No abstract

Background: Intraoperative mortality is now rare, but death within 30 days of surgery remains surprisingly common. Perioperative myocardial infarction is associated with a remarkably high mortality. There are strong associations between hypotension and myocardial injury, myocardial infarction, renal injury, and death. Perioperative arterial blood pressure management was thus the basis of a Perioperative Quality Initiative consensus-building conference held in London in July 2017. Methods: The meeting featured a modified Delphi process in which groups addressed various aspects of perioperative arterial pressure.

Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Ministry of Health and Long-Term Care, Ontario Ministry of Research, Innovation and Science, UK National Institute of Academic Anaesthesia, UK Clinical Research Collaboration, Australian and New Zealand College of Anaesthetists, and Monash University.

Minable phosphorus (P) reserves are being depleted and will need to be replaced by recovering P that currently is lost from the agricultural system, causing water-quality problems. The largest two flows of lost P are in agricultural runoff and erosion (∼46% of mined P globally) and animal wastes (∼40%). These flows are quite distinct. Runoff has a very high volumetric flow rate, but a low P concentration; animal wastes have low flow rates, but a high P concentration together with a high concentration of organic material. Recovering the lost P in animal wastes is technically and economically more tractable, and it is the focus for this review of promising P-capture technologies. P capture requires that organic P be transformed into inorganic P (phosphate). For high-strength animal wastes, P release can be accomplished in tandem with anaerobic treatment that converts the energy value in the organic matter to CH(4), H(2), or electricity. Once present as phosphate, the P can be captured in a reusable form by four approaches. Most well developed is precipitation as magnesium or calcium solids. Less developed, but promising are adsorption to iron-based adsorbents, ion exchange to phosphate-selective solids, and uptake by photosynthetic microorganisms or P-selective proteins.

This study confirms that GFAP and S100B levels in serum are adjuncts to the assessment of brain damage after TBI and may enhance prognostication when combined with clinical variables.

European Society of Anaesthesiology.

This is a repository copy of Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH) : a stepped-wedge cluster-randomised trial. Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH) : a stepped-wedge cluster-randomised trial. The Lancet. ISSN 0140-6736 https://doi.org/10.1016/S0140-6736(18)32521-2 eprints@whiterose.ac.uk https://eprints.whiterose.ac.uk/ ReuseThis article is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs (CC BY-NC-ND) licence. This licence only allows you to download this work and share it with others as long as you credit the authors, but you can't change the article in any way or use it commercially. More information and the full terms of the licence here: https://creativecommons.org/licenses/ Implications of all the available evidenceDespite the success of some smaller projects, there was no survival benefit from a national quality improvement programme to implement a care pathway for patients undergoing emergency abdominal surgery. To succeed, large national quality improvement programmes need to allow for differences between hospitals and ensure teams have both the time and resources needed to improve patient care.

The case for radical pathway re-design before surgery is in part driven by healthcare system pressures which are in turn the result of continuously rising demand in the face of tightly constrained resources. Such circumstances tend to drive revolutionary, rather than incremental, change. The current approach to preoperative assessment, that typically occurs in the weeks leading up to surgery, but is all too often only a few days before surgery, results in a lost opportunity for perioperative physicians to improve patient care. Re-engineering this process based on a patient-focused, pathway-driven vision of perioperative medicine offers a means of exploiting this opportunity. This review explores drivers for change, the opportunity offered by pathway re-design, and suggests a variety of strategies to add value in the preoperative pathway, each of which is facilitated by early engagement between perioperative physician and patient: collaborative decision-making, collaborative behavioural change, targeted comorbidity management as well as expectation management and psychological preparation for surgery including surgery schools.