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.
Background Despite the recognised advantages of bariatric and metabolic surgery, only a small proportion of patients receive this intervention. In the UK, weight management systems are divided into four tiers. Tier 3 is a clinician-lead weight loss service while tier 4 considers surgery. While there is little evidence that tier 3 has any long-term benefits for weight loss, this study aims to determine whether tier 3 improves the uptake of surgery. Method A retrospective cohort study of all referrals to our unit between 2013 and 2016 was categorised according to source—tier 3, directly from the general practitioner (GP) or from another speciality. The likelihood of surgery was calculated using a regression model after considering patient demographics, comorbidities and distance from our hospital. Results Of the 399 patients, 69.2% were referred directly from the GP, 21.3% from tier 3, and 9.5% from another speciality of which 69.4%, 56.2%, and 36.8% progressed to surgery ( p = 0.01). On regression analysis, patients from another speciality or GP were more likely to decide against surgery (OR 2.44 CI 1.13–6.80 p = 0.03 and OR 1.65 CI 1.10–3.12 p = 0.04 respectively) and more likely to be deemed not suitable for surgery by the MDT (OR 6.42 CI 1.25–33.1 p = 0.02 and OR 3.47 CI 1.11–12.9 p = 0.03) compared with tier 3 referrals. Conclusion As patients from tier 3 were more likely to undergo bariatric and metabolic surgery, this intervention remains a relevant step in the pathway. Such patients are likely to be better informed about the benefits of surgery and risks of severe obesity.
Objective:There are multiple documented advantages of undertaking total knee arthroplasty (TKA) without tourniquet, however, increased rates of blood loss and transfusion are often cited as contraindications to this approach. The aim of this study was to examine the effect of intra-operative TA administration on blood loss and transfusion rates in TKA without pneumatic tourniquet, using Rivaroxaban as thrombo-embolic prophylaxis.Method:120 patients split into two continuous data sets, (A+B), underwent TKA without application of above knee tourniquet, receiving a post-operative dose of oral Rivaroxaban within 8 hours. Group B patients received an intra-operative dose of 1 gram of Tranexamic Acid intravenously before the first cut, whilst those in group A did not. Haemoglobin and Haematocrit levels were recorded peri-operatively. A revised Gross formula was used to calculate blood loss. Four patients were excluded from the study for incomplete data.Result:58 patients (M34F24) in Group A, average age 6, had a mean Haemoglobin drop of 33gram/litre, Haematocrit drop of 0.097litre/litre (9.7%), with an average calculated blood loss of 1393 ml. 58 (M34, F24) patients in group B, average age 67, had a Haemoglobin drop of 25.2gram/litre, Haematocrit drop of 0.076litre/litre (7.6%) with an average calculated blood loss of1079 ml. Thus Group A patients were seen to sustain significantly more blood loss without TA administration, with a 29.1% larger calculated blood loss, a 25.5% larger drop in Haemoglobin and a 27.6% larger fall in Haematocrit. Transfusion rate was 5.2%(3 patients) per group.Conclusion:TA was shown to be effective in reducing blood loss in TKA without tourniquet using Rivaroxaban. Transfusion rates of 5.2% across both groups is close to 1/10th of the transfusion rate reported for major studies of TKA using Rivaroxaban with tourniquet application, and 1/8th of the transfusion rate in studies of TKA with administration of TA and use of tourniquet.
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