European Society of Anaesthesiology and Intensive Care consensus document on sustainability: 4 scopes to achieve a more sustainable practice.

Climate change is a defining issue for our generation. The carbon footprint of clinical practice accounts for 4.7% of European greenhouse gas emissions, with the European Union ranking as the third largest contributor to the global healthcare industry's carbon footprint, after the United States and China. Recognising the importance of urgent action, the European Society of Anaesthesiology and Intensive Care (ESAIC) adopted the Glasgow Declaration on Environmental Sustainability in June 2023. Building on this initiative, the ESAIC Sustainability Committee now presents a consensus document in perioperative sustainability. Acknowledging wider dimensions of sustainability, beyond the environmental one, the document recognizes healthcare professionals as cornerstones for sustainable care, and puts forward recommendations in four main areas: direct emissions, energy, supply chain and waste management, and psychological and self-care of healthcare professionals. Given the urgent need to cut global carbon emissions, and the scarcity of evidence-based literature on perioperative sustainability, our methodology is based on expert opinion recommendations. A total of 90 recommendations were drafted by 13 sustainability experts in anaesthesia in March 2023, then validated by 36 experts from 24 different countries in a two-step Delphi validation process in May and June 2023. To accommodate different possibilities for action in high- versus middle-income countries, an 80% agreement threshold was set to ease implementation of the recommendations Europe-wide. All recommendations surpassed the 80% agreement threshold in the first Delphi round, and 88 recommendations achieved an agreement >90% in the second round. Recommendations include the use of very low fresh gas flow, choice of anaesthetic drug, energy and water preserving measures, "5R" policies including choice of plastics and their disposal, and recommendations to keep a healthy work environment or on the importance of fatigue in clinical practice. Executive summaries of recommendations in areas 1, 2 and 3 are available as cognitive aids that can be made available for quick reference in the operating room.

Resource allocation.

PURPOSE OF REVIEW: The coronavirus disease 2019 pandemic and recent global recessions have brought to the forefront of the medical-political discussion the fact that medical resources are finite and have focused a spotlight on fair allocation and prioritization of healthcare resources describe why this review is timely and relevant. RECENT FINDINGS: This review presents past and present concepts related to the ethics of resource allocation. Included are discussions regarding the topics of who should determine resource allocation, what types of research require allocation, methods currently in use to determine what resources are appropriate and which should be prioritized.describe the main themes in the literature covered by the article. SUMMARY: Models for resource allocation must differentiate between different types of resources, some of which may require early preparation or distribution. Local availability of specific resources, supplies and infrastructure must be taken into consideration during preparation. When planning for long durations of limited resource availability, the limitations of human resilience must also be considered. Preparation also requires information regarding the needs of the specific population at hand (e.g. age distributions, disease prevalence) and societal preferences must be acknowledged within possible limits.

Bioethics: cancelling patient operations.

PURPOSE OF REVIEW: This review aims to surmise a bioethical approach to the phenomenon of cancelling patient operations. There is increasing public and political interest in the matter with a rise in the frequency of cancellations. Cancellations are emotional for patients and are difficult clinical decisions. RECENT FINDINGS: Reasons for cancellation involve patient factors and resource allocation applying to elective and emergency surgery. The four pillars of bioethics are easily applied, (autonomy, beneficence, nonmaleficence and justice), although their failings are becoming more prominent with the rise of more encompassing virtue ethics. These include dignity, solidarity, phronesis and trust. Importantly patient dignity should be preserved, this complimenting solidarity and trust in specialist knowledge more than autonomy does. Beauchamp and Childress have provided a descriptive framework describing futility, which may aid communication and mental clarity when deliberating if it is the right choice to cancel. With regards to resource factors, ideally managerial staff should be involved in these decisions leaving the physician to be the patient's clinical advocate. SUMMARY: Although cancellations are undesirable, they are inevitable and form part of the duties of a doctor. When they do occur, care must remain patient-centred, asking how we can improve this situation.

The ethics of treating family members.

PURPOSE OF REVIEW: Many medical professionals receive requests from family and friends asking for medical advice and treatment. But should medics treat their family? Ethically can we treat, or refuse to treat, family members? This is a common ethical challenge that most doctors face during their career and there is limited evidence available. By examining ethical principles, we aim to answer these questions and provide a framework that will guide decision making in this area. RECENT FINDINGS: There is a paucity of evidence available. Many ethical systems exist and have been discussed since ancient Greece but in recent years, bioethics has become more prominent in medical thinking and debate. SUMMARY: We examine ethical systems such as virtue ethics, utilitarianism, deontology and principlism and how they relate to treating family members. We then look at cases in different contexts and describe a system for approaching such cases, allowing doctors to conform to moral standards, and consider ethical arguments, prior to embarking upon any treatment course with a relative.

Resource allocation in ICU: ethical considerations.

