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.

Caregiver involvement in an approach favoring sustainable development in the operating theater.

The climate emergency alarm is resounding. Tasked with caregiving, healthcare facilities are nonetheless responsible for apparently innumerable greenhouse gas emissions. Predominantly atmospheric pollution causes 9 million deaths a year throughout the world. While legislative measures have been taken to favor change in climate-related business practices, the effects of their implementation are far from visible. On a parallel track, caregivers have been coming together and calling into question their practices, the objective being to institute concrete actions leading to reduction of healthcare-related carbon footprint. Not all of these actions have the same ecological impact or ease of implementation. To demonstrate their effectiveness and set the stage for readjustments, the existing initiatives require qualitative assessment and quantitative appraisal. While they demand personal motivation and professional investment, these efforts have a triple impact, at once ecological, economic and related to quality of life. Multidisciplinary teams come together in the pursuit of a common project epitomizing our missions as caregivers; is not that the essence of our presence in hospital?

Oxygen supplementation in anesthesia can block FLASH effect and anti-tumor immunity in conventional proton therapy.

BACKGROUND: Radiation-induced neurocognitive dysfunction is a major adverse effect of brain radiation therapy and has specific relevance in pediatric oncology, where serious cognitive deficits have been reported in survivors of pediatric brain tumors. Moreover, many pediatric patients receive proton therapy under general anesthesia or sedation to guarantee precise ballistics with a high oxygen content for safety. The present study addresses the relevant question of the potential effect of supplemental oxygen administered during anesthesia on normal tissue toxicity and investigates the anti-tumor immune response generated following conventional and FLASH proton therapy. METHODS: Rats (Fischer 344) were cranially irradiated with a single high dose of proton therapy (15 Gy or 25 Gy) using FLASH dose rate proton irradiation (257 ± 2 Gy/s) or conventional dose rate proton irradiation (4 ± 0.02 Gy/s), and the toxicities in the normal tissue were examined by histological, cytometric and behavioral analysis. Glioblastoma-bearing rats were irradiated in the same manner and tumor-infiltrating leukocytes were quantified by flow cytometry. RESULTS: Our findings indicate that supplemental oxygen has an adverse impact on both functional and anatomical evaluations of normal brain following conventional and FLASH proton therapy. In addition, oxygen supplementation in anesthesia is particularly detrimental for anti-tumor immune response by preventing a strong immune cell infiltration into tumoral tissues following conventional proton therapy. CONCLUSIONS: These results demonstrate the need to further optimize anesthesia protocols used in radiotherapy with the goal of preserving normal tissues and achieving tumor control, specifically in combination with immunotherapy agents.

Proton therapy is a type of precise radiotherapy that can have reduced side effects. Children undergoing proton therapy are often given a general anesthetic, supplemented with high oxygen levels as a measure of safety. However, the consequences of modifying the oxygen concentration in the treatment have not been studied. In this study, we evaluated the consequences of adding oxygen in the anesthesia in a model of brain tumor after conventional proton therapy and a new radiotherapy technique, FLASH proton therapy. We observed that oxygen supplementation can cause more brain damage in FLASH proton therapy and block anti-tumor immune cell infiltration into the tumor in conventional proton therapy. Overall, this study should be taken into consideration when designing new protocols of radiotherapy, specifically those including FLASH proton therapy and combinations with immune-targeted treatments.

The green anaesthesia dilemma: to which extent is it important to preserve as many drugs available as possible.

