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06/25/21

Reduce Pollution by Eliminating Anesthesia Gases
By Matthew J. Meyer, MD
Critical Care Anesthesiologist
Assistant Professor of Anesthesiology
University of Virginia
Charlottesville, VA

Disclaimer: Matthew Meyer serves as a member on the steering committee of “Virginia Clinicians for Climate Action”.

Dr. Matthew J. Meyer

The United States healthcare industry creates 8.5% of the United States’ carbon footprint.1 NHS (National Health System) UK estimates 2% of its carbon footprint comes from anesthesia gases.2 In a single hospital, anesthesia gases may be up to 63% of the carbon footprint of the entire operating room suite.3

As anesthesiologists, we can make a major improvement in the health of the world simply by dialing back (or off) our volatile anesthesia consumption.

The health of our patients is dependent upon the health of our community and environment. Fossil fuel pollution has been linked to 10 million deaths per year.4 Pollution and waste directly and indirectly cause exacerbations of acute and chronic health conditions. In respect of the impact humans are having on the world, the World Health Organization identified climate change as the greatest threat to public health in the 21st century.5

Once administered, anesthesia gases are vented directly into the atmosphere. Volatile anesthesia gases are hydrofluorocarbons (desflurane and sevoflurane) and chlorofluorocarbons (isoflurane).6 These volatile anesthesia gases along with nitrous oxide have tremendous atmospheric energy trapping capability.

Over a twenty-year period, desflurane has 3,714 times the energy trapping of carbon dioxide, isoflurane has 1401 times, sevoflurane is 349 times, and nitrous oxide is 289 times; notably, nitrous oxide’s impact is underestimated using a twenty-year period as it remains in the atmosphere for 114 years.7

The movement to minimize or eliminate desflurane due to its financial cost and climate impact is mature.8,9 Now, the focus is reducing the impact of the remaining anesthesia gases. The American Society for Anesthesiology sponsored the Inhaled Anesthetic Challenge 2020 with the goal of reducing anesthesia gas related emissions by 50%. NHS UK identified a reduction in the usage of anesthesia gases as a key step towards their goal of a 51% reduction in the NHS carbon footprint.2

As clinicians, our purpose is to care for our patients while avoiding unintended harm. If an equivalent option exists that results in less harm to public health, we are ethically obligated to choose this.

Volatile anesthetics could probably disappear from our armamentarium in adult anesthesia with minimal disruption to our ability to deliver high quality anesthesia. For patients who require general anesthesia, total intravenous anesthesia with propofol leads to greater patient satisfaction10 and has a carbon footprint that is orders of magnitude less than volatile anesthetics.11 For appropriate patients and procedures, neuraxial and regional anesthesia provide a huge potential reduction in climate and environmental impact compared to volatile anesthetics.12

Volatile anesthesia gases are frequently used because they are easy to use—they are built into modern anesthesia machines. Total intravenous anesthesia involves more setup. However, this slight time investment may prove beneficial to the large subset of patients; primarily, oncological patients13 and patients with sensitivity to postoperative nausea and vomiting.10

Transitioning from volatile anesthesia should be considered seriously. There does not need to be an abolition of volatile anesthetics, as they are the right tool in patients requiring mask inductions and other specific situations. However, there should be true clinical rationale for their utilization knowing the outsized harm they cause to the global environment and public health. Additionally, the mass adoption of alternatives needs to be done thoughtfully. If volatile anesthetics are replaced with increased nitrous oxide usage,14 this may actually worsen the impact of anesthesia on the global environment and public health.

Sustainability interventions that reduce waste and use less energy often save money too. This was demonstrated by an educational intervention at UW Health directed at volatile anesthetics and reducing fresh gas flows. This multipronged intervention saved the health system $25,000 per month in volatile anesthesia expenditures while reducing the average CO2 equivalent emissions per patient by 64%.15 The savings are even greater when the social cost of carbon is considered.

The social cost of carbon is an economic tool to financially assess the impact of energy trapping emissions on the world. A single ton of CO2 equivalent emissions is estimated to have a financial cost of $417.16 The 64% reduction in carbon equivalent emissions per OR case at UW Health saves approximately $120,000 in global financial loss each month.16

Climate change is an existential threat and many nations, including the US, are already being affected by climate related migration17 and morbidity18 such as that related to Hurricane Maria.

People’s health and well-being are affected by more heat waves, more flooding, more wildfires, and more and different vector-borne infectious diseases.19 Reducing the usage of volatile anesthetics will not independently stop climate change, but it can be done today, and provide additional time for our world to make and implement technological advances that may be needed to address the problem in its entirety.

If interested in learning more about these challenges, their impact on our clinical practice, and the opportunities that will come from solving them, there are many organizations local, national, and international, focused on the interaction of the environment and patient health and well-being.

