Use of volatile anaesthetic agents in anaesthesia: A survey of practice in France in 2012

Promoting behavioural change by educating anaesthetists about the environmental impact of inhalational anaesthetic agents: A systematic review

Of the total carbon footprint of Australia, 7% is attributed to healthcare. In the UK, inhalational agents make up 5% of the healthcare carbon footprint. This systematic review aims to determine which methods of education about the environmental impact of inhalational anaesthetic agents can be utilised to promote behaviour change, reducing the anaesthetic-related carbon footprint. This systematic review sourced records from CINAHL, EMBASE, ERIC, JBI and MEDLINE from 1970 to March 2022. The search identified 589 records, 13 of which met eligibility criteria after the screening process, in which 10 of these records were conference abstracts. Education curricula focused on inhalational agent choice (69%), lowering the fresh gas flow during maintenance anaesthesia (69%), encouraging alternatives such as total intravenous anaesthesia (23%) and/or switching off the gas on transfer (8%). The most common teaching techniques utilised in education curricula were didactic lectures (85%), visual prompts (54%), emails (46%), and conversation forums (31%). All but one study reported a positive relationship between teaching sessions and behavioural change resulting in lower inhalational anaesthetic use by participants and their organisations, reducing healthcare-associated emissions. This systematic review has demonstrated that single education sessions as well as multi-focused, multimodal education curricula on the topic of greener anaesthesia can be beneficial in promoting behavioural change.

Propofol TCI or sevoflurane anesthesia without muscle relaxant for thoracoscopic thymectomy in myasthenia gravis patients: a prospective, observational study

BACKGROUND

Myasthenia gravis (MG) patients interact unpredictably with anesthetic agents, including neuromuscular blocking agents. Here, we investigate the effectiveness of general anesthesia without muscle relaxants using either propofol via target-controlled infusion systems (TCI) or sevoflurane in MG patients undergoing thoracoscopic thymectomy.

METHODS

This prospective, open-label, observational study was conducted in a university hospital. We included 90 myasthenic patients undergoing thoracoscopic thymectomy with general anesthesia. Patients received induction and maintenance anesthesia with propofol TCI (group P, n = 45) or induction with propofol 2-3 mg.kg-1 and maintenance anesthesia with sevoflurane (group S, n = 45). In both groups, the procedure was performed under the guidance of entropy with sufentanil but not a muscle relaxant. Intubation conditions, hemodynamic changes, respiratory function, neuromuscular transmission, arterial blood gas, and complications were evaluated.

RESULTS

All patients achieved good intubation conditions. Hemodynamic instability was more frequent in group S than in group P, mostly in the induction stage, and was controllable. The reduction in the intraoperative train-of-four ratio from baseline at 30 min, 60 min, and 90 min in group S was 10.3%, 14.2%, and 14.3%, respectively, significantly higher than that in group P (6.8%, 7.2%, and 8.4%, respectively), which completely recovered at the end of the surgery. All patients were extubated in the operating room without complications. No other significant differences between the groups were observed.

CONCLUSIONS

Anesthesia with propofol TCI or sevoflurane without muscle relaxants in MG patients offered safe and effective conditions for thoracoscopic thymectomy. Sevoflurane achieved higher levels of intraoperative muscular relaxation than propofol TCI. Postoperative neuromuscular function was not affected by these anesthetics.

A call for immediate climate action in anesthesiology: routine use of minimal or metabolic fresh gas flow reduces our ecological footprint

PURPOSE

Climate change is a global threat, and inhalational anesthetics contribute to global warming by altering the photophysical properties of the atmosphere. On a global perspective, there is a fundamental need to reduce perioperative morbidity and mortality and to provide safe anesthesia. Thus, inhalational anesthetics will remain a significant source of emissions in the foreseeable future. It is, therefore, necessary to develop and implement strategies to minimize the consumption of inhalational anesthetics to reduce the ecological footprint of inhalational anesthesia.

SOURCE

We have integrated recent findings concerning climate change, characteristics of established inhalational anesthetics, complex simulative calculations, and clinical expertise to propose a practical and safe strategy to practice ecologically responsible anesthesia using inhalational anesthetics.

PRINCIPAL FINDINGS

Comparing the global warming potential of inhalational anesthetics, desflurane is about 20 times more potent than sevoflurane and five times more potent than isoflurane. Balanced anesthesia using low or minimal fresh gas flow (≤ 1 L·min-1) during the wash-in period and metabolic fresh gas flow (0.35 L·min-1) during steady-state maintenance reduces CO2 emissions and costs by approximately 50%. Total intravenous anesthesia and locoregional anesthesia represent further options for lowering greenhouse gas emissions.

