Efforts to reduce the environmental footprint of anaesthesia have focused predominantly on greenhouse gas emissions, with desflurane widely recognised as an extreme climate outlier. In Australia, desflurane accounts for approximately 3% of volatile anaesthetic cases yet contributes nearly 60% of volatile anaesthetic-related greenhouse gas emissions, making its phase-out one of the most effective mitigation measures immediately available to anaesthetists. However, climate forcing represents only one dimension of the environmental burden of volatile anaesthesia. All fluorinated volatile anaesthetics, including sevoflurane, desflurane and isoflurane, meet the Organisation for Economic Co-operation and Development definition of per- and polyfluoroalkyl substances (PFAS) that generate persistent degradation products, most notably trifluoroacetic acid, leading to irreversible accumulation in water, soil and biota. This Point of View examines both dimensions. We argue that desflurane represents a disproportionate climate burden, whereas PFAS pollution is an inherent class effect of volatile anaesthesia. Using quantitative estimates, we illustrate the scale of both impacts and consider the regulatory and ethical implications for Australian practice.
The aim of this study was to review cases of wrong-sided nerve blockade among the 11,425 incidents reported to webAIRS—a centralised Australian and New Zealand anaesthetic incident reporting system—as of April 2024. Cases were reviewed if a reporter selected ‘peripheral nerve blockade’ as a main category, or narrative word search identified the terms ‘wrong/incorrect/error’ and ‘site/side’. Seven hundred and seventy-one reports under the category ‘peripheral nerve blockade’ were reviewed, and 43 incidents were ultimately included for analysis, involving 38 wrong-sided blocks and five near misses. Both quantitative and qualitative factors contributing to laterality errors were assessed by two independent analysers. Although most incidents of wrong-sided block had minimal reported sequelae, one patient required unplanned admission to intensive care, while another had an operation cancelled. Wrong-side blockade remains a ‘never event’, and its occurrence can have significant physical and psychological consequences for patients. Regional anaesthetic errors are contributed to by various factors that have been well described in previous publications on the topic; however, this study demonstrated a disproportionate commonality in failure to confirm the correct procedural side (63% of cases).
Electronic medical records (eMRs) could support perioperative outcomes registries, but the completeness of routinely collected data remains uncertain. This study evaluated the availability of perioperative data within a large Australian hospital eMR against the Perioperative Clinical Outcomes Registry Extended (PCOREx) dataset. A retrospective audit of all elective inpatient procedures involving anaesthetists at Westmead Hospital (Sydney, New South Wales) in June 2022 was performed. Records were reviewed in Cerner® PowerChart (Cerner Corporation, Kansas City, MO, USA) and completeness was defined as the presence of PCOREx variables across Baseline Risk, Intraoperative Risk, Process of Care, In-Hospital Outcomes and Post-Discharge Outcomes. A total of 405 patients met inclusion criteria. Overall completeness was 63%; excluding post-discharge variables, inpatient completeness was 77.5%. Demographic, procedural and intraoperative physiological data-mostly structured or automatically captured-were consistently recorded (>90%). Comorbidities, frailty indices, intraoperative temperature, and fluid balance were less complete (<50%). Post-discharge outcomes were recorded in only 7.9% of patients, limited to those who re-presented to hospital. Missingness reflected both structural gaps (absence of fields, siloed intensive care unit systems) and clinical behaviour (selective documentation, variable pathology ordering). While routine eMR data capture many perioperative variables, significant gaps remain, particularly for post-discharge outcomes and selectively documented fields. Mapping completeness within the Clinical Adoption Meta Model framework highlights barriers at system and clinical levels. Standardised data capture, linkage with external databases, and improved interoperability are needed to realise the potential of eMRs for perioperative outcomes registries.
Pre-anaesthesia fasting guidelines typically recommend a six-hour fast for solids and a two-hour fast for clear liquids. Jelly is a fruit-flavoured gelatin dessert that exists as a viscoelastic semi-solid mass when refrigerated but melts back into its liquid form once ingested; therefore, it is not obvious to which category it should belong. We used ultrasound to investigate gastric emptying following ingestion of jelly in a pilot study of 10 fasted healthy adult volunteers. First, a baseline scan was performed to confirm their estimated gastric volume was less than 2.3 ml/kg (the 95th centile for a fasted population). Subjects then ate 400 g of jelly and underwent repeated scans every 10 minutes until their estimated gastric volume had returned to baseline. Median (interquartile range) estimated gastric volume was 0 (0-0.6) ml/kg at baseline, peaked at 3.1 (2.7-4.3) ml/kg 10 minutes post-ingestion and had decreased to 0 (0-0.9) ml/kg by two hours. It took a median (interquartile range) of 70 (47.5-80.0) minutes for estimated gastric volume to fall below 2.3 ml/kg, and 110 (110-130) minutes before it had returned to baseline. These data suggest that, for serving sizes up to 400 grams of jelly there might be no justification for mandating a six-hour fast prior to anaesthesia.