PURPOSE OF REVIEW: Increasing scarcity of resources on the background of ever improving medical care and prolonged life expectancy has placed a burden on all aspects of health care. In this article we examine the current problems with resource allocation in intensive care and question whether we can find guidance on appropriate resource allocation through ethical models. RECENT FINDINGS: The problem of fair and ethical resource allocation has perpetually plagued health care. Recent work has looked at value for money, benefits of therapies and how we define futility, but these still fall victim to the same problems that classical schools of ethical thought have tried to tackle. SUMMARY: Many ethical principles provide a framework on which to allocate resources to certain cohorts of patients, however, most appear too rigid to be fully and primarily utilized for intensive care admission. We suggest a collaboration of principles be applied to achieve a moral, ethical and common sense approach to this issue. Over resourcing and under resourcing is also suggested to be problematic for patients and healthcare workers alike.

Analysis of Anthrax Immune Globulin Intravenous with Antimicrobial Treatment in Injection Drug Users, Scotland, 2009-2010.

We studied anthrax immune globulin intravenous (AIG-IV) use from a 2009-2010 outbreak of Bacillus anthracis soft tissue infection in injection drug users in Scotland, UK, and we compared findings from 15 AIG-IV recipients with findings from 28 nonrecipients. Death rates did not differ significantly between recipients and nonrecipients (33% vs. 21%). However, whereas only 8 (27%) of 30 patients at low risk for death (admission sequential organ failure assessment score of 0-5) received AIG-IV, 7 (54%) of the 13 patients at high risk for death (sequential organ failure assessment score of 6-11) received treatment. AIG-IV recipients had surgery more often and, among survivors, had longer hospital stays than did nonrecipients. AIG-IV recipients were sicker than nonrecipients. This difference and the small number of higher risk patients confound assessment of AIG-IV effectiveness in this outbreak.

Research ethics committee approval as reported for abstracts submitted to the annual Euroanaesthesia meeting.

BACKGROUND: The annual congress of the European Society of Anaesthesiology (ESA) is one of the largest anaesthesia congresses in the world and exhibits more than 1200 abstracts annually. OBJECTIVES: The aims of this study were to quantify the frequency of inadequate evidence of ethical approval for abstracts submitted to the ESA congress and to examine whether abstracts without appropriate ethical approval were subsequently accepted. DESIGN AND SETTING: All abstracts submitted in 2015 were adjudicated according to European ethical criteria. MAIN OUTCOME MEASURE: The proportion of submitted abstracts that lacked evidence of appropriate ethics committee approval. Secondary outcomes included the proportion of accepted abstract that lacked evidence of appropriate ethical approval; the proportion of correctly identified case reports; the proportion of accepted abstracts that lacked evidence of appropriate ethics committee approvals corresponding to location (within/outside Europe); and the proportion of accepted abstracts that lacked evidence of appropriate ethics committee approvals corresponding to a specific area of research. RESULTS: In total, 1792 abstracts were reviewed and 1572 (87.7%) involved humans. In 527 (29.4%), the authors failed to demonstrate adequate ethical approval with higher rates in abstracts submitted from Europe (32.1%) than the rest of the world (23.5%), P < 0.001. Appropriate approvals were reported in 80% of animal studies, 74.6% of case reports and 57.6% of human research studies. The proportion with evidence of adequate ethical approvals was lowest in obstetric anaesthesia and emergency medicine. Case reports were identified correctly 98.6% (347/352) of the time, but 14 research abstracts were assigned wrongly to this category. Most abstracts (68.5%, 361/527) lacking evidence of ethical approval were still accepted for presentation. CONCLUSION: Research abstracts lacking evidence of appropriate ethical approval are common worldwide. Societies shoulder the responsibility for ensuring that only ethically sound abstracts are presented at meetings. Abstract submission systems must include mechanisms to ensure that publications are accepted and judged not just on scientific merit but also on adherence to best ethical practice.

Confirmed Bacillus anthracis infection among persons who inject drugs, Scotland, 2009-2010.

In Scotland, the 2009 outbreak of Bacillus anthracis infection among persons who inject drugs resulted in a 28% death rate. To compare nonsurvivors and survivors, we obtained data on 11 nonsurvivors and 16 survivors. Time from B. anthracis exposure to symptoms or hospitalization and skin and limb findings at presentation did not differ between nonsurvivors and survivors. Proportionately more nonsurvivors had histories of excessive alcohol use (p = 0.05) and required vasopressors and/or mechanical ventilation (p≤0.01 for each individually). Nonsurvivors also had higher sequential organ failure assessment scores (mean ± SEM) (7.3 ± 0.9 vs. 1.2 ± 0.4, p<0.0001). Antibacterial drug administration, surgery, and anthrax polyclonal immune globulin treatments did not differ between nonsurvivors and survivors. Of the 14 patients who required vasopressors during hospitalization, 11 died. Sequential organ failure assessment score or vasopressor requirement during hospitalization might identify patients with injectional anthrax for whom limited adjunctive therapies might be beneficial.

Intensive care following in-hospital cardiac arrest / periarrest calls-experience from one Scottish hospital.

