Easy-to-implement educational interventions to bring climate-smart actions to daily anesthesiologic practice: a cross-sectional before and after study.

BACKGROUND: Anesthesia contributes significantly to a hospital's carbon footprint. Climate-smart actions have the potential to reduce greenhouse gas emissions. Prerequisites for sustainable behavior of providers are knowledge and awareness. We aimed to assess the change in anesthesiologists' climate-friendly behavior before and after educational interventions in three areas that every anesthesiologist can address in their daily clinical routine: 1) energy use; 2) recycling opportunities; 3) consumption of volatile anesthetics. METHODS: We performed a cross-sectional before-and-after single center sub-study within the multicenter "Provider Education and Evaluation Project" at the Department of Anesthesiology, RWTH Aachen University hospital from May3 2021 to May 1 2022. Educational interventions consisted of stickers, posters and a presentation on climate-smart actions in anesthesiologists' work routine between the first and the second assessment. For each cross-sectional assessment, all central 28 ORs were observed for one week. During the before-and-after comparison we analyzed: 1) energy wasted in unoccupied ORs because of running computers and turned-on lights at 9 p.m.; 2) feasibility of recycling preoperative anesthesia plastic packaging by determining the difference between calculated weight of unseparated preoperative plastic waste in the first assessment and the weight of actual separated waste in the second assessment; 3) fresh gas flow in balanced anesthesia cases in steady state at 9 a.m., and purchased hypnotics converted to bottles/1000 general anesthesia cases in 2018-2022. RESULTS: We observed a reduction of wasted energy by 44% in unoccupied ORs. Usage of low fresh gas flow settings increased from 55% to 75%. The average of purchased desflurane in 2018-2020 decreased by 72% in 2022. We calculated 10.33 kg of preoperative plastic waste per week but were unable to implement waste separation for infrastructural and logistical reasons. CONCLUSIONS: We found that environment-friendly working behaviors increased after the implementation of educational interventions. The causality between the interventions and the observed improvements remains to be proven.

Mitigation of climate change in health care: A survey for the evaluation of providers' attitudes and knowledge, and their view on their organization's readiness for change.

BACKGROUND: Climate change is the 21st century's greatest threat to health. Anaesthesia is responsible for high levels of waste production, significant greenhouse gas emissions and extensive energy consumption. Our aim was to design an instrument to assess attitudes and knowledge among anaesthetists as well as their organisation's readiness for change regarding climate action. METHODS: In 2020, the Provider Education and Evaluation Project (PEEP) questionnaire was sent to anaesthetists working at a university hospital, which contains 65 items in five areas: demographics, personal attitudes, organisational readiness, opportunities, and specific anaesthesiologic knowledge regarding climate action. Except for two open text questions, all questions were closed questions. RESULTS: 104 anaesthetists responded to the survey (response rate 62%). Environmental protection and sustainability were important to all participants (100%). Most felt threatened by the ongoing climate crisis (94.2%). While most participants agreed that their employer had the financial or technological capacities and that sustainability targets were compatible with core business activities (approval >60% for all), they felt unprepared and stated that they had too little time to consider environmental aspects during daily routines (disapproval >60% for all). Furthermore, knowledge on topics such as ongoing efforts to tackle climate change or the climate footprint of drugs and medical products, was rather scarce. CONCLUSION: The PEEP questionnaire is an applicable and viable tool to assess anaesthetists' knowledge and attitudes towards climate change and organisational readiness for change. While participants care about the climate crisis, organisational readiness was low, especially when it comes to staff readiness (i.e., skills and knowledge) and cultural readiness (i.e., shared values). These aspects need to be considered in order to successfully implement a carbon neutral health care system.

Mapping of Arithmetic Processing by Navigated Repetitive Transcranial Magnetic Stimulation in Patients with Parietal Brain Tumors and Correlation with Postoperative Outcome.

BACKGROUND: Preserving functionality is important during neurosurgical resection of brain tumors. Specialized centers also map further brain functions apart from motor and language functions, such as arithmetic processing (AP). The mapping of AP by navigated repetitive transcranial magnetic stimulation (nrTMS) in healthy volunteers has been reported. OBJECTIVE: The present study aimed to correlate the results of mapping AP with functional patient outcomes. METHODS: We included 26 patients with parietal brain tumors. Because of preoperative impairment of AP, mapping was not possible in 8 patients (31%). We stimulated 52 cortical sites by nrTMS while patients performed a calculation task. Preoperatively and postoperatively, patients underwent a standardized number-processing and calculation test (NPCT). Tumor resection was blinded to nrTMS results, and the change in NPCT performance was correlated to resected AP-positive spots as identified by nrTMS. RESULTS: The resection of AP-positive sites correlated with a worsening of the postoperative NPCT result in 12 cases. In 3 cases, no AP-positive sites were resected and the postoperative NPCT result was similar to or better than preoperatively. Also, in 3 cases, the postoperative NPCT result was better than preoperatively, although AP-positive sites were resected. CONCLUSIONS: Despite presenting only a few cases, nrTMS might be a useful tool for preoperative mapping of AP. However, the reliability of the present results has to be evaluated in a larger series and by intraoperative mapping data.

Associations between clinical outcome and navigated transcranial magnetic stimulation characteristics in patients with motor-eloquent brain lesions: a combined navigated transcranial magnetic stimulation-diffusion tensor imaging fiber tracking approach.