Leaks from nitrous oxide (N2O) infrastructure have been identified as a significant contributor to the greenhouse gas emissions of healthcare facilities. Recent studies in Australia and in the United Kingdom have found at least half (and often more than 70%) of the N2O supplied to many healthcare facilities leaks from medical pipelines and associated infrastructure before clinical administration. To assist in addressing this issue, the University of Melbourne, in collaboration with the Interim Australian Centre for Disease Control and the Australian Government's Department of Health and Aged Care, published Detecting and reducing nitrous oxide leaks in healthcare facilities - a practical guide (the 'Guide') in 2024. This article summarises the Guide and best practice approaches for detection and reduction of N2O leaks in healthcare facilities across Australia. It is intended to assist clinicians and facility managers to identify appropriate methods to test for N2O leaks, make an informed choice about the most appropriate way to supply N2O to a facility and reduce waste from N2O leaks in their healthcare facility.
Nitrous oxide (N2O) has both MAC (Minimum Anaesthetic Concentration) sparing and rapid pharmacokinetic washout properties. We hypothesised that adding N2O at the end of surgery would hasten emergence from anaesthesia, decrease variability in emergence duration and reduce the number of prolonged emergences. Adult patients, American Society of Anesthesiologists Physical Status I-III, undergoing general anaesthesia for surgery with duration of over 120 min were randomised into two groups according to carrier gas: air/30% oxygen, and the same mixture until the last 30 min of surgery when 70% N2O in 30% oxygen was used. Anaesthesia was maintained at ~1 MAC with sevoflurane in both groups. Early and late recovery, postoperative nausea and vomiting, and pain scores and analgesic use were assessed. Time to extubation time was deemed prolonged if it lasted more than 15 min. Fifty-one patients in N2O/O2 and 50 in air/O2 were enrolled. N2O administration lasted (mean ± standard deviation) 24.8 ± 9.4 min. Time to extubation was faster with N2O/O2 (5.5 ± 2.6 min) than with air/O2 (9.1 ± 4.0 min), mean difference 3.6 min; 95% confidence interval 2.3 to 4.9, p < 0.001. Ability to open eyes, follow commands and being oriented were similarly significantly faster (mean differences 3.6, 3.4 and 3.7 min, respectively, p < 0.001 in all). None of the patients with N2O/O2, but 6% of patients with air/O2, had prolonged time to extubation, p < 0.001. There were no differences between the groups in postoperative pain scores, or in early and late postoperative recovery. Patients administered N2O/O2 received significantly less analgesics: tramadol (medians 0 vs 100 mg, p = 0.037), paracetamol (33% vs 62%, p = 0.004) and ketoprofen (16% vs 32%, p = 0.054). Adding N2O at the end of sevoflurane-based anaesthesia hastened extubation, eye opening, following commands and orientation, and eliminated prolonged time to extubation without increasing early or late complications.
Arterial catheters are commonly inserted for intraoperative monitoring but are known to cause complications. We analysed all cases of arterial catheter complications and incidents related to arterial line monitoring reported to webAIRS. Anaesthetists voluntarily reported cases between 2009 and 2023. Included incidents met keyword search criteria and involved the insertion and presence of an arterial catheter, covering complications relating to the accuracy of arterial blood pressure readings, equipment or monitoring malfunction or human error related to equipment usage. Our aim was to promote awareness of both common and rare complications of arterial lines. Of the 10,518 incidents, 53 incidents met criteria, with 54 events described. Twenty-seven (50%) incidents were related to equipment failure, 17 (31%) compromised flow, five (9%) nerve injury, two (4%) medication error, one (2%) injury to skin, one (2%) infection and one (2%) inability to place an arterial catheter. The most common equipment problem was related to inappropriate transducer height causing inaccurate readings. No harm occurred in 16 (29.5%) of the patients, mild harm in 25 (46%), moderate harm in 10 (18.5%), severe harm in two (4%) and death in one (2%). Clinician vigilance is critical in the preparation, insertion and monitoring of arterial catheters, to allow the detection of problems and prevention of patient harm.