BACKGROUND: In-hospital cardiac arrest/periarrest is a recognised trigger for consideration of admission to the intensive care unit (ICU). We aimed to investigate the rates of ICU admission following in-hospital cardiac arrest/periarrest, evaluate the outcomes of such patients and assess whether anticipatory care planning had taken place prior to the adult resuscitation team being called. METHODS: Analysis of all referrals to the ICU page-holder within our district general hospital is between 1st November 2018 and 31st May 2019. From this, the frequency of adult resuscitation team calls was determined. Case notes were then reviewed to determine details of the events, patient outcomes and the use of anticipatory care planning tools on wards. RESULTS: Of the 506 referrals to the ICU page-holder, 141 (27.9%) were adult resuscitation team calls (114 periarrests and 27 cardiac arrests). Twelve patients were excluded due to health records being unavailable. Admission rates to ICU were low - 17.4% for cardiac arrests (4/23 patients), 5.7% (6/106) following periarrest. The primary reason for not admitting to ICU was patients being "too well" at the time of review (78/129 - 60.5%). Prior to adult resuscitation team call, treatment escalation plans had been completed in 27.9% (36/129) with Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms present in 15.5% of cases (20/129). Four cardiac arrest calls were made in the presence of a valid DNACPR form, frequently due to a lack of awareness of the patient's resuscitation status. CONCLUSIONS: This study highlights the significant workload for the ICU page-holder brought about by adult resuscitation team calls. There is a low admission rate from these calls, and, at the time of resuscitation team call, anticipatory planning is frequently either incomplete or poorly communicated. Addressing these issues requires a collaborative approach between ICU and non-ICU physicians and highlights the need for larger studies to develop scoring systems to aid objective admission decision-making.

Parent and medical team disagreements in the UK: universal lessons in the origins and resolution in conflict.

In recent decades, there has been an increase in life expectancy in children with life-limiting conditions. Ideally, parents and clinicians would work together to ensure the best care for these children. Several cases have appeared in the media in recent years where conflict has risen between parents and healthcare professionals acting in the 'best interests' of children, which have resulted in court action. However, the legislation itself promotes conflict. Similar laws exist across Europe based on Article 24 of the UN Convention on the Rights of the Child.The aim of the Children's Act 1989 in the UK was to place the 'child's welfare' as the 'paramount consideration'. It has prevented draconian care and supervision orders, which can only be made if the child is at risk of 'significant harm'. This threshold does not apply to healthcare teams. Healthcare decisions are based on 'best interests', which are not explicitly defined. This sets the threshold for progression to court action much lower, and due to a lack of definitive definition of what 'best interests' are, this has unfortunately escalated conflict rather than resolve it.Healthcare institutions have been criticised for not utilising alternative approaches first, such as mediation. We propose an alternative approach based on collaboration, reasonableness and the threshold of significant harm, which we have explored in this review.Conflict management frameworks are a tool that can be used to recognise early signs of conflict and develop strategies to prevent escalation at ward level. They can be tailored to individual institutions and utilise content-oriented and empathetic communication strategies through designated clinicians. They should offer guidance on when to refer to the courts.Parental wishes should be assessed on whether they represent significant harm or not. If not, they cannot simply be wrong. Acknowledgement of the 'reasonableness' of parental requests can be a key factor which is diffusing conflict. Therefore, setting the threshold for state intervention at 'significant harm' rather than 'best interests' would help to reduce the number of these cases progressing to courts.

Three model systems measure oxidation/nitration damage caused by peroxynitrite.

Diseases activate the innate immune response which causes ancillary damage to the human body. Peroxynitrite (OONO-) or its carbon dioxide derivatives cause oxidation/nitration and hence mutation to various body polymers e.g. DNA, RNA, protein, lipids and sugars. The control of the ancillary damage can come from antioxidants which inhibit control the amount of peroxynitrite available for damage. In this paper we have developed three different levels of antioxidant screening: (i) Peroxynitrite or SIN-1 reaction with luminol to produce light, and the inhibition of light by substances therefore represents antioxidation. (ii) Nicking of plasmid DNA occurs via oxidants: and is prevented by antioxidants. (iii) Detection of plasmid luciferase activity post-oxidation and infection indicates either prevention or repair of damage: via antioxidants. We found green tea and a number of its polyphenolic constituents effective only at the first level of antioxidation, while extracts of various fruit help at all levels antioxidation. In the final analysis, a combination of green tea extracts and fruits is suggested to produce more complete antioxidant protection.

Accidental intraventricular administration of phenytoin through an external ventricular drain: case report.

A 52-year-old man with an external ventricular drain was transferred from the local neurosurgical intensive care unit to the general intensive care unit for renal replacement therapy. While the patient was in the general intensive care unit, phenytoin was accidentally administered via the external ventricular drain. Tachycardia and hypertension ensued and then seizure activity. The drain was aspirated and then washed out. Propofol was infused for 24 hours and then was stopped to allow continuing neurological assessment. The route of administration of phenytoin was changed from intravenous to oral, and care continued as before. After resolution of the renal failure, the patient was returned to the neurological intensive care unit. He recovered slowly and had no adverse effects due to the error in administration of phenytoin.