Action guidance for addressing pollution from inhalational anaesthetics

Climate change is a real and accelerating existential danger. Urgent action is required to halt its progression, and everyone can contribute. Pollution mitigation represents an important opportunity for much needed leadership from the health community, addressing a threat that will directly and seriously impact the health and well-being of current and future generations. Inhalational anaesthetics are a significant contributor to healthcare-related greenhouse gas emissions and minimising their climate impact represents a meaningful and achievable intervention. A challenge exists in translating well-established knowledge about inhalational anaesthetic pollution into practical action. CODA is a medical education and health promotion charity that aims to deliver climate action-oriented recommendations, supported by useful resources and success stories. The CODA-hosted platform is designed to maximise engagement of the global healthcare community and draws upon diverse experiences to develop global solutions and accelerate action. The action guidance for addressing pollution from inhalational anaesthetics is the subject of this article. These are practical, evidence-based actions that can be undertaken to reduce the impact of pollution from inhalational anaesthetics, without compromising patient care and include: removal of desflurane from drug formularies; decommissioning central nitrous oxide piping; avoidance of nitrous oxide use; minimising fresh gas flows during anaesthesia; and prioritising total intravenous anaesthesia and regional anaesthesia when clinically safe to do so. Guidance on how to educate, implement, measure and review progress on these mitigation actions is provided, along with means to share successes and contribute to the essential, global transition towards environmentally sustainable anaesthesia.     

Priorities for peri-operative research in Africa

Deaths following surgery are the third largest contributor to deaths globally, and in Africa are twice the global average. There is a need for a peri-operative research agenda to ensure co-ordinated, collaborative research efforts across Africa in order to decrease peri-operative mortality. The objective was to determine the top 10 research priorities for peri-operative research in Africa. A Delphi technique was used to establish consensus on the top research priorities. The top 10 research priorities identified were (1) Develop training standards for peri-operative healthcare providers (surgical, anaesthesia and nursing) in Africa; (2) Develop minimum provision of care standards for peri-operative healthcare providers (surgical, anaesthesia and nursing) in Africa; (3) Early identification and management of mothers at risk from peripartum haemorrhage in the peri-operative period; (4) The role of communication and teamwork between surgical, anaesthetic, nursing and other teams involved in peri-operative care; (5) A facility audit/African World Health Organization situational analysis tool audit to assess emergency and essential surgical care, which includes anaesthetic equipment available and level of training and knowledge of peri-operative healthcare providers (surgeons, anaesthetists and nurses); (6) Establishing evidence-based practice guidelines for peri-operative physicians in Africa; (7) Economic analysis of strategies to finance access to surgery in Africa; (8) Establishment of a minimum dataset surgical registry; (9) A quality improvement programme to improve implementation of the surgical safety checklist; and (10) Peri-operative outcomes associated with emergency surgery. These peri-operative research priorities provide the structure for an intermediate-term research agenda to improve peri-operative outcomes across Africa.     

Addressing the Global Burden of Surgical Disease: Proceedings from the 2nd Annual Symposium at the American College of Surgeons

In the past decade, interest in surgery as a means to improve public health and engage in international service has increased significantly. International organizations, academic institutions, professional associations, and humanitarian aid organizations recognize that disparate access to surgical care affects global health and they have recently joined forces to address access to surgical care. Current initiatives focus on quantitatively defining surgical disparity, prioritizing a surgical agenda, and developing economically sustainable models for health care assistance, training, and delivery. The Global Burden of Surgical Disease Working Group (GBoSD WG) strives to (1) quantitatively define global disparity in surgical care; (2) assess unmet surgical need; (3) identify priorities; (4) develop sustainable models for improved health care delivery; and (5) advocate for a surgical presence within the global public health agenda. This article formally introduces the GBoSD Working Group and papers presented during the 2009 Symposium at the American College of Surgeons in Chicago.     

