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

Platypnea-orthodeoxia: Patent foramen ovale unmasked by pulmonary emboli

This report describes an 84 year old woman who presented with breathlessness from platypnea-orthodeoxia. This was due to a distortion of a patent foramen ovale by lower thoracic vertebral fractures which allowed a right-to-left intracardiac shunt. The right-to-left shunt was, in this case, triggered by small bilateral pulmonary emboli. Platypnea-orthodeoxia is rare, complex, and underdiagnosed. The pathogenesis requires an anatomical substrate for a shunt and a functional component that triggers reversal of the flow across it. Recognition is critical and may prevent provision of sedation, invasive ventilatory support, and vasopressor; all of which actually exacerbate right-to-left extrapulmonary shunt

Strategies to prevent ventilator-associated lung injury in critically Ill patients

Life-saving mechanical ventilation (MV) induces or exacerbates a range of pulmonary pathologies, collectively known as ventilator-induced lung injury if there is evidence of direct causation (i.e., in the research laboratory). However, in clinical practice, the term ventilator-associated lung injury (VALI) is more appropriate. While several factors are involved, the main drivers of the pathogenesis are regional overdistention and clinical atelectasis. This understanding has led to search for strategies to attenuate VALI and improve survival. The current approaches focus on reduction of lung stress and strain by limitation of alveolar–plateau pressure and tidal volume. Recent data suggest that control of driving pressure (plateau pressure–positive end-expiratory pressure) and mechanical power applied during ventilation may also be beneficial. More exciting are the various new techniques for MV (e.g., airway pressure release ventilation and neurally adjusted ventilatory assist), emerging alternative modalities for gas exchange (e.g., extracorporeal membrane oxygenation), and novel biological therapies (e.g., anti-inflammatory stem cells) that promise to revolutionize the management of respiratory failure and relegate VALI to the ash heap of history. However, there are currently insufficient data to recommend their use in routine clinical practice