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Douglas HF, Midon M, Floriano D, Hopster K. Peri-anesthetic Environmental and Occupational Exposure to Desflurane Waste Anesthetic Gas in a Large Animal Veterinary Hospital. J Occup Environ Med 2024; 66:666-672. [PMID: 38729178 DOI: 10.1097/jom.0000000000003134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
OBJECTIVES The goals were to determine the environmental levels of desflurane waste anesthetic gas and the desflurane occupational exposure of operating room staff during the anesthesia of large animal veterinary patients. METHODS Active environmental sampling was performed using single-beam infrared spectrophotometry. Passive sampling with dosimeter badges was used to measure the occupational exposure of anesthesia and operating room staff. RESULTS Higher concentrations of desflurane (n = 16) were measured at all recovery timepoints relative to the concentrations measured at all locations and timepoints at the start of anesthesia and surgery ( P < 0.05). Time-weighted average desflurane concentrations from dosimeter badges (n = 310) were higher for anesthesia staff than for other operating room personnel ( P < 0.0001). CONCLUSIONS The anesthetic recovery of large animal patients is a period of increased exposure to desflurane waste anesthetic gas for veterinary staff.
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Affiliation(s)
- Hope F Douglas
- From the Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, Pennsylvania
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2
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Lui B, White RS, Bryant-Huppert J, Kelleher DC. Environmental sustainability in obstetric anesthesia. Int J Obstet Anesth 2024; 60:104216. [PMID: 39018740 DOI: 10.1016/j.ijoa.2024.104216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 03/15/2024] [Accepted: 06/06/2024] [Indexed: 07/19/2024]
Affiliation(s)
- B Lui
- Weill Cornell Medical College, New York, NY, USA
| | - R S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - J Bryant-Huppert
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - D C Kelleher
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA.
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3
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Gonzalez-Pizarro P, Brazzi L, Koch S, Trinks A, Muret J, Sperna Weiland N, Jovanovic G, Cortegiani A, Fernandes TD, Kranke P, Malisiova A, McConnell P, Misquita L, Romero CS, Bilotta F, De Robertis E, Buhre W. European Society of Anaesthesiology and Intensive Care consensus document on sustainability: 4 scopes to achieve a more sustainable practice. Eur J Anaesthesiol 2024; 41:260-277. [PMID: 38235604 DOI: 10.1097/eja.0000000000001942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Climate change is a defining issue for our generation. The carbon footprint of clinical practice accounts for 4.7% of European greenhouse gas emissions, with the European Union ranking as the third largest contributor to the global healthcare industry's carbon footprint, after the United States and China. Recognising the importance of urgent action, the European Society of Anaesthesiology and Intensive Care (ESAIC) adopted the Glasgow Declaration on Environmental Sustainability in June 2023. Building on this initiative, the ESAIC Sustainability Committee now presents a consensus document in perioperative sustainability. Acknowledging wider dimensions of sustainability, beyond the environmental one, the document recognizes healthcare professionals as cornerstones for sustainable care, and puts forward recommendations in four main areas: direct emissions, energy, supply chain and waste management, and psychological and self-care of healthcare professionals. Given the urgent need to cut global carbon emissions, and the scarcity of evidence-based literature on perioperative sustainability, our methodology is based on expert opinion recommendations. A total of 90 recommendations were drafted by 13 sustainability experts in anaesthesia in March 2023, then validated by 36 experts from 24 different countries in a two-step Delphi validation process in May and June 2023. To accommodate different possibilities for action in high- versus middle-income countries, an 80% agreement threshold was set to ease implementation of the recommendations Europe-wide. All recommendations surpassed the 80% agreement threshold in the first Delphi round, and 88 recommendations achieved an agreement >90% in the second round. Recommendations include the use of very low fresh gas flow, choice of anaesthetic drug, energy and water preserving measures, "5R" policies including choice of plastics and their disposal, and recommendations to keep a healthy work environment or on the importance of fatigue in clinical practice. Executive summaries of recommendations in areas 1, 2 and 3 are available as cognitive aids that can be made available for quick reference in the operating room.