OBJECTIVE Navigated transcranial magnetic stimulation (nTMS) and diffusion tensor imaging fiber tracking (DTI FT) based on nTMS data are increasingly used for preoperative planning and resection guidance in patients suffering from motor-eloquent brain tumors. The present study explores whether nTMS-based DTI FT can also be used for individual preoperative risk assessment regarding surgery-related motor impairment. METHODS Data derived from preoperative nTMS motor mapping and subsequent nTMS-based tractography in 86 patients were analyzed. All patients suffered from high-grade glioma (HGG), low-grade glioma (LGG), or intracranial metastasis (MET). In this context, nTMS-based DTI FT of the corticospinal tract (CST) was performed at a range of fractional anisotropy (FA) levels based on an individualized FA threshold ([FAT]; tracking with 50%, 75%, and 100% FAT), which was defined as the highest FA value allowing for visualization of fibers (100% FAT). Minimum lesion-to-CST distances were measured, and fiber numbers of the reconstructed CST were assessed. These data were then correlated with the preoperative, postoperative, and follow-up status of motor function and the resting motor threshold (rMT). RESULTS At certain FA levels, a statistically significant difference in lesion-to-CST distances was observed between patients with HGG who had no impairment and those who developed surgery-related transient or permanent motor deficits (75% FAT: p = 0.0149; 100% FAT: p = 0.0233). In this context, no patient with a lesion-to-CST distance ≥ 12 mm suffered from any new surgery-related permanent paresis (50% FAT and 75% FAT). Furthermore, comparatively strong negative correlations were observed between the rMT and lesion-to-CST distances of patients with surgery-related transient paresis (Spearman correlation coefficient [rs]; 50% FAT: rs = -0.8660; 75% FAT: rs = -0.8660) or surgery-related permanent paresis (50% FAT: rs = -0.7656; 75% FAT: rs = -0.6763). CONCLUSIONS This is one of the first studies to show a direct correlation between imaging, clinical status, and neurophysiological markers for the integrity of the motor system in patients with brain tumors. The findings suggest that nTMS-based DTI FT might be suitable for individual risk assessment in patients with HGG, in addition to being a surgery-planning tool. Importantly, necessary data for risk assessment were obtained without significant additional efforts, making this approach potentially valuable for direct clinical use.

Resection of Navigated Transcranial Magnetic Stimulation-Positive Prerolandic Motor Areas Causes Permanent Impairment of Motor Function.

BACKGROUND: Navigated transcranial magnetic stimulation (nTMS) helps to determine the distribution of motor eloquent areas prior to brain surgery. Yet, the eloquence of primary motor areas frontal to the precentral gyrus identified via nTMS is unclear. OBJECTIVE: To investigate the resection of nTMS-positive prerolandic motor areas and its correlation with postsurgical impairment of motor function. METHODS: Forty-three patients with rolandic or prerolandic gliomas (WHO grade I-IV) underwent nTMS prior to surgery. Only patients without ischemia within the motor system in postoperative MRI diffusion sequences were enrolled. Based on the 3-dimensional fusion of preoperative nTMS motor mapping data with postsurgical MRI scans, we identified nTMS points that were resected in the infiltration zone of the tumor. We then classified the resected points according to the localization and latency of their motor evoked potentials. Surgery-related paresis was graded as transient (≤6 weeks) or permanent (>6 weeks). RESULTS: Out of 43, 31 patients (72%) showed nTMS-positive motor points in the prerolandic gyri. In general, 13 out of 43 patients (30%) underwent resection of nTMS points. Ten out of these patients showed postoperative paresis. There were 2 (15%) patients with a transient and 8 (62%) with a permanent surgery-related paresis. In 3 cases (23%), motor function remained unimpaired. CONCLUSION: After resection of nTMS-positive motor points, 62% of patients suffered from a new permanent paresis. Thus, even though they are located in the superior or middle frontal gyrus, these cortical areas must undergo intraoperative mapping.

Cortical plasticity of motor-eloquent areas measured by navigated transcranial magnetic stimulation in patients with glioma.

OBJECTIVE The goal of this study was to obtain a better understanding of the mechanisms underlying cerebral plasticity. Coupled with noninvasive detection of its occurrence, such an understanding has huge potential to improve glioma therapy. The authors aimed to demonstrate the frequency of plastic reshaping, find clues to the patterns behind it, and prove that it can be recognized noninvasively using navigated transcranial magnetic stimulation (nTMS). METHODS The authors used nTMS to map cortical motor representation in 22 patients with gliomas affecting the precentral gyrus, preoperatively and 3-42 months postoperatively. Location changes of the primary motor area, defined as hotspots and map centers of gravity, were measured. RESULTS Spatial normalization and analysis of hotspots showed an average shift of 5.1 ± 0.9 mm (mean ± SEM) on the mediolateral axis, and 10.7 ± 1.6 mm on the anteroposterior axis. Map centers of gravity were found to have shifted by 4.6 ± 0.8 mm on the mediolateral, and 8.7 ± 1.5 mm on the anteroposterior axis. Motor-eloquent points tended to shift toward the tumor by 4.5 ± 3.6 mm if the lesion was anterior to the rolandic region and by 2.6 ± 3.3 mm if it was located posterior to the rolandic region. Overall, 9 of 16 (56%) patients with high-grade glioma and 3 of 6 (50%) patients with low-grade glioma showed a functional shift > 10 mm at the cortical level. CONCLUSIONS Despite the small size of this series, analysis of these data showed that cortical functional reorganization occurs quite frequently. Moreover, nTMS was shown to detect such plastic reorganization noninvasively.