A few notable organizations that are quite active include: Virginia Clinicians for Climate Action (virginiaclinicians.org), Practice Greenhealth (practicegreenhealth.org), and Healthcare Without Harm (noharm.org).

References

  1. Eckelman MJ, Huang K, Lagasse R, Senay E, Dubrow R, Sherman JD. Health Care Pollution And Public Health Damage In The United States: An Update. Health Aff (Millwood). 12 2020;39(12):2071-2079.
  2. NHS. Putting anaesthetic-generated emissions to bed. Accessed May 7, 2020. https://www.england.nhs.uk/greenernhs/whats-already-happening/putting-anaesthetic-generated-emissions-to-bed/
  3. MacNeill AJ, Lillywhite R, Brown CJ. The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems. Lancet Planet Health. Dec 2017;1(9):e381-e388. doi:10.1016/S2542-5196(17)30162-6
  4. Vohra K, Vodonos A, Schwartz J, Marais EA, Sulprizio MP, Mickley LJ. Global mortality from outdoor fine particle pollution generated by fossil fuel combustion: Results from GEOS-Chem. Environ Res. 04 2021;195:110754. doi:10.1016/j.envres.2021.110754
  5. WHO | WHO calls for urgent action to protect health from climate change – Sign the call. WHO. 2016-04-14 10:26:57 2016;doi:/entity/globalchange/global-campaign/cop21/en/index.html
  6. Charlesworth M, Swinton F. Anaesthetic gases, climate change, and sustainable practice. Lancet Planet Health. 09 2017;1(6):e216-e217. doi:10.1016/S2542-5196(17)30040-2
  7. Ryan SM, Nielsen CJ. Global warming potential of inhaled anesthetics: application to clinical use. Anesth Analg. Jul 2010;111(1):92-8. doi:10.1213/ANE.0b013e3181e058d7
  8. Meyer MJ. Desflurane Should Des-appear: Global and Financial Rationale. Anesth Analg. 10 2020;131(4):1317-1322. doi:10.1213/ANE.0000000000005102
  9. Shelton CL, Sutton R, White SM. Desflurane in modern anaesthetic practice: walking on thin ice(caps)? Br J Anaesth. 12 2020;125(6):852-856. doi:10.1016/j.bja.2020.09.013
  10. Schraag S, Pradelli L, Alsaleh AJO, et al. Propofol vs. inhalational agents to maintain general anaesthesia in ambulatory and in-patient surgery: a systematic review and meta-analysis. BMC Anesthesiol. 11 2018;18(1):162. doi:10.1186/s12871-018-0632-3
  11. Sherman J, Le C, Lamers V, Eckelman M. Life cycle greenhouse gas emissions of anesthetic drugs. Anesth Analg. May 2012;114(5):1086-90. doi:10.1213/ANE.0b013e31824f6940
  12. Kuvadia M, Cummis CE, Liguori G, Wu CL. ‘Green-gional’ anesthesia: the non-polluting benefits of regional anesthesia to decrease greenhouse gases and attenuate climate change. Reg Anesth Pain Med. Sep 2020;45(9):744-745. doi:10.1136/rapm-2020-101452
  13. Chang CY, Wu MY, Chien YJ, Su IM, Wang SC, Kao MC. Anesthesia and Long-term Oncological Outcomes: A Systematic Review and Meta-analysis. Anesth Analg. 03 2021;132(3):623-634. doi:10.1213/ANE.0000000000005237
  14. Muret J, Fernandes TD, Gerlach H, et al. Environmental impacts of nitrous oxide: no laughing matter! Comment on Br J Anaesth 2019; 122: 587-604. Br J Anaesth. 10 2019;123(4):e481-e482. doi:10.1016/j.bja.2019.06.013
  15. Zuegge KL, Bunsen SK, Volz LM, et al. Provider Education and Vaporizer Labeling Lead to Reduced Anesthetic Agent Purchasing With Cost Savings and Reduced Greenhouse Gas Emissions. Anesth Analg. 06 2019;128(6):e97-e99. doi:10.1213/ANE.0000000000003771
  16. Ricke KD, L. Caldeira, K. Tavoni, M. Country-level social cost of carbon. Nature Climate Change. 2018;8:895-900. doi:https://doi.org/10.1038/s41558-018-0282-y
  17. Gamboa S. Puerto Rico’s population fell 11.8% to 3.3 million, census shows. Apr 27, 2021 2021;
  18. Kishore N, Marqués D, Mahmud A, et al. Mortality in Puerto Rico after Hurricane Maria. N Engl J Med. Jul 2018;379(2):162-170. doi:10.1056/NEJMsa1803972
  19. Watts N, Amann M, Arnell N, et al. The 2020 report of The Lancet Countdown on health and climate change: responding to converging crises. Lancet. Jan 2021;397(10269):129-170. doi:10.1016/S0140-6736(20)32290-X
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