Privacy,confidentiality, and security of healthcare information

Patients must trust doctors, their decisions and actions; this confidence extends to how we treat patients’ information. Healthcare information should be accurate and securely stored in a readily accessible format. With the digital revolution it is increasingly simple to do this, but it is important to be mindful of just how easy it is to breach confidentiality. There is extensive legislation governing the use of healthcare information and the Caldicott principles describe good practice. All healthcare professions have a moral, ethical, regulatory and legal duty to be familiar with these and ensure adherence in daily practice.     

Self-warming blanket versus forced-air warming blanket during total knee arthroplasty under spinal anaesthesia: A randomised non-inferiority trial

Background

Arthroplasty patients are at high risk of hypothermia. Pre-warming with forced air has been shown to reduce the incidence of intraoperative hypothermia. There is, however, a lack of evidence that pre-warming with a self-warming (SW) blanket can reduce the incidence of perioperative hypothermia. This study aims to evaluate the effectiveness of an SW blanket and a forced-air warming (FAW) blanket peri-operatively. We hypothesised that the SW blanket is inferior to the FAW blanket.

Methods

In total, 150 patients scheduled for primary unilateral total knee arthroplasty under spinal anaesthesia were randomised to this prospective study. Patients were pre-warmed with SW blanket (SW group) or upper-body FAW blanket (FAW group) set to 38°C for 30 min before spinal anaesthesia induction. Active warming was continued with the allocated blanket in the operating room. If core temperature fell below 36°C, all patients were warmed using the FAW blanket set to 43°C. Core and skin temperatures were measured continuously. The primary outcome was core temperature on admission to the recovery room.

Results

Both methods increased mean body temperature during pre-warming. However, intraoperative hypothermia occurred in 61% of patients in the SW group and in 49% in the FAW group. The FAW method set to 43°C could rewarm hypothermic patients. Core temperature did not differ between groups on admission to the recovery room, p = .366 (CI: −0.18–0.06).

Conclusions

Statistically, the SW blanket was non-inferior to the FAW method. Yet, hypothermia was more frequent in the SW group, requiring rescue warming as we strictly held to the NICE guideline.

Trial Registration

Clinicaltrials.gov identifier: NCT03408197.     

Comparison of a radiant patient warming device with forced air warming during laparoscopic cholecystectomy

The importance of maintaining a patient's core body temperature during anaesthesia to reduce the incidence of postoperative complications has been well documented. The standard practice of this institution is the use of a forced air device for intraoperative warming. The purpose of this study was to compare this standard with an alternative warming device using a radiant heat source which only heated the face. This prospective, randomized controlled trial compared the efficacy of two methods of intraoperative warming: the BairHugger (Augustine Medical, U.S.A.) forced air device and the SunTouch (Fisher & Paykel Healthcare, N.Z.) radiant warmer during laparoscopic cholecystectomy in 42 female patients. Oesophageal core temperatures were recorded automatically on to computer during operations using standardised anaesthesia, intravenous infusions and draping. The study failed to show any statistical or clinical difference between the two patient groups in terms of mean core temperature both intraoperatively (P = 0.42) and in the recovery period (P = 0.54). Mean start to end core temperature differences were marginally lower in the radiant group (0.08 degree C) but not statistically or clinically significantly different. Given some of the drawbacks with forced air systems, such as the expense of the single use blanket, this new radiant warming device offers an alternative method of active warming with advantages in terms of cost and possible application to a wide variety of surgical procedures.     

Implementing advance care plans in the peri-operative period,including plans for cardiopulmonary resuscitation: Association of Anaesthetists clinical practice guideline

Contemporary guidance takes a patient-centred approach and recommends discussing and planning treatments that should be considered, not just those that should be withheld. Although some organisations and communities still use specific DNACPR (do not attempt cardiopulmonary resuscitation) forms to recommend that cardiopulmonary resuscitation is not attempted, this approach has been shown to have disadvantages and is no longer regarded as best practice. The following guidelines have been produced in response to this change. They are designed to help anaesthetists, as part of the wider healthcare team, to implement and respond to advance care planning documents before and during procedures. The guidelines apply to all procedures, however minor and low risk they are considered to be, and the same ethical and legal principles apply to procedures carried out under local or regional anaesthesia and/or conscious sedation, as well as to those under general anaesthesia.     