PURPOSE OF REVIEW: This article aims to summarize the current literature describing the availability of different anaesthetic drugs, and to discuss the advantages and limitations of a self-imposed restriction on the scarcely existing anaesthetic drugs. RECENT FINDINGS: Earth temperature has risen 1.2°C since the beginning of industrial age, and it is expected to exceed a 1.5°C increase by 2050. The Intergovernmental Panel on Climate Change depicts five different scenarios depending on how these increased temperatures will be controlled in the future. The European Commission has formulated a proposal to regulate fluorinated greenhouse gases (F-gases), among which desflurane, isoflurane and sevoflurane belong to, due to their high global warming potential. This proposal shall ban, or severely restrict, the use of desflurane starting January 2026. It is not clear what might happen with other F-gas anaesthetics in the future. Due to climate change, a higher number of health crisis are expected to happen, which might impair the exiting supply chains, as it has happened in previous years with propofol scarcity. SUMMARY: There are just a handful number of available anaesthetics that provide for a safe hypnosis. Major stakeholders should be consulted prior making such severe decisions that affect patient safety.

Guidelines for clothing in the operating theatre, 2021.

OBJECTIVE: To provide guidelines for the choice of items of clothing (except sterile surgical gown) for staff working in the operating theatre. DESIGN: A committee of nine experts from SFAR and the SF2H learned societies was convened. A formal conflict-of-interest policy was developed at the beginning of the process and enforced throughout. Likewise, it did not benefit from any funding from a company marketing a health product (drug or medical device). The authors were required to follow the rules of the GRADE® method (Grading of Recommendations Assessment, Development and Evaluation) to assess the quality of the evidence on which the recommendations were based. METHODS: We aimed to formulate recommendations according to the GRADE® methodology for four different fields: operating theatre suits, operating theatre hats, masks, and shoes/over-shoes. Each question was formulated according to the PICO format (Patient, Intervention, Comparison, Outcome). The literature review and recommendations were formulated according to the GRADE® methodology. RESULTS: The experts' synthesis work and their application of the GRADE® method resulted in 13 recommendations. As the GRADE® method could not be integrally applied to all questions, some recommendations were formulated as expert opinions. CONCLUSION: Based on strong agreement between experts, we produced 13 recommendations to guide the choice of operating theatre attire.

Environmental sustainability in anaesthesia and critical care.

The detrimental health effects of climate change continue to increase. Although health systems respond to this disease burden, healthcare itself pollutes the atmosphere, land, and waterways. We surveyed the 'state of the art' environmental sustainability research in anaesthesia and critical care, addressing why it matters, what is known, and ideas for future work. Focus is placed upon the atmospheric chemistry of the anaesthetic gases, recent work clarifying their relative global warming potentials, and progress in waste anaesthetic gas treatment. Life cycle assessment (LCA; i.e. 'cradle to grave' analysis) is introduced as the definitive method used to compare and contrast ecological footprints of products, processes, and systems. The number of LCAs within medicine has gone from rare to an established body of knowledge in the past decade that can inform doctors of the relative ecological merits of different techniques. LCAs with practical outcomes are explored, such as the carbon footprint of reusable vs single-use anaesthetic devices (e.g. drug trays, laryngoscope blades, and handles), and the carbon footprint of treating an ICU patient with septic shock. Avoid, reduce, reuse, recycle, and reprocess are then explored. Moving beyond routine clinical care, the vital influences that the source of energy (renewables vs fossil fuels) and energy efficiency have in healthcare's ecological footprint are highlighted. Discussion of the integral roles of research translation, education, and advocacy in driving the perioperative and critical care environmental sustainability agenda completes this review.

Guidelines: Anaesthesia in the context of COVID-19 pandemic.

OBJECTIVES: The world is currently facing an unprecedented healthcare crisis caused by the COVID-19 pandemic. The objective of these guidelines is to produce a framework to facilitate the partial and gradual resumption of intervention activity in the context of the COVID-19 pandemic. METHODS: The group has endeavoured to produce a minimum number of recommendations to highlight the strengths to be retained in the 7 predefined areas: (1) protection of staff and patients; (2) benefit/risk and patient information; (3) preoperative assessment and decision on intervention; (4) modalities of the preanaesthesia consultation; (5) specificity of anaesthesia and analgesia; (6) dedicated circuits and (7) containment exit type of interventions. RESULTS: The SFAR Guideline panel provides 51 statements on anaesthesia management in the context of COVID-19 pandemic. After one round of discussion and various amendments, a strong agreement was reached for 100% of the recommendations and algorithms. CONCLUSION: We present suggestions for how the risk of transmission by and to anaesthetists can be minimised and how personal protective equipment policies relate to COVID-19 pandemic context.

