Anesthesia in the News
  • Anesthesiology and Climate Change

    An international group of anesthesia practitioners has released a consensus statement emphasizing the need to reduce greenhouse gas emissions and medical waste in daily anesthesia practice as well as promote environmental sustainability in education, research, and quality-improvement initiatives.

    The document, published online November 1 in Anaesthesia, lays out seven general principles which the group states are “achievable globally, with minimal material resources and financial investment.”  The working group was led by the World Federation of Societies of Anesthesiologists and included 45 anesthesia practitioners from 29 countries across all continents except Antarctica.

    Although professional groups such as the American Society of Anesthesiologists and the European Society of Anaesthesiology have previously released sustainability guidelines, the authors note the prior recommendations were mainly applicable to anesthesia practitioners in high-income countries.

    While emphasizing that patient care should never be compromised by sustainable practice, the participants reached consensus on 7 main principles to promote environmental sustainability in anesthesia and critical care:

    • Clinical practice should have minimal effect on the environment.
    • Medications and equipment that are less damaging to the environment should be preferred when doing so is clinically safe.
    • The overuse/waste of medications, equipment, energy, and water should be minimized.
    • Environmental sustainability principles should be incorporated within formal anesthesia education.
    • Environmental sustainability principles should be incorporated into anesthesia research and quality improvement programs.
    • Local healthcare organizations should support environmental sustainability.
    • The field of anesthesia and critical care should collaborate with industry to improve environmental sustainability.

    Under each principle, the group included more descriptive, actionable points to guide practitioners.  To reduce emissions, for example, the group recommends use of single inhalational anesthetics that have the lowest global-warming potential.  Halothane or sevoflurane should be considered before isoflurane, the authors write, and isoflurane is preferable to desflurane.  (The group notes that desflurane has the highest atmospheric heat-trapping properties of all the inhalational agents.)  In countries where it is available, high-emission inhalational agents such as nitrous oxide and desflurane should only be used in “specific agreed cases.”

    The authors also endorse the use of low air flows during sedation, general anesthesia when appropriate, and reducing unnecessary preoperative investigations.

    Scope of the issue

    Globally, healthcare is responsible for nearly 5% of total global greenhouse gas emissions and similar fractions of harmful air pollutants.  Commonly used inhalational anesthetics, such as desflurane and sevoflurane, are recognized greenhouse gases, and operating rooms alone produce one fourth of all medical waste.

    The authors also focus attention on waste, highlighting that operating theaters produce 25% of all hospital waste, of which 25% arises from anesthesia care.  Approximately 25% of all operating room waste is readily recyclable they state, yet overall recycling rates remain very low.

    The group acknowledges that estimates of global emissions stemming from anesthesia practice are unavailable due to data gaps.  However, they cite that inhalational anesthetic agents alone are estimated to contribute nearly 3% of these healthcare-related emissions in the United Kingdom, where the National Health Service (NHS) has been tracking its emissions for over a decade.  Thus, they conclude “regardless of the exact level of impact of anesthesia gases in individual countries, their total global impact on the climate is substantial and can no longer be ignored.”

    Unlike other greenhouse gases, inhalational anesthetic agents have not previously been included in international regulation and reporting under the Kigali Amendment of the Montreal Protocol, the Kyoto Protocol, or the Paris Agreement, possibly due to their perceived medical necessity, the authors state.  As a result, there is an absence of accurate production and consumption data, making it challenging to engage policymakers, professional societies, healthcare organizations, and health professionals in practice improvements.

    Use or reuse?

    One of the challenges for the group to agree upon was whether single-use disposable equipment should be used preferentially over sterilizing and reusing devices, since single-use devices can appear to be more wasteful, though high amounts of energy and water can be used in the sterilization process for reuse of devices.

    The authors noted that the ‘single-use vs. reuse’ debate requires a nuanced understanding, balancing the needs of the individual patient with those of the anesthesia provider, the hospital’s financial situation, and the population, as part of wider environmental health considerations, concluding that “there is also considerable scope for further exploration into improving the energy efficiency of device manufacture, transport and disposal, single-use device reprocessing and reusable device sterilization.”

    Fundamental imperatives

    The Group noted that the mission to reduce the environmental impact of anesthesia must align with three underlying fundamentals:  patient safety should not be compromised by sustainable anesthesia practices; high-, middle-, and low-income countries should support each other appropriately in delivering sustainable healthcare (including anesthesia); and healthcare systems should be mandated/monitored to reduce their contribution to global warming.

    The authors conclude: “We suggest that [these 7] consensus principles form the basis of sustainable anesthesia practice.  Our expert opinion is that these recommendations are achievable globally, with minimal material resources and financial investment.  A number of resources already exist on how to implement the recommendations made in this paper, which anesthesia providers should discuss regularly at institutional and national meetings.  This work is iterative, with opinion forming much of the basis for the recommendations, informed by published evidence.  We suggest that these principles undergo re-evaluation and updates as better evidence is published, and we strongly encourage institutions to sponsor anesthesia providers in undertaking the necessary research as a matter of urgency.”

    The full consensus statement is downloadable here.

    And see AANA’s paper on policy considerations for Management of Waste Anesthetic Gases here