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

Management of acute pancreatitis in the critically ill

The major causes of morbidity and mortality in acute pancreatitis are organ dysfunction and infection of necrotic tissue. Management should aim to prevent, or to diagnose and treat, the complications of pancreatic inflammation, and any predisposing factors to avoid recurrence. Medical management is essentially supportive with oxygen, intravenous fluids, analgesia, enteral or parenteral nutrition, and correction of metabolic abnormalities. Patients with severe acute pancreatitis are unlikely to resume prompt oral intake so nutritional support is also required. Post-pyloric feeding is not required if nasogastric feeding is tolerated. However, enteral nutrition, whether oral, gastric, or post-pyloric, can cause pain, recurrence of pancreatitis or an increase in fluid collections, so parenteral nutrition may be necessary. The necrotic pancreas becomes infected in a third of patients with severe acute pancreatitis. Treatment of infection includes systemic antimicrobials, enteral nutrition, percutaneous aspiration, and necrosectomy. However, compared with open necrosectomy, a minimally invasive step-up approach consisting of percutaneous drainage followed, if necessary, by open necrosectomy, reduces morbidity and mortality. The aetiology of the pancreatitis must also be treated to prevent recurrence and the complications of pancreatic failure. Gallstones are the most common cause of pancreatitis that requires specific treatment. Endoscopic or surgical removal of stones may reduce the severity of pancreatitis. Patients should also have cholecystectomy after recovery from gallstone pancreatitis. Effective management of acute pancreatitis requires multidisciplinary engagement. The mainstay of management involves supportive prevention and treatment of complications, infection, and organ failure to avoid or delay surgery.</p

Risk stratification to guide management in cardiogenic shock due to acute myocardial infarction. An illustrative case series and review of the literature

In patients who sustain an Acute Myocardial Infarction (AMI), Cardiogenic Shock (CS) is the most common cause of inpatient death. Despite significant advances in medical and surgical management, mortality rates approaching 80% have been described in some cohorts. However, the severity of CS and outcomes after AMI vary widely. Management requires a rapid, well-organised response and accurate risk stratification must guide complex decisions on ceilings of therapy in the acute setting. Whilst validated risk scores (e.g. the IABP-SHOCK II score and the CardShock score) are available, as highlighted in the present illustrative case series, their use must be guided by clinical judgement.in the setting of CS due to AMI, it is the author’s opinion that, the IABP-SHOCK II score should be used for risk stratification after PCI. It may also be appropriate to use the IABP-SHOCK II score in conjunction with the operator’s opinion on the likelihood of restoration of TIMI 3 flow if the coronary anatomy and targets for PCI are known. However, in patients with AMI who develop CS prior to angiography the author recommends use of the CardShock score for risk stratification rather than consider the pre-PCI IABP-SHOCK II score. However, more data are required to validate this approach.</p

Eating, drinking, smoking and cancer prevention:A focus on acetaldehyde

At room temperature acetaldehyde (ethanal) is a flammable, colourless gas with a fruity odour. In 2009, the International Agency for Research on Cancer of the world health organisation classified acetaldehyde as a Class 1 toxin (human carcinogen) [2]. Acetaldehyde is an aldehyde that is highly reactive and toxic, causing damage at the cellular and genomic levels. The main source of the exposure of the general public to this toxin is through consumption of alcohol. In vivo, ethanol is predominantly metabolised to acetaldehyde. However, there are many natural and manufactured sources of acetaldehyde and even those who are teetotal are exposed to this carcinogen. The development of cancer is a multifactorial process in which acetaldehyde has an important role. However, exposure to acetaldehyde and therefore risk of the associated cancers is affected by a complex matrix of behavioural, dietary and genetic factors. Despite the widespread prevalence of acetaldehyde, exposure to the toxin can be limited. For example, potential public health measures to reduce acetaldehyde exposure include reduction of smoking and alcohol consumption. For such measures to be effective it is important to concurrently sensitise the general public to the potential adverse effects of acetaldehyde.</p