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

Intra-Aortic Balloon Counterpulsation in Acute Myocardial Infarction Complicated by Cardiogenic Shock

Acute myocardial infarction complicated by cardiogenic shock is one of the main reasons of death in severely ill patients. One of the main indications for intra-aortic balloon counterpulsation is acute myocardial infarction complicated by cardiogenic shock. Aortic counterpulsation is associated with the risk of several important complications: bleeding, thrombosis, thrombocytopenia, limb ischemia, and aortic wall damage. The analysis of complications is necessary to better understand the course of myocardial infarction using aortic counterpulsation and to reduce the risk of complications. The aim of the study was to analyze the course of acute myocardial infarction complicated by cardiogenic shock in patients managed by intra-aortic balloon counterpulsation as well as to determine intra-aortic balloon counterpulsation-related complications. Material and Methods. The course of acute myocardial infarction complicated by cardiogenic shock in patients with aortic counterpulsation was analyzed. Patients were recruited from the Cardiology Intensive Care Unit, Department of Cardiology, Lithuanian University of Health Sciences, during the period of 2004–2010. The study comprised 73 patients: 30 women (41.1%) and 43 men (58.9%). Results. Atrial fibrillation and asystolia were the most common cardiac complications during counterpulsation. Atrioventricular block was the predominant disorder of cardiac conduction system; acute renal failure was the most common noncardiac complication. Complications such as major bleeding, infection, aortic wall damage, or amputations were not documented in our study. Successful percutaneous coronary intervention was associated with fewer complications and reduced mortality rate. Conclusions. Aortic counterpulsation may be successfully employed providing significant hemodynamic support with rare major complications in a high-risk patient population. A unique finding of this study is a high rate of successful applications of aortic counterpulsation

Detection and evaluation of ventricular repolarization alternans: An approach to combined ECG, thoracic impedance, and beat-to-beat heart rate variability analysis

Background and objective: Beat-to-beat alteration in ventricles repolarization reflected by alternans of amplitude and/or shape of ECG S-T,T segment (TWA) is known as phenomena related with risk of severe arrhythmias leading to sudden cardiac death. Technical difficulties have caused limited its usage in clinical diagnostics. Possibilities to register and analyze multimodal signals reflecting heart activity inspired search for new technical solutions. First objective of this study was to test whether thoracic impedance signal and beat-to-beat heart rate reflect repolarization alternans detected as TWA. The second objective was revelation of multimodal signal features more comprehensively representing the phenomena and increasing its prognostic usefulness. Materials and methods: ECG, and thoracic impedance signal recordings made during 24 h follow-up of the patients hospitalized in acute phase of myocardial infarction were used for investigation. Signal morphology variations reflecting estimates were obtained by the principal component analysis-based method. Clinical outcomes of patients (survival and/or rehospitalization in 6 and 12 months) were compared to repolarization alternans and heart rate variability estimates. Results: Repolarization alternans detected as TWA was also reflected in estimates of thoracic impedance signal shape and variation in beat-to-beat heart rate. All these parameters showed correlation with clinical outcomes of patients. The strongest significant correlation showed magnitude of alternans in estimates of thoracic impedance signal shape. Conclusions: The features of ECG, thoracic impedance signal and beat-to-beat variability of heart rate, give comprehensive estimates of repolarization alternans, which correlate, with clinical outcomes of the patients and we recommend using them to improve diagnostic reliability