Guideline of guidelines: social media in urology

The use of social media is rapidly expanding. This technology revolution is changing the way healthcare providers share information with colleagues, patients, and other stakeholders. As social media use increases in urology, maintaining a professional online identity and interacting appropriately with one's network are vital to engaging positively and protecting patient health information. There are many opportunities for collaboration and exchange of ideas, but pitfalls exist without adherence to proper online etiquette. The purpose of this article is to review professional guidelines on the use of social media in urology, and outline best practice principles that urologists and other healthcare providers can reference when engaging in online networks.     

The future of decision-making in critical care after Cuthbertson v. Rasouli

Purpose

The Supreme Court of Canada (SCC) ruling on Cuthbertson v. Rasouli has implications for all acute healthcare providers. This well-publicized case involved a disagreement between healthcare providers and a patient’s family regarding the principles surrounding withdrawal of life support, which the physicians involved considered no longer of medical benefit and outside the standard of care, and whether consent was required for such withdrawals. Our objective in writing this article is to clarify the implications of this ruling on the care of critically ill patients.

Source

SCC ruling Cuthbertson v. Rasouli.

Principal findings

The SCC ruled that consent must be obtained for all treatments that serve a “health-related purpose”, including withdrawal of such treatments. The SCC did not fully consider what the standard of care should be. Health-related purpose is not sufficient in and of itself to mandate treatment, and clinicians must still ensure that their patients or decision-makers are aware of the possible medical benefits, risks, and expected outcomes of treatments. The provision of treatments that have no potential to provide medical benefit and carry only risks would still fall outside the standard of care. Nevertheless, due to their health-related purpose, physicians must seek consent for the discontinuation of these treatments.

Conclusion

The SCC ruled that due to the legal definition of “health-related purpose”, which is distinct from medical benefit, consent is required to withdraw life-support and outlined the steps to be taken should conflict arise. The SCC decision did not directly address the role of medical standard of care in these situations. In order to ensure optimal decision-making and communication with patients and their families, it is critical for healthcare providers to have a clear understanding of the implications of this legal ruling on medical practice.     

A procedure-specific systematic review and consensus recommendations for postoperative analgesia following total knee arthroplasty

The PROSPECT Working Group, a collaboration of anaesthetists and surgeons, conducts systematic reviews of postoperative pain management for different surgical procedures (http://www.postoppain.org). Evidence-based consensus recommendations for the effective management of postoperative pain are then developed from these systematic reviews, incorporating clinical practice observations, and transferable evidence from other relevant procedures. We present the results of a systematic review of pain and other outcomes following analgesic, anaesthetic and surgical interventions for total knee arthroplasty (TKA). The evidence from this review supports the use of general anaesthesia combined with a femoral nerve block for surgery and postoperative analgesia, or alternatively spinal anaesthesia with local anaesthetic plus spinal morphine. The primary technique, together with cooling and compression techniques, should be supplemented with paracetamol and conventional non-steroidal anti-inflammatory drugs or COX-2-selective inhibitors, plus intravenous strong opioids (high-intensity pain) or weak opioids (moderate- to low-intensity pain).     

Heat conservationvs convective warming in adults undergoing elective surgery

Purpose

To determine the relative efficacy of heat conservation and convective warming in maintaining penoperative normothermia. (central temperature ≥36°C).

Methods

Thirty-seven patients undergoing elective gynaecological, orthopaedic, or general surgery scheduled to last two hours were prospectjvely studied. Patients were randomized to one of two groups. Group I patients received heat conservation with reflective blankets (Thermadrape?, Vital Signs, Inc., Totowa, NJ) applied preoperatively and warmed iv fluids (Hotline? SIMS Level I Technologies, Inc, Rockland, MA). Group 2 patients received convective warming (BairHugger, Augustine Medical, Inc., Eden Prairie, MN) after induction of anaesthesia andiv fluids at room temperature. All patients received general anaesthesia with isoflurane. Tympanic membrane and forearm-fingertip skin temperature gradients were measured penoperatively at 15 min intervals.

