Healthcare services rely on large amounts of disposable medical devices, even though similar reusable devices exist. This retrospective audit of operating theatre and endoscopy procurement data across two hospitals aimed to examine the number and mass of simple single-use devices and cost (purchasing and disposal) of such devices in operating theatres where a reusable device alternative exists. This was assessed at one health service across two hospitals with a total of 19 operating theatres and five endoscopy procedure rooms. The main outcome was the number of single-use devices procured and disposed of, mass of devices procured, cost of procurement, cost of disposal, and estimated environmental impact of device procurement and disposal. In a five-year period of operating at two hospitals, 2,683,412 simple single-use devices that have a reusable alternative were purchased and disposed of, with a combined mass of 748 t, an approximate purchasing cost of A$16.1m, and an approximate disposal cost of around A$1.2m. The associated environmental impact of these devices was estimated at 3690 tonnes carbon dioxide equivalent. Simple disposable medical devices in operating theatres such as bowls, jugs, drapes, gowns, scissors, towels and anaesthesia equipment produce tonnes of waste per annum, cost millions to procure and dispose of, and produce greenhouse gas emissions from production to disposal. Replacing some single-use devices with reusable alternatives presents an opportunity for health services to save money from purchasing and disposing of single-use devices, as well as reducing their waste and greenhouse gas footprint. Replacing disposable equipment with reusable equipment can divert tonnes of waste from landfill and save on procurement and disposal costs.

Arterial haemoglobin oxygen desaturation is common during gastroscopy and is associated with patient harm. Obesity increases the risk of desaturation during gastroscopy. High-flow nasal oxygen may reduce the risk of desaturation, but data are lacking. We conducted a single-centre, parallel group, randomised controlled trial of high-flow nasal oxygen at 50-70 l/min compared with oxygen via nasal prongs 4-10 l/min, enrolling adults having gastroscopy procedures who had a body mass index greater than 30 kg/m2. The primary outcome was the incidence of desaturation, defined as any peripheral oxygen saturation less than 90% during the procedure. We recruited 150 participants (75 in each group). The mean body mass index was similar in each group (35 vs. 36 kg/m2). High-flow nasal oxygen reduced the incidence of desaturation compared with standard oxygen therapy (three (4%) vs. 14 (19%), P = 0.005), and increased the median minimum peripheral oxygen saturation (98% (interquartile range 92-97%) vs. 94% (interquartile range 97-100%), P < 0.001). Fewer patients administered high-flow oxygen required airway interventions (39 (52%) vs. 58 (77%), P < 0.001), while the number of patients requiring interruption to the procedure for airway management were similar in each group (seven (9%) vs. five (7%), P = 0.57). High-flow nasal oxygen was associated with a higher risk of apnoea compared with standard oxygen delivery (17 (23%) vs. six (8%), P = 0.013), and a similar risk of arrhythmias existed between the groups (two (3%) vs. one (1%), P = 0.56). High-flow nasal oxygen reduced the incidence of desaturation during gastroscopy in obese patients.

A 40-year-old high functioning woman developed severe anaphylaxis to rocuronium immediately following induction for laparoscopic appendectomy. Circulation and oxygenation were rapidly restored, the operation was abandoned and a 2-day intensive care unit stay, intubated with an adrenaline infusion for upper airway swelling, followed. The abdominal condition resolved with conservative management over a 5-day inpatient stay. Despite apparent full recovery from anaphylaxis, after discharge she had difficulty resuming baseline activities of daily living. Ongoing profound neurogenic fatigue prevented return to professional duties for over a year. Cognitive dysfunction following rapid resuscitation from anaphylaxis was unexpected. This case report examines relevant literature.