Implications of Perioperative Polypharmacy in Adolescents Undergoing Bariatric Surgery: a Single-Center Experience.

Adolescents seeking bariatric surgery may present with pre-existing psychiatric diagnoses for which they use chronic medications. To heighten awareness concerning perioperative polypharmacy in adolescents with extreme obesity, we conducted a retrospective review of patients undergoing laparoscopic sleeve gastrectomy between February 2010 and May 2017 at Children's National Health System (CNHS). A total of 167 adolescent patients had pre-existing psychiatric diagnoses which included depression (50%), anxiety (23%), ADHD (23%), and binge eating disorder (11%). Medications prescribed to treat these diagnoses included selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). Additionally, all patients were given fentanyl, ondansetron, morphine, and acetaminophen perioperatively. Although no life threatening symptoms of drug-drug interactions (DDIs) were appreciated, the combined use of many different potent drugs in these patients warrants attention.

Analgesic Requirements in Adolescents Undergoing Bariatric Surgery-an Observational Study.

AIM: To examine the impact of preexisting psychiatric/psychological diagnoses on perioperative analgesic requirements in adolescents with morbid obesity undergoing bariatric surgery. METHODS: A retrospective cohort study of adolescents with morbid obesity undergoing bariatric surgery. Primary and secondary outcomes included perioperative analgesic intake and pain scores (Numerical Rating Scale (0-10) NRS) throughout the hospital stay. RESULTS: From our Bariatric Surgery Research Registry, we identified 17 adolescents with psychiatric/psychological diagnoses prior to undergoing bariatric surgery. Fifteen patients from the same registry and without such diagnosis undergoing bariatric surgery during the same time interval served as controls. In both groups, there was a predominance of female patients. During the perioperative period, in both groups, oral morphine equivalent and ketorolac and acetaminophen intake were similar. Notably, the perioperative median pain scores at the times examined were below 5 for all patients. The median pain scores in the PACU, day of surgery, and first postoperative day were similar. Conversely, on postoperative day 2, pain scores were higher in patients with diagnoses of psychiatric/psychological disorders (p = 0.004) compared to those without. CONCLUSION: In this cohort of morbidly obese adolescents undergoing bariatric surgery, patients with and without preexisting psychiatric/psychological diagnoses had similar analgesic requirements during the perioperative period. This finding appears contrary to those suggesting that preexisting depression and/or anxiety might be associated with increased analgesic requirements during the perioperative period.

Single-cell genetic analysis validates cytopathological identification of circulating cancer cells in patients with clear cell renal cell carcinoma.

CONTEXT: Circulating Rare Cells (CRC) are non-haematological cells circulating in blood. They include Circulating Cancer Cells (CCC) and cells with uncertain malignant features (CRC-UMF) according to cytomorphology. Clear cell renal cell carcinomas frequently bear a mutated Von Hippel-Lindau (VHL) gene. AIM: To match blind genetic analysis of CRC and tumor samples with CRC cytopathological diagnosis. RESULTS: 29/30 patients harboured CRC (20 harboured CCC, 29 CRC-UMF) and 25/29 patients carried VHL mutations in their tumour. 205 single CRC (64 CCC, 141 CRC-UMF) provided genetic data. 57/57 CCC and 104/125 CRC-UMF from the 25 patients with VHL-mutated tumor carried the same VHL mutation detected in the tumor. Seven CCC and 16 CRC-UMF did not carry VHL mutations but were found in patients with wild-type VHL tumor tissue. CONCLUSIONS: All the CCC and 83,2% (104/125) of the CRC-UMF were found to carry the same VHL mutation identified in the corresponding tumorous tissue, validating cytopathological identification of CCC in patients with clear cell renal cell carcinoma. METHODS: The blood of 30 patients with clear cell renal cell carcinoma was treated by ISET® for CRC isolation, cytopathology and single-cell VHL mutations analysis, performed blindly and compared to VHL mutations of corresponding tumor tissues and leukocytes.