Results

Central temperature decreased after induction to a minimum level of 35.9 ± 0.1°C in group I and 36.0 ± 0.1°C in group 2 and then increased towards pre-induction values in group 2, and were higher (P < 0.05) than in group 1: 95% group 2 patients had central temperature ≥ 36.0°C at the end of surgery (vs 69% of group l.P < 0.05). During the first 30 mm in PACU, central temperatures were higher in group 1 than in group 2 (36.8 ± 0.1°C vs 36.2 ± 0.2°C. P< 0.05). After 60 mm, central temperatures were similar (36.8°C). The incidence of shivering and degree of penpheral cutaneous vasoconstnction were also similar.

Conclusion

Patients receiving convective warming were more likely to leave the operating room normothermic. and had higher central temperatures dunng the first 30 mm in the recovery room. The intergroup temperature differences were small, and by 60 min, had disappeared.     

Current state and future directions of genomic medicine in aortic dissection: A path to prevention and personalized care

Aortic dissection confers high mortality and morbidity rates despite advances in treatment, impacts quality of life, and contributes immense burden to the healthcare system globally. Efforts to prevent aortic dissection through screening and management of modifiable risk factors and early detection of aneurysms should incorporate genomic information, as it is integral to stratifying risk. However, effective integration of genomic-guided risk assessment into clinical practice will require addressing implementation barriers that currently permeate our healthcare systems. The Aortic Dissection Collaborative was established to define aortic dissection research priorities through patient engagement. Using a collaborative patient-centered feedback model, our Genomic Medicine Working Group identified related research priorities that could be investigated by pragmatic interventional studies aimed at aortic dissection prevention, utilization of genomic information to improve patient outcomes, and access to genomic medicine services. Further research is also needed to identify the genomic, lifestyle, and environmental risk factors that contribute to aortic dissection so these data can be incorporated into future comparative effectiveness studies to prevent aortic dissection.     

A comparison of the pelvic angle applied using lateral table tilt or a pelvic wedge at elective caesarean section

Lateral table tilt or a pelvic wedge are commonly used to reduce inferior vena cava compression during obstetric anaesthesia in the supine position. Direct measurement of pelvic angle allows individual assessment of the effectiveness of these manoeuvres in achieving a tilted position. We observed routine practice during caesarean section after random allocation to one or other of these methods. The anaesthetist managing the case was asked to position the women after induction of spinal anaesthesia using either left table tilt or a wedge under the right hip. We then measured pelvic angle in all women, and the table angle in women who had table tilt. The mean (SD [range]) pelvic angle was 20.2° (8.1° [9°–37°]) in 18 women with table tilt and 21.0° (7.5° [10°–36°]) in 17 women with a wedge. The mean (SD [range]) table angle was 12.4° (3.1° [8°–21°]) in the women with table tilt. There was a significant difference between table angle and pelvic angle in the women with table tilt (p = 0.0003), but no significant difference in pelvic angle between the table tilt and wedge groups. Measurement of table angle does not represent pelvic position adequately in the majority of women. However, this study showed that lateral table tilt and a pelvic wedge were equally effective in producing tilt of the pelvis.     

Diabetic foot and foot debridement technique

Surgical foot debridement is widely practised in diabetic foot care. Although minor debridement could be done at the bedside with or without local anaesthesia, more extensive debridement would require regional or general anaesthesia in operating theatres. Delayed surgery could increase the risk of limb loss and mortality. The International Working Group of the Diabetic Foot (IWGDF) or the Infectious Diseases Society of America classifications could be used to assist management of the diabetic foot sepsis. A detailed knowledge of the anatomy of the foot is required to achieve the best outcome. Complications of diabetes and any amputation further disrupts the biomechanics of the diabetic foot and increases the risk of transfer ulceration. Foot biomechanics should be considered while debridement and reconstructive techniques employed, although adequate debridement shouldn't be compromised.     

