{"id":10430,"date":"2022-04-10T10:38:46","date_gmt":"2022-04-10T00:38:46","guid":{"rendered":"https:\/\/codachange.org\/?page_id=10430"},"modified":"2023-01-31T07:35:00","modified_gmt":"2023-01-30T20:35:00","slug":"anaesthetic-gases-info","status":"publish","type":"page","link":"https:\/\/codachange.org\/anaesthetic-gases-info","title":{"rendered":"ACT – Shift Practice – Anaesthetic Gases"},"content":{"rendered":"

[vc_row full_width=”stretch_row_content” gap=”30″ full_height=”yes” bg_type=”image” parallax_style=”vcpb-default” bg_image_new=”id^12255|url^https:\/\/codachange.org\/wp-content\/uploads\/2022\/06\/shutterstock_1302822568-scaled.jpg|caption^null|alt^null|title^Anesthesia,Machine,In,Hospital,Operating,Room.|description^null” bg_image_repeat=”no-repeat” bg_override=”full” enable_overlay=”enable_overlay_value” overlay_color=”rgba(0,0,0,0.38)” css=”.vc_custom_1655788718913{padding-top: 100px !important;padding-bottom: 100px !important;background-position: center !important;background-repeat: no-repeat !important;background-size: cover !important;}” el_class=”funky-header earth-header no-dot”][vc_column css_animation=”fadeInRight” width=”1\/4″][\/vc_column][vc_column width=”1\/2″ css=”.vc_custom_1651633177414{background-color: #232323 !important;}” el_class=”funky-header-inner”][vc_row_inner content_placement=”middle” css=”.vc_custom_1620064050533{margin-top: 0px !important;margin-right: 0px !important;margin-bottom: 0px !important;margin-left: 0px !important;padding-top: 50px !important;padding-bottom: 50px !important;}”][vc_column_inner css=”.vc_custom_1606433526260{border-top-width: 5px !important;border-right-width: 5px !important;border-bottom-width: 5px !important;border-left-width: 5px !important;}”][vc_column_text css_animation=”fadeInDown” css=”.vc_custom_1651455483993{padding-top: 20px !important;padding-bottom: 20px !important;}” el_class=”green”]<\/p>\n

Shift Practice<\/h1>\n

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Decrease greenhouse gas pollution in anaesthesia<\/h3>\n

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PROBLEM<\/h2>\n

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Volatile anaesthetic drugs alone are estimated to be responsible for 0.01 \u2013 0.1% of total global CO2 equivalent (CO2e) emissions\n\t\t\t\t\t <\/div>\t
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[vc_column_text]Anaesthesia is a carbon-intensive specialty, involving the routine use of inhaled drugs which are potent greenhouse gases. After patient use, these gases are exhausted directly to the environment, where they accumulate in the atmosphere contributing to global warming. Such inhaled anaesthetic drugs are volatile halogenated organic compounds (sevoflurane, desflurane, isoflurane, halothane) and nitrous oxide (N2<\/sub>O). The environmental impacts of desflurane and N2<\/sub>O are several times greater than the other inhaled anaesthetics, making them an even higher mitigation priority.<\/p>\n

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Volatile anaesthetic agents have been estimated to be responsible for 0.01 \u2013 0.1% of total global CO2 <\/sub>equivalent (CO2<\/sub>e) emissions contributing to global warming; and based on atmospheric sampling of volatile agents, their accumulation is increasing (particularly desflurane). Whilst a seemingly small contribution to total global emissions, inhaled anaesthetics frequently account for 5% of acute hospital CO2<\/sub>e emissions, and 50% of perioperative department emissions (in high income countries). Their use is directly within the control of anaesthesia providers and thus, their stewardship is an important opportunity for greenhouse gas mitigation and leadership in healthcare environmental sustainability.[\/vc_column_text]<\/div><\/div>\n\n\t\t\t<\/div>[\/vc_column][\/vc_row][vc_row el_class=”coda-big-toggle”][vc_column width=”1\/6″][vc_column_text]<\/p>\n

Action<\/h2>\n

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Important ways you can decrease greenhouse gas pollution in anaesthesia\n\t\t\t\t\t <\/div>\t
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Anaesthesia practitioners to exercise stewardship in the use of volatile anaesthetic agents, when clinically safe to do so.<\/p>\n