A 1939 German publication on a search for novel synthetic atropine substitutes reported that 'Substanz III', named Dolantin (now generically known as pethidine and meperidine), was found coincidentally to also have morphine-like, albeit markedly weaker, analgesic properties. With a chemical structure not obviously related to morphine, it was thus an 'accidental opioid' and was soon successfully marketed in many countries for pain relief. By the 1970s, continuing advances in analytical chemistry were enabling pharmacokinetic studies of countless drugs. Among opioid analgesic agents, pethidine's larger dosing requirements made it suitable for such research, which was performed in healthy volunteers and patients with various doses and routes of administration, with some reports also including pharmacological responses. Standard postoperative intramuscular pethidine administration revealed steep and unpredictable plasma concentration-analgesic response relationships characterised by marked variability between patients. Novel computer-designed intravenous infusions based on typical pethidine pharmacokinetic data were trialled to replace intramuscular injections. These infusions improved the reliability of postoperative pain management but could not overcome the variability in individual patient requirements. This limitation accelerated the development of empirical 'patient-controlled analgesia' techniques, initially with pethidine, and subsequently with other opioid analgesic agents, thereby enabling personalised pain management. The 1970s' discovery of spinal opioid receptors and mechanisms led to neuraxial pethidine administration being investigated and subsequently integrated into standard clinical practice. Although pethidine has now been superseded in many countries, it served as an important 'model' drug to investigate how to improve the use of opioid analgesic agents for the management of severe pain.
Large language models (LLMs) can achieve passing scores in specialist-level examinations, yet their capacity to author high-stakes examination content remains under-explored. Compared with published human benchmarks, LLMs create questions roughly 10 times faster, and contextual memory across sessions enables rapid diversification of topic coverage. Prompt design therefore emerges as an academic, not merely technical, craft. This article synthesises the emerging literature on artificial intelligence-assisted item writing and illustrates, through stepwise experimentation with OpenAI GPT-4o, how deliberate prompt engineering can align LLM output with the high standards of medical examinations. Key strategies explored include defining clinical context, imposing structural constraints, supplying exemplar items, assigning examiner roles, sequencing chain-of-thought instructions and requesting rationales. In a worked example, these approaches are layered sequentially while generating short-answer questions mapped to Australian and New Zealand College of Anaesthetists curriculum statements. An evidence-based approach to LLM use for question generation could markedly reduce examiner workload, provide educational integrity and enrich item banks.
Propofol-based total intravenous anaesthesia (TIVA) is being increasingly used for maintenance of general anaesthesia due to benefits over volatile anaesthetic-based anaesthesia. An ongoing concern with the use of TIVA is the increased incidence of unintended awareness. The bispectral index (BIS) monitor has been proven to reduce the risk of awareness in relaxant general anaesthesia; however, it does not directly measure or ensure adequate anaesthesia delivery. Volatile anaesthetic delivery is confirmed by end-tidal gas monitoring; however, there is no comparable monitoring in TIVA. Recent research has thus focused on the development of technologies supporting the real-time monitoring of propofol levels, which could allow TIVA to operate with the same direct feedback that end-tidal monitoring provides for the volatile anaesthetics. It would not replace pharmacodynamic effect monitoring such as BIS, as inter-patient variability in anaesthesia doses required for an adequate depth of anaesthesia remains. It could, however, complement it, allowing TIVA to operate with the same level of real-time monitoring, and overall risk of awareness, as volatiles. There are currently no technologies for this in use in the clinical setting. This review provides an overview of the various propofol measuring technologies that have been or are being developed, as well as some of the key ongoing attempts at applying these technologies in clinical settings. We discuss challenges that have impeded the implementation of promising innovations, and outline future directions for making real-time propofol monitoring a clinical reality.
Neck rescue encompasses a variety of techniques and terms used to describe direct access to the trachea to allow delivery of oxygen into the airway, typically in the context of a 'can't intubate, can't oxygenate' (CICO) scenario. Anaesthetists rely on CICO simulation exercises to obtain competency in neck rescue using commercially available plastic airway models. Recently, innovations in three-dimensional (3D)-printed airway models and 'symbiotic culture of bacteria and yeast' (SCOBY) skins have been trialled for CICO training. We undertook a study to compare the fidelity of a 3D-printed airway model and SCOBY skin model with a commercially available plastic and foam model (Crico-Trainer 'Frova', VBM-Medizintechnik GmbH, Sulz am Neckar, Germany) trialled by 27 volunteer anaesthesia specialists and trainees. Study participants performed neck rescue on all model variants and provided structured feedback. The 3D-printed model with SCOBY skin was found to have the highest fidelity for neck rescue training and was the model preferred by most participants. Model fidelity, environmental impact, and ethical considerations were rated as important or very important by participants. Further studies are needed to confirm these findings in other hospital settings.
