Tranexamic acid (TXA) has been reported to reduce transfusion requirements in liver transplantation (LT). However, clinical evidence regarding the impact of TXA on graft function and other outcomes in liver transplant recipients remains limited. This study aimed to evaluate the effect of TXA on early allograft function following LT. In this prospective, single-centre, randomised study, 89 adult participants scheduled for LT were randomised to receive either TXA or placebo. After anaesthesia induction, a continuous infusion of TXA (10 mg/kg/h) was maintained until portal vein unclamping in the TXA group, while the control group received an equivalent volume of 0.9% saline. The anaesthesia protocol was standardised across both groups. Within 7 days post-transplantation, early allograft dysfunction occurred in 12 of 43 patients in the TXA group compared with 6 of 46 patients in the control group (28% vs 13%, P=0.08). Median aspartate transaminase level was significantly higher in the TXA group on post-operative day 1 compared to the control group (841 vs 622 IU/L, P=0.03). No significant differences were observed between the two groups in transfusion volume, acute kidney injury incidence, thromboembolic events, hospital length of stay, total hospitalisation costs, in-hospital mortality and 180-day survival. TXA administration in liver transplant patients failed to demonstrate beneficial effects on incidence of early graft dysfunction, transfusion requirements or other perioperative outcomes compared to placebo. The routine use of TXA must be undertaken with caution.

Acute pulmonary embolism (PE) management has become increasingly complex, resulting in clinical uncertainty and practice variability. Pulmonary Embolism Response Teams (PERT) are recommended to facilitate timely, consensus-driven management in complex cases. A statewide survey was conducted in 2025 across major public hospitals in Queensland, Australia, with emergency, internal medicine or thoracic services and intensive care units. The survey assessed available resources, the presence of PERTs and the use of management protocols for acute PE. Of 26 eligible hospitals, 80 departmental responses were received (response rate 86%), representing at least one department per hospital. While 96.2% of hospitals could rapidly assess and provide treatment for patients with acute PE, only 10 (38.5%) were able to deliver the full spectrum of medical, surgical and endovascular therapies. Multidisciplinary follow-up was available in 73.1% of hospitals, but only 57.7% routinely collected outcome data. Established PERTs were present in 26.9% of hospitals, predominantly larger academic teaching hospitals. For hospitals with a PERT, all had a single point of contact while only three of seven used a conference calling system. While an intensivist was involved in calls at all participating facilities, a thoracic physician was routinely involved in the PERT call process in five hospitals (71.4%), and a cardiologist in just three (42.9%) hospitals. Considerable variability was identified in protocol awareness, follow-up arrangements, PERT structure and activation processes. Despite widespread capacity for PE management, significant variability exists in resource availability, protocol use, specialist follow-up and PERT implementation.

Patient-reported outcomes in the post-anaesthesia care unit (PACU), such as pain, postoperative nausea and vomiting (PONV) and hypothermia, are often used for quality improvement (QI) purposes and to benchmark hospitals and anaesthetists. However, it is unclear whether variations in these measures reflect differences between clinicians or are driven by factors beyond clinician control. The aim of this study was to quantify how much of the variation in patient outcomes of severe pain, PONV and hypothermia in PACU, was associated with individual anaesthetists and PACU nurses, after adjusting for patient and surgical factors. Data from 71,113 adult surgical cases at a single tertiary institution were analysed. PACU outcomes of pain, PONV and hypothermia were assessed using mixed-effect logistic regression models, where clinicians were random effects, and patient and surgical factors were fixed effects. For each outcome, the proportion of variance associated with PACU nurses, after adjustment for patient and surgical factors, exceeded that associated with anaesthetists (pain 2.9% vs 1.1%; PONV 1.9% vs 1.1%; hypothermia 14.2% vs 1.5%). The majority of variation was explained by patient, surgical and unmeasured factors. These findings indicate that the outcomes examined predominantly reflect case-mix and system factors, with little observable variability attributable to individual anaesthetists. Consequently, these outcomes should not be used as performance indicators for anaesthetists, but rather for focused QI projects in targeted patient and surgical groups.

