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

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

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

Bispectral index value correlates with Glasgow Coma Scale in traumatic brain injury patients

Tjokorda Gde Agung Senapathi, Made Wiryana, I Gusti Ngurah Mahaalit Aribawa, Christopher Ryalino Department of Anesthesiology and Intensive Care, Udayana University, Sanglah General Hospital, Denpasar, Bali, Indonesia Background: Accuracy of consciousness level assessment is very important. It may determine and influence further clinical decisions, thus influences patients’ outcomes. The widest method in determining the level of awareness is the Glasgow Coma Scale (GCS). Despite its common use, GCS scores obtained by one clinician may differ from others depending on their interpretations and past experience. One of the tools used to assess the level of consciousness objectively is bispectral index (BIS). The aim of this study was to identify the correlation between BIS and GCS score in patients with traumatic brain injury. Patients and Methods: A total of 78 patients who were admitted to emergency room for traumatic brain injury were included in this study. One observer evaluated the GCS of all patients to minimize subjectivity. Another investigator then obtained the BIS values for each patient. Spearman’s rank correlation coefficient was used to determine whether GCS correlated with BIS value. Results: In 78 patients, the BIS was found to be significantly correlated with GCS (r=0.744, p<0.01). The BIS values increased with an increasing GCS. Mean BIS values of mild, moderate, and severe head injury were 88.1±5.6, 72.1±11.1, and 60.4±11.7, respectively. Conclusion: In this study, a significant correlation existed between GCS and BIS. This finding suggests that BIS may be used for assessing GCS in patients with traumatic brain injury. However, the scatters of BIS values for any GCS level may limit the BIS in predicting GCS accurately. Keywords: decreased consciousness, head injury, BIS monitor, consciousness level, anesthesia depth, prediction, associatio

Modified Revised Trauma–Marshall score as a proposed tool in predicting the outcome of moderate and severe traumatic brain injury

Tjokorda Gde Bagus Mahadewa,1 Nyoman Golden,1 Anne Saputra,1 Christopher Ryalino2 1Department of Surgery, Division of Neurosurgery, Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia; 2Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia Background: Traumatic brain injury (TBI) is a common healthcare problem related to disability. An easy-to-use trauma scoring system informs physicians about the severity of trauma and helps to decide the course of management. The purpose of this study is to use the combination of both physiological and anatomical assessment tools that predict the outcome and develop a new modified prognostic scoring system in TBIs. Patients and methods: A total of 181 subjects admitted to the emergency department (ED) of Sanglah General Hospital were documented for both Marshall CT scan classification score (MCTC) and Revised Trauma Score (RTS) upon admission. Glasgow Outcome Scale (GOS) was then documented at six months after brain injury. A new Modified Revised Trauma–Marshall score (m-RTS) was developed using statistical analytic methods. Results: The total sample enrolled for this study was 181 patients. The mean RTS upon admission was 10.2±1.2. Of the 181 subjects, 110 (60.8%) were found to have favorable GOS (GOS score >3). Best Youden’s index results were obtained with any of the RTS of ≤10 with area under receiver operating characteristic (ROC) curve of 0.2542 and with risk ratio of 2.9 (95% CI=1.98−4.28; P=0.001); and Marshall score ≤2 with area under ROC curve of 0.2249 with risk ratio of 3.9 (95% CI=2.52−5.89; P=0.001). The RTS–Marshall combination has higher sensitivity with risk ratio of 4.5 (CI 95%=2.55−8.0; P=0.001) for screening tools of unfavorable outcome. The Pearson’s correlation between RTS and Marshall classification is 0.464 (P<0.001). Conclusion: Combination of physiological and anatomical score improves the prognostic of outcome in moderate and severe TBI patients, formulated in this accurate, simple, applicable and reliable m-RTS prognostic score model. Keywords: head injury, CT scan, revised score, prognostic scor

The impact of prostate-transurethral resection on erectile dysfunction in benign prostatic hyperplasia