Actions to reduce inhaled anaesthetic atmospheric waste include:<\/p>\n

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1. Use lowest fresh gas flow rates during all stages of anaesthesia (e.g. <1L\/minute during maintenance).<\/p>\n

2. Avoid high impact inhaled anaesthetics: desflurane, nitrous oxide.<\/p>\n

3. Decommission N2<\/sub>O central piping, and switch to portable tanks that remain closed between uses.<\/p>\n

4. Consider intravenous and regional techniques, when safe to do so.<\/p>\n

5. Measure inhaled anaesthetic greenhouse gas emissions at an institutional and provider level to support education, practice improvement and set targets for mitigation.<\/p>\n

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N.B. More research is needed before investing in waste anaesthetic gas (WAG) trapping (for volatiles only) or WAG destroying (N2<\/sub>O only) technology. While such technology appears promising, only a fraction of WAG is captured\/re-processable for potential reuse.\u00a0 Further, reuse requires regulatory approval, and thus storage of reprocessed volatiles is presently required.\u00a0 Avoidance of these inhaled anaesthetics and reduction of fresh gas flows (FGFs) are much higher priorities.[\/vc_column_text]<\/div><\/div>\n\n\t\t\t<\/div>[\/vc_column][\/vc_row][vc_row el_class=”coda-big-toggle”][vc_column width=”1\/6″][vc_column_text]<\/p>\n

Journal Article<\/h2>\n

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Read the associated journal article here\n\t\t\t\t\t <\/div>\t
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[vc_column_text]This action guidance has been published in Anaesthesia.\u00a0<\/i>To read the full article, please click here\u00a0<\/a>[\/vc_column_text]<\/div><\/div>\n\n\t\t\t<\/div>[\/vc_column][\/vc_row][vc_row el_class=”coda-big-toggle”][vc_column width=”1\/6″][vc_column_text]<\/p>\n

Success Story<\/h2>\n

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Be Inspired by some success stories\n\t\t\t\t\t <\/div>\t
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[vc_column_text]1. Desflurane, which has a global warming potential over 100 years of 2540 CO2<\/sub> equivalents (CO2<\/sub>e), was eliminated from the Yale New Haven Health System formulary in 2013 in favor of sevoflurane, saving an estimated US$1.2 million and 1.6 million kg CO2<\/sub>e (the equivalent of 360 passenger vehicles) annually from the flagship hospital alone.<\/p>\n

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2. In Australia and New Zealand, a network of anaesthesia trainees has formed a group to drive research and other initiatives around environmental sustainability in anaesthesia (TRA2SH \u2013 Trainee-led Research and Audit in Anaesthesia for Sustainability in Healthcare).\u00a0 \u00a0This group has promoted an online pledge to encourage anaesthesia departments to immediately reduce their use of desflurane and remove it from their hospital formulary by 2025.\u00a0 Several large institutions, including The Alfred, Western Health and Fiona Stanley Hospital, have already removed desflurane from their formulary, along with many others who have pledged to do so prior to 2025 Link<\/strong><\/a>.<\/strong><\/strong><\/p>\n

At the Fiona Stanley Hospital in Perth, the removal of desflurane from their formulary has saved approximately AUD$90 000 and approximately 300 tonnes CO2<\/sub>e per year (equivalent of 60 return flights from Perth to London). At Western Health in Melbourne, this same action has saved AUD$30 000 and reduced emissions by 140 tonnes per year (the equivalent of 36 return flights from Melbourne to London). Following their action in 2021, The Alfred Hospital reported only positive, supportive departmental feedback Link<\/strong><\/a>.<\/strong><\/strong><\/p>\n

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3. After labelling on environmental impact at the point of use, desflurane use at the University of Wisconsin was reduced by 55% in favour of sevoflurane. This resulted in a saving of $25,000\/month in 2015, and an average reduction of per anaesthetic case emissions from 163kg CO2<\/sub>e pre-intervention to 58kg CO2<\/sub>e post-intervention. Link<\/strong><\/a><\/p>\n