Desflurane is a potent greenhouse gas (GHG) and major contributor to healthcare carbon emissions. Clinician-led interventions to reduce its use have been implemented, but their effectiveness has not been systematically reviewed. We aimed to synthesise available evidence on the effectiveness of hospital-based interventions designed to reduce desflurane use. Four databases were searched from inception to 3 July 2025. Randomised and non-randomised controlled trials (RCTs), interrupted time series (ITS) and controlled or uncontrolled before-and-after studies were included. Outcome measures were desflurane consumption (primary), GHG emissions, costs, alternate anaesthetic consumption and staff outcomes. Paired authors independently screened studies, extracted data, assessed risk of bias and certainty of the evidence. Due to heterogeneity, results were synthesised using a structured summary of intervention effects with no meta-analysis. Twenty-three studies were included: 13 uncontrolled before-after studies, seven ITSs and three RCTs. Common interventions were environmental changes (n = 20) and education (n = 19). No study was rated at low risk of bias across all criteria. All studies that reported impacts on desflurane consumption (17/17), GHG emissions (16/16) and costs (14/14) found reductions. Use of alternative anaesthetics was inconsistent for sevoflurane (n = 15) and isoflurane (n = 7) but increased for propofol (n = 7). Staff knowledge (3/4) and behaviour (3/3) improved; however, attitudes were unfavourable (1/1) and acceptability was inconsistent (1/1). The evidence was very uncertain for all outcomes. Hospital-based interventions targeting desflurane use may reduce consumption, GHG emissions and costs, with inconsistent effects on alternative anaesthetic use and staff outcomes. However, the evidence is very uncertain.

Desflurane use is declining in Australia, owing to awareness of its environmental impacts, high costs, effective comparator agents and decisions by hospitals and Medicines and Therapeutics Committees (MTCs) to restrict its use. At a roundtable in June 2024, the Council of Australian Therapeutic Advisory Groups (CATAG) agreed to establish an expert advisory group (EAG) to review evidence on desflurane and provide recommendations for its use in Australian hospitals. The Position Statement on the formulary listing of desflurane was released in March 2025. This article provides the evidence review, alongside recommendations, with updates demonstrating continued progress on the reduction of desflurane use. The review found that desflurane is similar to sevoflurane in its clinical efficacy and safety profile, with desflurane demonstrating modest improvements in extubation times that do not translate to reduced stay in the post-anaesthesia care unit or a reduction in complications. In addition, desflurane is a greenhouse gas, with an impact 40-50 times that of sevoflurane. The review also found that cost savings accompany policies to curtail the use of desflurane in health services. The EAG agreed to the following recommendations, which were endorsed by CATAG: 1. Health Service Organisations and MTCs should consider not listing desflurane on hospital or state-based formularies; 2. Health Service Organisations and MTCs should undertake consultation and planning prior to removal of desflurane from theatres; 3. MTCs may consider establishing limited provisions for exceptional use of desflurane based on clinical need.

In contrast to the public spectacle of the Ether Demonstration in 1846, modern regional anaesthesia had a quiet beginning in 1784. That year, James Moore (1762-1860), a Scottish junior surgeon, published the first English book devoted solely to anaesthesia: 'A Method of Preventing or Diminishing Pain in Several Operations of Surgery'. Using a purpose-made iron nerve compressor, Moore successfully anaesthetised the lower limb and completed a near-painless below-knee amputation with John Hunter (1728-1793). Similarly, he also performed the first brachial plexus anaesthesia, introducing the concept of 'plexus anaesthesia'. Beyond this achievement, Moore's 50-page book covers essential perioperative practices that are still relevant today. With the recent rediscovery of a Moore's compressor in Scotland by the authors, this paper critically analyses Moore's contribution. It reframes his narrative through frameworks such as the sociological tipping point, self-experimentation, anatomical analysis and collaboration, challenging the prevailing historical paradigm.

We report the use of dexmedetomidine sedation, high-flow nasal oxygen and regional anaesthesia for a term neonate (16 days old, 2.6 kg) with amniotic band syndrome undergoing hand surgery. We discuss the pharmacokinetics of dexmedetomidine and use of high-flow nasal oxygen insufflation in this age group. Age-dependent pharmacokinetics and pharmacodynamic effects of dexmedetomidine make dosing challenging in neonates, but when used appropriately it can minimise the need for exposure to general anaesthesia, airway instrumentation and mechanical ventilation, all of which are associated with adverse perioperative events in neonates, such as apnoea, bradycardia and prolonged postoperative ventilation.