[The challenges of sustainable development in healthcare facilities]. / Les enjeux du développement durable en établissement de santé.

Healthcare and medical-social facilities have a major responsibility within society, that of the quality of care, but also that of developing a system of sustainable and socially-responsible health. This system must meet the three pillars which constitute such an approach: economic, social and environmental sustainability. Innovation remains central to the sustainable evolution of practices and the first results are now visible.

Transcriptional response to hypoxic stress in melanoma and prognostic potential of GBE1 and BNIP3.

Gradients of hypoxia occur in most solid tumors and cells found in hypoxic regions are associated with the most aggressive and therapy-resistant fractions of the tumor. Despite the ubiquity and importance of hypoxia responses, little is known about the variation in the global transcriptional response to hypoxia in melanoma. Using microarray technology, whole genome gene expression profiling was first performed on established melanoma cell lines. From gene set enrichment analyses, we derived a robust 35 probes signature (hypomel for HYPOxia MELanoma) associated with hypoxia-response pathways, including 26 genes up regulated, and 9 genes down regulated. The microarray data were validated by RT-qPCR for the 35 transcripts. We then validated the signature in hypoxic zones from 8 patient specimens using laser microdissection or macrodissection of Formalin fixed-paraffin-embedded (FFPE) material, followed with RT-qPCR. Moreover, a similar hypoxia-associated gene expression profile was observed using NanoString technology to analyze RNAs from FFPE melanoma tissues of a cohort of 19 patients treated with anti-PD1. Analysis of NanoString data from validation sets using Non-Negative Matrix Factorization (NMF) analysis (26 genes up regulated in hypoxia) and dual clustering (samples and genes) further revealed that the increased level of BNIP3 (Bcl-2 adenovirus E1B 19 kDa-interacting protein 3)/GBE1 (glycogen branching enzyme1) differential pair correlates with the lack of response of melanoma patients to anti-PD1 (pembrolizumab) immunotherapy. These studies suggest that through elevated glycogenic flux and induction of autophagy, hypoxia is a critical molecular program that could be considered as a prognostic factor for melanoma.

Percutaneous Computed Tomography-Guided Thermal Ablation of Pulmonary Osteosarcoma Metastases in Children.

INTRODUCTION: The role of percutaneous thermal ablation as a minimally-invasive treatment has not been evaluated in children under 18 years of age with pulmonary osteosarcoma metastases. METHODS: This was a retrospective review of children treated with percutaneous thermal ablation for pulmonary osteosarcoma metastasis after prior surgical metastasectomy and chemotherapy. Selection criteria included number of pulmonary nodules <5 and nodule size smaller than 2 cm. Indications were discussed at multidisciplinary meetings. The goal was to achieve complete remission using percutaneous thermal ablation, thereby avoiding additional thoracotomies. RESULTS: A total of 26 pulmonary nodules (mean size 6.7 mm, range 2-16 mm) were successfully treated by percutaneous computed tomography (CT)-guided thermal ablation in 11 children with osteosarcoma between the ages of 7 and 17 years (median 12.5). Patients denied post-procedure pain. Complications were limited to three pneumothoraxes (two minor, one major), and median hospitalization duration was 2.0 days. One patient died of rapidly progressive lumbar metastasis discovered 20 days post-ablation. Of the remaining 10 patients, local control at the ablation site was achieved, with median follow up of 16.7 months (range 4.1-41.8). Five patients remained in complete remission after median follow-up of 37.5 months, and five patients developed new metastases (one osseous, four pulmonary), of which two are in remission after subsequent treatment. CONCLUSION: Percutaneous thermal ablation is a safe and effective minimally-invasive curative local treatment alternative for children with oligometastatic pulmonary osteosarcoma in whom surgical intervention is clinically contraindicated or unappealing.