CONCLUSION

Responsible anesthetic management choices should prioritize patient safety and consider all available options. If inhalational anesthesia is chosen, the use of minimal or metabolic fresh gas flow reduces the consumption of inhalational anesthetics significantly. Nitrous oxide should be avoided entirely as it contributes to depletion of the ozone layer, and desflurane should only be used in justified exceptional cases.

[French national overview of the inclusion of environmental criteria in the public purchasing of health products (drugs and sterile medical devices)]

OBJECTIVES

Healthcare products (HP) have a significant carbon footprint that must be included by regulation in the facility's purchasing policy. A national overview of the inclusion of environmental criteria (EC) in the public procurement (PP) of HP in hospitals has been carried out.

METHODS

Thirty EC were identified in the literature. Two questionnaires were proposed: (i) for buyers that analyze the level of "importance" and "ease of application" for public tenders (PT), and (ii) for suppliers that declare their commitments and evidence.

RESULTS

Six regional buyers and 28 suppliers participated. Buyers recognize the "importance" of sustainable development (SD) but are more reticent about the "applicability" of EC in PT. The environmental rating remains low: on average 4.38 (0.25-10.00) % of the total rating. Only 12 EC are integrated within some PT. Suppliers report a high and diversified commitment to SD: 18 suppliers sent 474 evidence. Buyers and suppliers converge on the optimization of primary packaging and the establishment of a minimum order or delivery group.

CONCLUSIONS

Since the efficiency of PP is inevitable, EC that combines SD and savings should be prioritized. The integration of additional EC, simple and easily documented, allowing cost containment for both suppliers and buyers, is possible to promote sustainable purchasing.

A survey of the choice of general anaesthetic agents in Australia and New Zealand

Strategies to reduce the adverse environmental costs of anaesthesia include choice of agent and fresh gas flows. The current preferences of Australian and New Zealand anaesthetists are unknown. We conducted a survey of Australian and New Zealand anaesthetists to determine the use of volatiles, nitrous oxide and intravenous anaesthesia, lowest fresh gas flow rates, automated end-tidal volatile control, and the rationales for these choices. The survey was answered by 359/1000 (36%), although not all questions and multiple responses within single questions were answered by all respondents. Sevoflurane was preferred by 246/342 (72%, 95% confidence interval (CI) 67%–77%), followed by propofol, 54/340 (16%, 95% CI 12%–20%), desflurane 39/339 (12%, 95% CI 8%–16%) and isoflurane 3/338(1%, 95% CI 0–3%). When asked about all anaesthetics, low-risk clinical profile was the most common reason given for using sevoflurane (129/301 (43%, 95% CI 37%–49%)), reduced postoperative nausea for propofol (297/318 (93%, 95% CI 90%–96%)) and faster induction/awakening times for desflurane (46/313 (79%, 95% CI 74%–83%)). Two-thirds (226/340 (66%, 95% CI 61%–71%)) of respondents used nitrous oxide in 0–20% of general anaesthetics. Low fresh gas flow rates for sevoflurane were used by 310/333 (93%, 95% CI 90%–95%) and for 262/268 (98%, 95% CI 95%–99%) for desflurane. Automated end-tidal control was used by 196/333 (59%, 95% CI 53%–64%). The majority of respondents (>70%) preferred sevoflurane at low flows. These data allow anaesthetists to consider further whether changes are required to the choices of anaesthetic agents for environmental, financial, or any other reasons.

Breath gas concentrations mirror exposure to sevoflurane and isopropyl alcohol in hospital environments in non-occupational conditions

Anaesthetic gases and disinfectants are a primary source of air contamination in hospitals. A highly sensitive sorbent-trap methodology has been used to analyse exhaled breath samples with detection limits in the pptv range, which allows volatile organic compounds (VOCs) to be detected at significantly lower levels (5-6 orders of magnitude below) than the recommended exposure limits by different organizations. Two common VOCs used in hospital environments, isopropyl alcohol (IPA) and sevoflurane, have been evaluated. Forced-expiratory breath samples were obtained from 100 volunteers (24 hospital staff, 45 hospital visitors and 31 external controls). Significant differences for IPA were found between samples from volunteers who had not been in contact with hospital environments (mean value of 8.032 ppbv) and people staying (20.981 ppbv, p  =  0.0002) or working (19.457 ppbv, p  =  0.000 09) in such an environment. Sevoflurane, an anaesthetic gas routinely used as an inhaled anaesthetic, was detected in all samples from volunteers in the hospital environment but not in volunteers who had not been in recent contact with a hospital environment. The levels of sevoflurane were significantly higher (p  =  0.000 24) among staff members (0.522 ppbv) than among visitors to the hospital (0.196 ppbv). We conclude that highly sensitive methods are required to detect anaesthetic gas contamination in hospital environments.