During the Second World War, acute shortages of medically qualified personnel prompted Addenbrooke's Hospital, Cambridge to train experienced nursing sisters to administer anaesthetics. Drawing on material from the Addenbrooke's archives, personal memoirs of participants, records from hospitals in Norwich and Ipswich, and contemporaneous correspondence published in the British Medical Journal and the Lancet, this article examines the development, professional reception, and eventual cessation of the Sister Anaesthetist scheme at Addenbrooke's Hospital. This scheme was formally proposed in May 1940, and modelled on an existing programme which had been established at the Norfolk and Norwich Hospital almost two decades previously. Despite the requirement for a structured 6-month apprenticeship and ongoing evidence of clinical competency by those enrolled, the scheme generated fierce opposition from local Honorary Anaesthetists, culminating in a collective threat of resignation in June 1941. Sister Anaesthetists were consistently framed as a temporary emergency measure and their employment formally ended in May 1946 when a medically qualified Resident Anaesthetist was appointed. We briefly consider how these historical patterns - pragmatic necessity versus professional identity, training variability, medicolegal uncertainty, and the contested temporariness of non-physician roles - resonate with present-day discussions surrounding Anaesthesia Associates in the United Kingdom.

The development of the taipan antivenom in Australia is a unique story, centred in Far North Queensland. It is infused with idealism and heroism. The taipan is one of the world's deadliest snakes. A live specimen of the coastal taipan was not captured until 1950, and the antivenom only became available in 1955. Until then a bite from the coastal taipan was universally fatal. Kevin Budden a snake enthusiast was bitten in the process of capturing the specimen. Budden extracted a promise from those around him that the snake would not be killed but be sent to the Commonwealth Serum Laboratories in Melbourne for milking. From this courageous act, the antivenom was developed and many lives subsequently saved. The first use of the taipan antivenom was on a boy in Cairns. He survived and grew up to become an anaesthetist.

Cuffed tracheal tubes are widely used in paediatric airway management, but passage through the relatively narrow subglottic airway may increase insertion resistance and risk mucosal trauma. This study evaluated whether spiral deflation (i.e. folding the cuff inward like an umbrella) and warming the tube could reduce cuff diameter and insertion force in a simulated trachea. Four commercially available polyvinyl chloride-cuffed tubes with an internal diameter of 5.0 mm (PORTEX[®] (Smiths Medical International Ltd, Ashford, UK), Sheridan[®] (Teleflex Inc., Morrisville, NC, USA), Shiley™ (Medtronic, Minneapolis, MN, USA), and VentiSeal™ (Flexicare Medical Ltd, Mountain Ash, UK)) were examined. Spiral deflation significantly reduced cuff diameter, with reductions of (mean difference, MD) -3.6 mm (95% confidence intervals, CI -4.5 to -2.7, P <0.001), -2.8 mm (-4.0 to -1.6, P <0.001), -3.5 mm (-5.0 to -2.1, P=0.001), and -4.9 mm (-6.0 to -3.9, P <0.001), respectively. Spiral deflation also decreased insertion force, with reductions of (MD (CI)) -1.01 N (-1.52 to -0.50, P=0.008), -0.34 N (-0.63 to -0.05, P=0.115), -0.49 N (-0.61 to -0.37, P <0.001), and -2.33 N (-3.83 to -0.84, P=0.028), respectively. Additional warming at 40°C further lowered insertion force, with reductions of (MD (CI)) -0.12 N (-0.19 to -0.05, P=0.020), -0.06 N (-0.08 to -0.03, P=0.002), -0.07 N (-0.11 to -0.03, P=0.010), and -0.48 N (-0.86 to -0.11, P=0.068), respectively. Spiral deflation with warming did not affect extubation force or sealing performance. Overall, spiral deflation effectively reduced cuff diameter by approximately 25% and lowered insertion force, while warming further enhanced ease of insertion. These approaches did not compromise sealing or extubation performance.