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

A surgeon in your corner.

The surgical emergencies presented in this article encompass the vast majority of the nontraumatic emergencies seen by a pediatric surgeon but represent only a small proportion of surgical disease in children. Most children seeking outpatient medical care do not need a surgeon, but those who do need one quickly. When one of the processes detailed above is suspected, it is always best to avail oneself of the opinion of a surgeon in a timely manner

Oxygen-induced vasodilation is blunted in pulmonary arterioles from fetal rats with nitrofen-induced congenital diaphragmatic hernia.

BACKGROUND/PURPOSE: Persistent pulmonary hypertension contributes to the high mortality rate associated with congenital diaphragmatic hernia (CDH). Oxygen is an important stimulus for pulmonary vasodilation in the perinatal period. The authors have investigated the responses of isolated pulmonary arterioles from fetal rats with and without CDH to an increase in oxygen tension. METHODS: CDHs were induced in fetal rats by feeding nitrofen to timed-pregnant rats at midgestation. A third-generation pulmonary arteriole was isolated from the right lung at term. Isolated arterioles were pressurized at their optimal distending pressure. Diameter changes in response to an increase in oxygen tension from 25 to 40 mm Hg ( hypoxic conditions) to 90 to 150 mm Hg ( normoxic conditions) were recorded for K(+) preconstricted arterioles from control rats, from rats with nitrofen-induced CDH, and from rats that were nitrofen exposed but did not have a CDH. RESULTS: Normoxic exposure reversed the K(+) preconstriction in control arterioles by 124 +/- 26%. In contrast, arterioles from rats with nitrofen-induced CDH dilated significantly less than controls (20 +/- 15% of the K(+) preconstriction). The responses of arterioles from rats that were nitrofen exposed but did not get a CDH were not different (P \u3e.05) from controls. CONCLUSIONS: Oxygen-induced vasodilation is blunted in pulmonary arterioles from rats with nitrofen-induced CDH. Blunted oxygen-induced vasodilation may contribute to persistent pulmonary hypertension in CDH. J Pediatr Surg 36:593-597

Repetitive deformation and pressure activate small bowel and colonic mucosal tyrosine kinase activity in vivo.

Physical forces like deformation and pressure modulate signaling and phenotype in cultured cells. However, it is more difficult to establish that such phenomena occur in vivo. We studied the effects of 0 to 10 minutes of rhythmic distension with an isotonic electrolyte and polyethylene glycol solution to 30 cm H(2)O pressure on defunctionalized small and large bowel segments in adult male Sprague Dawley rats. Mucosa was harvested at 0, 1, and 10 minutes and assayed for tyrosine kinase activity. Rhythmic distension caused a time-dependent increase in colonic mucosal tyrosine kinase activity, which was statistically significant at 10 minutes (140% +/- 41% increase, n = 5,

Intercostal hernia and spontaneous pneumothorax in a liver transplant recipient: a case report.

Intercostal hernia can occur after blunt trauma and can also complicate thoracotomy. This report describes a 13-year-old liver transplant recipient with chronic asymptomatic intercostal hernia at site of thoracotomy. This hernia became manifest upon development of spontaneous pneumothorax. She presented with pleuritic pain and radiographic evidence of spontaneous pneumothorax. Her history included liver transplantation at age 19 months for tyrosinemia, posttransplant lymphoproliferative disorder at age 7 years with thoracotomy for lung biopsy, and prolonged corticosteroid administration. Examination and computed tomography revealed an intercostal hernia. She underwent repair of hernia, stapled resection of apical blebs, and pleurodesis. Reconstruction of chest wall involved rib fracture and intercostal approximation with nonabsorbable sutures covered by serratus muscle advancement. She is symptom free with intact repair 2 years and 9 months after surgery and is able to participate in vigorous physical activity. This is the first report of an intercostal hernia detected upon development of spontaneous pneumothorax. The hernia occurred at the site of a prior thoracotomy, possibly because of impaired healing from corticosteroid administration. This case suggests that nonabsorbable sutures should be used for intercostal approximation after thoracotomy in patients with impaired wound healing

A 22-year experience in global transport extracorporeal membrane oxygenation.

BACKGROUND/PURPOSE: Transport extracorporeal membrane oxygenation (ECMO) is currently available at 12 centers. We report a 22-year experience from the only facility providing global transport ECMO. Indications for transport ECMO include lack of ECMO services, inability to transport conventionally, inability to wean from cardiopulmonary bypass, extracorporeal cardiopulmonary resuscitation, and need to move a patient on ECMO for specialized services such as organ transplantation. METHODS: Retrospective database review of children undergoing inhouse and transport ECMO from 1985 to 2007. RESULTS: Sixty-eight children underwent transport ECMO. Fifty-six were transported on ECMO into our facility. The remaining 12 were moved between 2 outside locations. Ground vehicles and fixed-wing aircraft were used. Distance transported was 8 to 7500 miles (13-12070 km), mean 1380 miles (2220 km). There were 116 inhouse ECMO runs. No child died during transport. Survival to discharge after transport ECMO was 65% (44/68) and, for inhouse ECMO, was 70% (81/116). CONCLUSIONS: Transport ECMO is feasible and effective, with survival rates comparable to inhouse ECMO. We have used transport ECMO to help children at non-ECMO centers with pulmonary failure who have not improved with inhaled nitric oxide and high-frequency ventilation. We have also transported a child after extracorporeal cardiopulmonary resuscitation, which may represent an emerging indication for transport ECMO. Transport ECMO often is the only option for children too unstable for conventional transport or those already on ECMO and requiring a specialized service at another facility, such as organ transplantation