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4. The University of California San Francisco implemented an electronic clinical decision support tool, aimed at nudging providers to reduce FGFs in real-time.\u00a0 The electronic health record tool alerts providers if FGFs > 0.7 L\/min for desflurane, and >1 L\/min for sevoflurane, during maintenance anaesthesia. In 2018, researchers demonstrated reductions in mean FGFs by 0.6 L\/min for sevoflurane and 0.2 L\/min for desflurane.<\/p>\n

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5. The primary driver of N2<\/sub>O emissions is loss of gas in the facility infrastructure.\u00a0 In 2019, Providence St. Vincent hospital in Portland, Oregon, USA, procured 991 metric tons of N2<\/sub>O.\u00a0 Investigators discovered infrastructure leak rates, ranging from <0.1 L\/min to >3.5 L\/min, resulting in use efficiency of 5-40%. Central piped N2<\/sub>O was subsequently decommissioned, and portable e-cylinders substituted, saving 958 metric tonnes of CO2<\/sub>e of N2<\/sub>O annually, equivalent to 2,407,644 fewer car miles driven, and $12,000 in procurement costs.<\/p>\n

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6. In 2020, Lothian NHS Scotland demonstrated system losses from 3 centrally piped N2<\/sub>O systems across two hospital sites, of approximately 790,000 and 685,000 litres, respectively. Mitigation activities, including fully decommissioning centrally piped N2<\/sub>O, eliminated the equivalent of 806 tonnes CO2<\/sub>e per annum. The national Nitrous Oxide Project was subsequently launched in January 2021. By the end of March 2021, 16 hospitals across the NHS reported an annual system loss of 13,770,000 litres, 95% of total procured N2<\/sub>O. This is equivalent to 7,219 tonnes CO2<\/sub>e, comparable to 7,600 flights from Paris to New York.[\/vc_column_text]<\/div><\/div>\n\n\t\t\t<\/div>[\/vc_column][\/vc_row][vc_row el_class=”coda-big-toggle” css=”.vc_custom_1651621277596{padding-bottom: 50px !important;}”][vc_column width=”1\/6″][vc_column_text]<\/p>\n

Further Reading<\/h2>\n

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Below is further information to support individuals in taking action\n\t\t\t\t\t <\/div>\t
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Supporting consensus guideline from the World Federation of Societies of Anaesthesiologists (WFSA):<\/h3>\n

White et al. (2021), \u2018Principles of environmentally-sustainable anaesthesia: a global consensus statement from the World Federation of Societies of Anaesthesiologists\u2019, Anaesthesia,<\/em> 77(2), 201-212 Link<\/a><\/p>\n

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Comprehensive review of basic science and anaesthesia sustainability literature:<\/h3>\n

McGain, Muret, Lawson & Sherman (2020), \u2018Environmental Sustainability in Anaesthesia and Critical Care\u2019, British Journal of Anaesthesia<\/em>, 125(5):680-692 Link<\/a><\/p>\n

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Checklists to improve environmental sustainability in perioperative environments:<\/h3>\n

The ASA Sustainability Checklist: Link<\/a><\/p>\n

The ANZCA Environmental Sustainability Audit Tool: Link<\/a><\/p>\n

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Calculate the comparative CO2<\/sub>e emissions associated with different anaesthesia methods:<\/h3>\n

Yale Gassing Greener App (free), provider educational calculator: Link<\/a><\/p>\n

American Society of Anesthesiologists (free), institutional calculator: Link<\/a><\/p>\n

AAGBI Anaesthetic Impact Calculator (free), provider calculator: available as an app Link <\/a>or spreadsheet Link<\/a><\/p>\n

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Further information and resources about the comparative environmental impact of desflurane and N2<\/sub>O:<\/h3>\n

Desflurane:<\/strong><\/p>\n

The greenhouse gas emissions (CO2<\/sub>e) for desflurane as clinically used are approximately 50 times that of sevoflurane and isoflurane over a 100-year period. Desflurane is also significantly more costly and lacks evidence of improved clinical outcomes over alternative anaesthetics.<\/p>\n

Resources:<\/em><\/p>\n

Sherman, Le, Lamers & Eckelman. (2012) Life Cycle Greenhouse Gas Emissions of Anaesthetic Drugs,<\/em> Anaesthesia and Analgesia, 114(5), 1086-90<\/em> Link<\/a><\/p>\n

