Due to the continued use of fossil fuels and other chemical pollutants, atmospheric greenhouse gas concentrations and environmental pollution continue to rise. The health sector is both a driver and a victim of these developments, and intensive care medicine (ICM), with its high energy demands, extensive use of disposable products, and large variety of pharmaceuticals, contributes substantially to the climate crisis and environmental degradation. The European Society of Anaesthesiology and Intensive Care (ESAIC) therefore aimed to develop consensus recommendations to reduce the environmental footprint of ICM across Europe. A total of 37 recommendations were initially drafted by four topic groups (1) energy, (2) waste management, (3) medication, and (4) ethics-each composed of three to five experts. To facilitate implementation in both middle- and high-income European countries, the agreement threshold was set at 80%. The recommendations were validated by 37 experts from 20 countries using a two-step Delphi procedure. In the first round, all recommendations reached at least 75% agreement. After amendments to four recommendations based on expert feedback, all achieved over 80% approval in the second round, with 32 receiving more than 90% agreement. The final recommendations address: (1) a complete transition to renewable energy and implementation of energy-saving strategies; (2) optimisation of procurement in clinical processes (10Rs) and waste management solutions for single-use plastics; (3) reduction of greenhouse gas emissions (mainly fluorinated gases) and water toxicity caused by medications, as well as prevention of a further increase in antimicrobial resistance (AMR); and (4) implementation of an environment-related, ethically guided precautionary principle. This ESAIC consensus provides a practical framework for sustainable ICM. Stakeholders at all levels should now introduce these recommendations through institutional policies, procurement criteria, guidelines and quality improvement programmes to align intensive care practice with planetary health goals.

Anaesthesia and surgery in the 21st century are the safest they have ever been, with over 300 million operations occurring worldwide every year. Mortality rates are consistently around 0.5-1% for elective non cardiac surgery; however, this commonly cited metric only describes part of the story. It is time for us to acknowledge, as many of our patients do, that mortality and length of hospital stay are useful but incomplete measures of perioperative success. Recently, there has been a shift in focus towards Value-Based HealthCare (VBHC), patient-centred outcome metrics (Patient-Reported Outcome Measures or PROMs) and Patient-Reported Experience Measures (PREMs) as markers of success. In this review, we examine the current state of patient-centred precision care (PC) with relevance to anaesthesia.

Anaesthesiologists, intensive care, and perioperative physicians work within multidisciplinary teams in high-risk environments where adverse events may threaten patient safety and are often avoidable. They face converging challenges, including multimorbidity and increasing clinical complexity, workforce shortages and burnout, technological evolution, and rising expectations for safety, equity, and sustainability. In this expert-driven evidence-based consensus review, we aim to demonstrate that simulation-based education and training (SBET) is uniquely positioned to address these challenges. We review how SBET adds value across the professional lifespan, from initial training to high-stakes examinations and continuing professional development. We further examine how SBET enhances team performance, identifies latent system threats, and supports organisational redesign through translational simulation. We examine how SBET can prepare for the future by fostering digital and ecological competencies. We explore key barriers to implementation, as despite SBET's value, its adoption across anaesthesiology, intensive care, and perioperative medicine remains fragmented, with limited interprofessional integration and few national frameworks. Above all, we advocate for coordinated value-based adoption of SBET across education and healthcare systems, recognising it not merely as an educational method but as a strategic infrastructure for high-reliability healthcare systems. Sustained investment, protected time, faculty development, and interprofessional integration are essential to realise its full potential. Aligned strategies to close the gap between evidence and practice are crucial. Without decisive and collective action, education and healthcare risk losing one of the most effective tools for improving patient safety, enhancing individual and system resilience, and maintaining the highest standards of excellence across our specialty and interprofessional practice.

Portal vein Doppler ultrasound has emerged as a promising tool for haemodynamic assessment in critical care and peri-operative medicine. This educational narrative review integrates fundamental cardiovascular physiology concepts, including Guyton's venous return model and the hepatic arterial buffer response, with practical clinical applications of portal vein assessment at the bedside. The portal vein's position at the intersection of splanchnic circulation and hepatic perfusion makes it relevant in evaluating venous haemodynamics. We describe the technical aspects of portal vein Doppler measurement, including probe positioning, anatomical landmarks and measurement standardisation. Portal vein Doppler ultrasound characteristics (diameters, flows, pulsatility) are primarily determined by backward right ventricular pressure wave transmission through the hepatic venous system, modulated by right ventricular function and systemic venous compliance. We present portal flow patterns across different haemodynamic conditions and discuss their clinical interpretation in three settings: cardiac surgery, general intensive care and peri-operative medicine. The relationship between portal vein Doppler and other venous congestion assessment tools, including the venous excess ultrasound score, is discussed. While portal vein pulsatility provides valuable information to guide clinical strategies regarding volume status and venous congestion, the current evidence is predominantly observational. Prospective multicentre validation studies are needed before portal vein Doppler-guided algorithms can be recommended for routine clinical use.