithotripter (Storz Modulith SLX-F2) during the initial National Lockdown (NL) period were compared with those treated over a similar time period in 2019. Patients with renal calculi were excluded for direct comparison as only a small number of patients with renal calculi were treated during NL. As the supraregional centre, we continued to provide acute treatment during NL albeit with restricted access due to staff redeployment, and within safety restrictions, and continued to receive patients from other network centres. Results: 25 patients with ureteric calculi treated in 2019 were compared with 23 patients treated during NL. The mean ages were 56.6 VS 50.0 (2019 VS NL). The mean time to treat were 20.9 VS 19.4 days (2019 VS NL). Two patients' 2nd treatment got delayed during NL. Treatment outcomes are outlined in table 1. The mean residual stone sizes were 4.9mm VS 5.7mm (2019 VS NL). In 2019, complication rate was 16.0% with the commonest being pain (75.0%) when compared to 21.7% during NL (80% pain). Steinstrasse were not seen in either group. One patient treated during NL sustained a moderate peri-renal haematoma managed conservatively. Treatment parameters such as number of shocks delivered and screening time were equivalent between groups. Conclusions: COVID-19 led to pressures on health services and also patients changed their patterns of presentation. Restricted access to the operating theatre made use of non-invasive treatments an essential part of patient management during the lockdown period. We show equivalent outcomes to normal practicedespite treating larger and potentially more challenging stones, with few complications and while minimising COVID- 19-related risks to the patient. (Table Presented).