Diabetic foot and foot debridement technique

Surgical foot debridement is widely practised in diabetic foot care. Although minor debridement could be done at the bedside with or without local anaesthesia, more extensive debridement would require regional or general anaesthesia in operating theatres. Delayed surgery could increase the risk of limb loss and mortality. The International Working Group of the Diabetic Foot (IWGDF) or the Infectious Diseases Society of America classifications could be used to assist management of the diabetic foot sepsis. A detailed knowledge of the anatomy of the foot is required to achieve the best outcome. Complications of diabetes and any amputation further disrupts the biomechanics of the diabetic foot and increases the risk of transfer ulceration. Foot biomechanics should be considered while debridement and reconstructive techniques employed, although adequate debridement should not be compromised.     

European Hernia Society guidelines on the treatment of inguinal hernia in adult patients

The European Hernia Society (EHS) is proud to present the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare. They have been developed by a Working Group consisting of expert surgeons with representatives of 14 country members of the EHS. They are evidence-based and, when necessary, a consensus was reached among all members. The Guidelines have been reviewed by a Steering Committee. Before finalisation, feedback from different national hernia societies was obtained. The Appraisal of Guidelines for REsearch and Evaluation (AGREE) instrument was used by the Cochrane Association to validate the Guidelines. The Guidelines can be used to adjust local protocols, for training purposes and quality control. They will be revised in 2012 in order to keep them updated. In between revisions, it is the intention of the Working Group to provide every year, during the EHS annual congress, a short update of new high-level evidence (randomised controlled trials [RCTs] and meta-analyses). Developing guidelines leads to questions that remain to be answered by specific research. Therefore, we provide recommendations for further research that can be performed to raise the level of evidence concerning certain aspects of inguinal hernia treatment. In addition, a short summary, specifically for the general practitioner, is given. In order to increase the practical use of the Guidelines by consultants and residents, more details on the most important surgical techniques, local infiltration anaesthesia and a patient information sheet is provided. The most important challenge now will be the implementation of the Guidelines in daily surgical practice. This remains an important task for the EHS. The establishment of an EHS school for teaching inguinal hernia repair surgical techniques, including tips and tricks from experts to overcome the learning curve (especially in endoscopic repair), will be the next step. Working together on this project was a great learning experience, and it was worthwhile and fun. Cultural differences between members were easily overcome by educating each other, respecting different views and always coming back to the principles of evidence-based medicine. The members of the Working Group would like to thank the EHS board for their support and especially Ethicon for sponsoring the many meetings that were needed to finalise such an ambitious project. This publication can be ordered via .     

Anaesthetic and management dilemmas in office-based surgery

Given the changing patterns of healthcare delivery in the USA, it can be anticipated that office-based surgery and anaesthesia will continue to grow over the next few years. The development of newer surgical technologies and anaesthetics have facilitated the ability of the office to provide services that until recently were restricted to a hospital-based practice. Notwithstanding this shift of ‘more intensive’ surgical procedures to the ‘less intensive’ office environment, regulations need to be established to ensure patient safety. The anaesthesiologist must step forward as an advocate for patient safety and assume the leadership role in defining the practice environment, appropriate patient selection and types of anaesthetics for this site. Basic to the practice of office anaesthesia must be the tenet that the office be held to the same stringent standards that would apply in the traditional anaesthetizing locations.     