Anak Agung Gde Oka,1 Gede Wirya Kusuma Duarsa,1 Putu Astri Novianti,2 Tjokorda Gde Bagus Mahadewa,2 Christopher Ryalino31Departments of Urology, Faculty of Medicine, Udayana University, Denpasar, Indonesia; 2Surgery, Faculty of Medicine, Udayana University, Denpasar, Indonesia; 3Anesthesiology, Faculty of Medicine, Udayana University, Denpasar, IndonesiaBackground: Erectile dysfunction (ED) after a prostate-transurethral resection (P-TUR) is one of the problems in the treatment of benign prostatic hyperplasia (BPH) that may affect the quality of life in middle-aged and older men. The aim of this study was to investigate the impact of P-TUR on ED in BPH patients.Methods: This study was conducted on 83 patients suffering from BPH that underwent a P-TUR. Clinically, testosterone levels, prostatic-specific antigen (PSA) levels, and prostate volume were measured before the P-TUR. Erectile function was measured prior to the P-TUR, as well as at 1 and 3 months after the P-TUR using the International Index of Erectile Function (IIEF). Suitability test of the model was done in a structural equation. Data were analyzed using the chi-square (χ2,) test by Analysis of Moment Structure (AMOS) software version 21.Results: The effects of PSA to IIEF before, 1 month after, and 3 months after P-TUR were 0.116, 0.084, and 0.097, respectively. The effects of body mass index to IIEF before, 1 month after, and 3 months after P-TUR were 0.180, 0.066, and 0.164, respectively. The effects of prostate volume to IIEF before, 1 month after, and 3 months after P-TUR were 0.049, 0.004, and 0.011, respectively. The effects of testosterone to IIEF before, 1 month after, and 3 months after P-TUR were –0.029, –0.453, and –0.415, respectively. The effects of age to IIEF before, 1 month after, and 3 months after P-TUR were –0.444, 0.921, and 0.911, respectively.Conclusion: There was a significant improvement of erectile function in patients that underwent P-TUR who previously had preoperative ED, especially 3 months after the surgery.Keywords: age, prostate volume, testosterone, PSA, IIEF, improvemen

Extended Glasgow Outcome Scale correlates with bispectral index in traumatic brain injury patients who underwent craniotomy

Tjokorda Gde Bagus Mahadewa,1 Tjokorda Gde Agung Senapathi,2 Made Wiryana,2 I Gusti Ngurah Mahaalit Aribawa,2 Ketut Yudi Arparitna,2 Christopher Ryalino2 1Department of Neurosurgery, Sanglah General Hospital, Denpasar, Indonesia; 2Department of Anesthesiology, Intensive Care, and Pain Management, Sanglah General Hospital, Denpasar, Indonesia Background: Assessing consciousness in traumatic brain injury is important because it also determines the treatment option, which will influence patients’ outcome. A tool used to objectively assess consciousness level is the bispectral index (BIS) monitor, which was originally designed to monitor the depth of anesthesia. Glasgow Outcome Scale-Extended (GOS-E) provides a measuring tool to assess traumatic brain injury (TBI) outcome. The goal of this study was to assess the correlation between GOS-E scores with BIS values in patients with TBI who underwent craniotomy. Patients and methods: A total of 68 patients admitted to the emergency department with decreased consciousness due to TBI who underwent craniotomy were included in the study. BIS value was measured upon admission, then GOS-E score was determined 6 months after the incident took place. Spearman’s correlation coefficient was used to assess the correlation between GOS-E score and BIS value. Results: In 68 patients, the GOS-E score was found to have a strong correlation (r =0.921, p<0.01) with BIS values. From this study, the formula to estimate GOS-E score based on BIS value upon admission stands as: GOS-E =0.19 (BIS) – 8.31. Conclusion: This study found that there is a strong correlation between GOS-E score and BIS value. These findings suggest that BIS scores upon admission may be used to predict the outcomes in patients with TBI. However, the wide distribution of BIS values for each GOS-E score may limit the use of BIS scores in accurately predicting GOS-E scores. Keywords: decreased consciousness, head injury, outcome, predictio

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

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 coprioritized 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