Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Difficult airway management in adults: Insights from an observational cohort study on the use of videolaryngoscopy and fiberoptic bronchoscopy in a direct laryngoscopy-based practice

Abstract Background Videolaryngoscopy has significantly improved the management of unanticipated difficult airways and replaced other intubation techniques. The goal of this study was to identify the indications for using videolaryngoscopy and fiberoptic bronchoscopy for adult patients, where direct laryngoscopy is the standard intubation technique. Methods Over a one-year period from January to December 2018, anesthesiologists were surveyed on their reasons for using a videolaryngoscope or fiberoptic bronchoscope for tracheal intubations. Additionally, retrospective data on all direct laryngoscopy intubations were collected for the same period from the anesthesia information management system. Results Out of 6251 tracheal intubations with direct laryngoscopy and 502 with videolaryngoscopy or fiberoptic bronchoscopy, data from 450 (89.6%) cases were collected. We excluded 46 cases where videolaryngoscopy and fiberoptic bronchoscopy were used for non-airway management reasons, resulting in 404 cases for analysis. Videolaryngoscopy was initially used in 356 (88.1%) patients. The primary reasons for using videolaryngoscopy or fiberoptic bronchoscopy were anticipated difficult intubation (218, 54.0%) and cervical pathology (109, 27.0%). Among the 42 cases of unanticipated failed direct laryngoscopy, videolaryngoscopy was used in 41 cases and fiberoptic bronchoscopy in 1 case. The overall rate of unanticipated failed direct laryngoscopy was 0.7%. Conclusions The routine use of videolaryngoscopy and fiberoptic bronchoscopy for anticipated difficult tracheal intubations led to a very low incidence of unanticipated failed tracheal intubations with direct laryngoscopy. Therefore, routinely using more expensive videolaryngoscopes for all intubations would prevent only very small numbers of unanticipated failed direct laryngoscopic intubations and is not financially justified

The correlation between high-sensitivity troponin-T and cell-free cardiac DNA in the blood of patients undergoing noncardiac, predominantly vascular surgery

Objective To present a novel method that uses an epigenetic fingerprint to measure changes in plasma concentrations of cardiac-specific cell-free DNA (CS-cfDNA) as a marker of myocardial cell death. Methods This prospective, analytic, observational comparative study included patients with heart disease or multiple risk factors for heart disease undergoing major noncardiac, mostly vascular surgery, requiring an arterial-line, and at least 24 h hospitalization in the post anaesthesia care unit or critical care unit after surgery. Blood samples were collected at least four times per patient to measure troponin-T (via high-sensitivity troponin-T test) and CS-cfDNA pre- and postoperatively. Results A total of 117 patients were included (group 1, 77 patients [66%] with low preoperative and postoperative troponin-T; group 2, 18 patients [15%] with low preoperative but increased postoperative troponin-T; group 3, 16 patients [14%] with high troponin-T both preoperatively and postoperatively; and group 4, six patients [5%] with elevated preoperative troponin-T that decreased postoperatively). The increase in CS-cfDNA after surgery was statistically significant only in group 2, which correlated with an increase in troponin-T in the same group. Conclusions CS-cfDNA increased early postoperatively, particularly in patients with silent postoperative troponin elevation, and was correlated with an increase in troponin-T. These results may suggest that, in the subgroup of patients with postoperative elevated troponin, cardiomyocyte death indeed occurred