Limited data suggest a subset of patients with acute respiratory distress syndrome receive high-dose and prolonged opioid and sedative infusions. With prolonged use, patients may be at risk for developing iatrogenic withdrawal syndrome after discontinuation or tapering of these agents. Iatrogenic withdrawal syndrome is well described in paediatric patients; however, limited guidance exists in adult intensive care unit patients regarding risk factors and ideal management strategies. This article discusses several weaning strategies for high-risk patients to minimise withdrawal symptoms and safely reduce or discontinue opioid and sedative infusions. Ideal weaning strategies are lacking, but several options exist. These include a gradual reduction of the agent, changing the route of delivery by switching to an enteral or parenteral longer-acting agent from the same class, and substitution to an alternative agent to help mitigate potential withdrawal symptoms. This should be accomplished through a multidisciplinary approach by involving experts from relevant specialties while closely observing for withdrawal symptoms.

Rates of misrepresenting smoking status on day of surgery varies with the clinical context. In perioperative smoking cessation trials, participants in the intervention group might be more likely to provide untruthful data about quitting when they have received substantial quit support but continued to smoke. The objective of this study was to determine misrepresentation rates of smoking status on day of surgery in mixed elective surgical populations, comparing groups offered or not offered additional cessation support. We undertook a post hoc analysis of data from three published randomised trials at a Melbourne public hospital that incorporated interventions during the wait-list period aimed at increasing smoking cessation. Participants were smokers (n = 1413) who were randomised to minimal cessation help at wait-listing (control group) or significant assistance, for example, mailed nicotine replacement (intervention group). Quit by day of surgery claims were verified by exhaled carbon monoxide (true cessation <8 parts per million). Verified cessation (>24 h) before surgery occurred in 161/1413 (11.4%) while 44/1413 (3.1%) misrepresented quitting. Continued smoking was in 1208/1413 (85.5%). Misrepresentations were higher in the intervention/offer of help groups (4.1%) than control groups (1.7%) (odds ratio (OR) 2.46, 95% confidence interval (CI) 1.17 to 5.63, P = 0.012). Offering cessation help increased quitting odds by 77%, (OR 1.77, 95% CI 1.24 to 2.52, P = 0.002). In contrast to other studies, we found group allocation in cessation trial settings had a significant effect on misrepresentation risk. The implication of this is that biochemical verification of quit status is essential in trial contexts for accurate data collection and to prevent misclassification bias.

Tubeless microlaryngoscopy optimises surgical access but typically relies on total intravenous anaesthesia, commonly using propofol and remifentanil infusions. We present a difficult airway case where an unrecognised drug error during programming of an infusion pump resulted in unexpected apnoea. Open airway surgery proceeded with the use of a prophylactic cannula cricothyroidotomy using a Rapid-O2® insufflation device to provide rescue oxygenation. Furthermore, cricothyroid membrane identification failed with digital palpation but was successful with ultrasonography. While the latter is currently not considered the standard of care for preparing for front-of-neck access in a time-critical 'can't intubate, can't oxygenate' scenario, in our case it proved helpful.

The purpose of this study was to identify haemodynamic factors that are associated with tissue hypoperfusion in flap/graft surgical patients that might be modified to reduce perioperative morbidity. We conducted a single-centre, retrospective, observational study of 1355 patients undergoing head and neck flap reconstructions. Logistic regression and chi-square analyses were employed to identify factors which signal perioperative complications. Study endpoints included postoperative lactic acidosis, acute kidney injury (AKI) and early surgical flap revision surgery. Intraoperative data were collected as time-weighted averages of the haemodynamic variables, including pulse pressure variation (PPV), mean arterial pressure, and vasopressor doses. Cumulative volume was used for intravenous (IV) fluids. Relevant patient comorbidities were also included in the analysis. The most common complication was hyperlactataemia (22.9%), followed by AKI (14.1%) and take-back surgery (3.3%). No patient factors were significantly correlated with flap complications. Elevated max PPV was significantly associated with elevated lactate and AKI in univariate regression, but only AKI in the multivariate analysis (P = 0.003). Case duration was the only variable associated with take-back surgery in the multivariate regression (P = 0.007); it was also associated with lactic acidosis (P = 0.003). Neither IV fluid administration nor the use of vasopressors appeared to be associated with study outcomes in the multivariate analysis.