Heat and moisture exchangers and breathing system filters: their use in anaesthesia and intensive care. Part 1 - history, principles and efficiency

Heat and moisture exchangers and breathing system filters are intended to replace the normal warming, humidifying and filtering functions of the upper airways when these structures are bypassed during anaesthesia and intensive care. Guidance on their use continues to evolve. The aim of this part of the review is to describe the principles of their action and efficiency and to summarise the findings from clinical and laboratory studies. Based on previous studies, an appropriate minimum target for moisture output is 30 and 20 g.m^?3 for long‐duration use in intensive care and short‐duration use in anaesthesia, respectively. The practice of reusing a breathing system in anaesthesia, provided it is protected by a filter, assumes that the filter is effective. However, there is wide variation in the gas‐borne filtration performance, and contaminated condensate can potentially pass through some filters under typical pressures encountered during mechanical ventilation.     

Forced-air surface warming versus oesophageal heat exchanger in the prevention of peroperative hypothermia

Background: In a prospective, randomized, placebo-controlled study we investigated the efficacy of 2 different heating methods in 24 patients undergoing abdominal surgery of at least 2 h expected duration.
Methods: Group I: control, no active warming. Group II: forced-air surface warming on upper extremities and upper thorax. Group III: warming with oesophageal heat exchanger. All patients had a standardized, combined general and epidural anaesthesia. Core and skin temperatures were measured at induction of general anaesthesia, and subsequently every 30 min, and changes in total body temperature were calculated.
Results: There were no statistically significant differences between the 3 groups regarding demographic data. Patients in groups I and III developed hypothermia, while this was not the case with patients in group II. When using analysis of variance with repeated measurements, there was no significant difference in core temperature, comparing group I and group III ( P =0.299) or the interaction between time and treatment of these groups ( P =0.373). As a consequence, data from groups I and III were pooled and regarded as an internal group on the one hand, and group II as an external group on the other hand. Core temperature, the mean skin temperature and total body temperature were significantly different comparing the internal group and the external group. The interaction between time and treatment was likewise found to be significantly different.
Conclusions: We conclude that in major abdominal procedures lasting 2 h or more, serious hypothermia develops unless effective measures to prevent hypothermia are used. Forced-air warming of the upper part of the body is effective in maintaining normothermia in these patients, while central heating with an oesophageal heat exchanger, at least in its present form, does not suffice to prevent hypothermia.     

The effects of educational curricula and training on LGBT‐specific health issues for healthcare students and professionals: a mixed‐method systematic review

Introduction : Poor access of lesbian, gay, bisexual and transgender (LGBT) people to healthcare providers with clinical and cultural competency contributes to health inequalities between heterosexual/cisgender and LGBT people. This systematic review assesses the effect of educational curricula and training for healthcare students and professionals on LGBT healthcare issues. Methods : Systematic review; the search terms, strategy and process as well as eligibility criteria were predefined and registered prospectively on PROSPERO. A systematic search of electronic databases was undertaken. Screening for eligible studies and data extraction were done in duplicate. All the eligible studies were assessed for risk of bias. The outcome of interest was a change in participants’ knowledge, attitude and or practice. Results : Out of 1171 papers identified, 16 publications reporting 15 studies were included in the review. Three were non‐randomized controlled studies and 12 had a pre/post‐design; two had qualitative components. Bias was reported in the selection of participants and confounding. Risk reported was moderate/mild. Most studies were from the USA, the topics revolved around key terms and terminology, stigma and discrimination, sexuality and sexual dysfunction, sexual history taking, LGBT‐specific health and health disparities. Time allotted for training ranged from 1 to 42 hours, the involvement of LGBT people was minimal. The only intervention in sub‐Saharan Africa focused exclusively on men who have sex with men. All the studies reported statistically significant improvement in knowledge, attitude and/or practice post‐training. Two main themes were identified from the qualitative studies: the process of changing values and attitudes to be more LGBT inclusive, and the constraints to the application of new values in practice. Conclusions : Training of healthcare providers will provide information and improve skills of healthcare providers which may lead to improved quality of healthcare for LGBT people. This review reports short‐term improvement in knowledge, attitudes and practice of healthcare students and professionals with regards to sexual and LGBT‐specific healthcare. However, a unified conceptual model for training in‐terms of duration, content and training methodology was lacking.