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Sherman, Feldman, Chesebro (2020), \u2018Inhaled Anesthetic 2020 Challenge: Reduce your Inhaled Carbon Emissions by 50%!\u201d, ASA Monitor, <\/em>84, 14-17: Link<\/a><\/p>\n

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Sherman & Berkow (2019), \u2018Scaling Up Inhaled Anesthetic Practice Improvement: The Role of Environmental Sustainability Metrics\u2019, Anesthesia & Analgesia<\/em>, 128(6), 1060-1062, Link<\/a><\/p>\n

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McGain et al. Why be sustainable? The ANZCA Professional Document PS64:\u00a0Statement on Environmental Sustainability in Anaesthesia and Pain Medicine. Anaesth Intens Care<\/em> 2019 Sep;47(5):413-422 Link<\/a><\/p>\n

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N2<\/sub>O:<\/strong><\/p>\n

N2<\/sub>O is less potent and must be used in high concentrations (typically 50%) and has a very long atmospheric lifetime (114 years). Therefore, its warming impacts are similar to desflurane in clinically relevant doses.<\/p>\n

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Resources:<\/em><\/p>\n

Sherman, Le, Lamers & Eckelman. (2012) \u2018Life Cycle Greenhouse Gas Emissions of Anaesthetic Drugs\u2019,<\/em> Anaesthesia and Analgesia, 114(5), 1086-90<\/em> Link<\/a><\/p>\n

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Association of Anaesthetists \u2018Nitrous Oxide Project\u2019: Link<\/a><\/p>\n

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Seglenieks R et al. (2022) \u2018Discrepancy between procurement and clinical use of nitrous oxide: waste not, want not\u2019, British Journal of Anaesthesia, 128(1):e32-e34<\/em> Link<\/a><\/p>\n

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Further information about low flow anaesthesia:<\/h3>\n

There have been historical concerns about a theoretical risk of renal injury associated with \u2018compound A\u2019 production when sevoflurane is used with low FGFs. There is no clinical evidence of harm associated with compound A in humans and it is advised that sevoflurane can safely be used with low FGFs to minimise its environmental impact. It is recommended to use CO2<\/sub> absorbers which contain low or no sodium hydroxide (NaOH) during low FGF anaesthesia with sevoflurane.<\/p>\n

Resources:<\/em><\/p>\n

Feldman (2012), \u2018Managing fresh gas flow to reduce environmental contamination\u2019, Anaesthesia and Analgesia, 114(5):1093-101 <\/em>Link<\/a><\/p>\n

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Sondekoppam et al. (2020), \u2018The impact of sevoflurane anesthesia on postoperative renal function: a systematic review and meta-analysis of randomized-controlled trials\u2019, Canadian Journal of Anaesthesia, 67(11):1595-1623 <\/em>\u00a0Link<\/a><\/p>\n

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Environmental impact and use of total intravenous anaesthesia (TIVA):<\/h3>\n

The environmental impact of TIVA is substantially less than volatile anaesthesia, even when consumables and the carbon cost of production is factored in.<\/p>\n

Resources:<\/em><\/p>\n

Sherman and Barrick (2019), \u2018Total Intravenous Anesthetic Versus Inhaled Anesthetic: Pick Your Poison\u2019, Anesthesia and Analgesia, 128(1):13-15. Link<\/a><\/p>\n

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Environmental impact of regional anaesthesia:<\/h3>\n

The use of regional anaesthesia is not a default low carbon alternative and consideration needs to be given to minimising O2 flows, reducing single use plastics and sources of energy generation, to minimise its impact.<\/p>\n

Resources:<\/em><\/p>\n

McGain et al. (2021), \u2018Carbon Footprint of General, Regional, and Combined Anesthesia for Total Knee Replacements\u2019, Anaesthesiology, 135(6):976-991 Link<\/a>[\/vc_column_text]<\/div><\/div>\n\n\t\t\t<\/div>[\/vc_column][\/vc_row][vc_row el_class=”coda-big-toggle” css=”.vc_custom_1651621277596{padding-bottom: 50px !important;}”][vc_column width=”1\/6″][vc_column_text]<\/p>\n

Action<\/h2>\n

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Download this action<\/h2>\n

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