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Affiliation(s)
- Patricio Gonzalez-Pizarro
- From the Department of Paediatric Anaesthesia and Critical Care. La Paz University Hospital, Madrid, Spain (PGP), the Department of Anaesthesia, Intensive Care and Emergency, 'Citta' della Salute e della Scienza' University Hospital, Department of Surgical Science, University of Turin, Turin, Italy (LB), the University of Southern Denmark (SDU) Odense, Department of Anesthesia, Hospital of Nykobing Falster, Denmark (SK), the Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt Universität zu Berlin, Campus Charité Mitte, and Campus Virchow Klinikum (SK), the Department of Anaesthesiology. LMU University Hospital, LMU Munich, Germany (AT), the Department of Anaesthesia and Intensive Care. Institute Curie & PSL Research University, Paris, France (JM), the Department of Anaesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands (NSW), the Department of Anaesthesia and Perioperatve Medicine. Medical Faculty, University of Novi Sad, Novi Sad, Serbia (GJ), the Department of Surgical, Oncological and Oral Science, University of Palermo, Italy. Department of Anesthesia, Intensive Care and Emergency, University Hospital Policlinico Paolo Giaccone, Palermo, Italy (AC), the Department of Anaesthesiology, Hospital Pedro Hispano, Matosinhos, Portugal (TDF), the Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Germany (PK), the Department of Anaesthesiology and Pain. P&A Kyriakou Children's Hospital Athens Greece (AM), Royal Alexandra Hospital. Paisley, Scotland, United Kingdom (PM), Department of Neuro-anaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust, London, England, United Kingdom (LM), the Department of Anesthesia, Critical care and Pain Unit, Hospital General Universitario de Valencia. Research Methods Department, European University of Valencia, Spain (CR), the "Sapienza" University of Rome, Department of Anesthesiology and Critical Care, Rome, Italy (FB), the Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery - University of Perugia Ospedale S. Maria della Misericordia, Perugia, Italy (EDR), the Division of Anaesthesiology, Intensive Care and Emergency Medicine, Department of Anaesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands (WB)
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4
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Biyani G, Metta R. Green anesthesia: How green is our practice? J Anaesthesiol Clin Pharmacol 2023; 39:519-520. [PMID: 38269172 PMCID: PMC10805192 DOI: 10.4103/joacp.joacp_515_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 12/04/2023] [Indexed: 01/26/2024] Open
Affiliation(s)
- Ghansham Biyani
- Department of Anaesthesiology, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India
| | - Rajasekhar Metta
- Department of Anaesthesiology, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India
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5
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Liu Y, Lee-Archer P, Sheridan NM, Seglenieks R, McGain F, Eley VA. Nitrous Oxide Use in Australian Health Care: Strategies to Reduce the Climate Impact. Anesth Analg 2023; 137:819-829. [PMID: 37471292 DOI: 10.1213/ane.0000000000006620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
Nitrous oxide is a useful inhaled analgesic. Due to its high global warming potential and ozone-depleting properties, the nitrous oxide emissions related to health care are being increasingly scrutinized. In this narrative review, we will discuss the clinical uses of nitrous oxide relevant to anesthetists, in addition to its contribution as a greenhouse gas. Using available data from Australia, we will explore potential strategies for reducing the impact of those emissions, which are likely to be applicable in other countries. These include destruction of captured nitrous oxide, minimizing nitrous oxide waste and reducing clinical use. Anesthesia clinicians are well placed to raise awareness with colleagues and consumers regarding the environmental impact of nitrous oxide and to promote cleaner alternatives. Reducing use is likely to be the most promising reduction strategy without large-scale changes to infrastructure and subsequent delay in action.
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Affiliation(s)
- Yigang Liu
- From the Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Paul Lee-Archer
- From the Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Anaesthesia and Pain Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Nicole M Sheridan
- Department of Anaesthesia, Pain and Perioperative Medicine, Western Health, Melbourne, Victoria, Australia
| | - Richard Seglenieks
- Department of Anaesthesia, Pain and Perioperative Medicine, Western Health, Melbourne, Victoria, Australia
- Department of Anaesthesia, Grampians Health, Ballarat, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Forbes McGain
- Department of Anaesthesia, Pain and Perioperative Medicine, Western Health, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Western Health, Melbourne, Victoria, Australia
| | - Victoria A Eley
- From the Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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6
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Rübsam ML, Kruse P, Dietzler Y, Kropf M, Bette B, Zarbock A, Kim SC, Hönemann C. A call for immediate climate action in anesthesiology: routine use of minimal or metabolic fresh gas flow reduces our ecological footprint. Can J Anaesth 2023; 70:301-312. [PMID: 36814057 PMCID: PMC10066075 DOI: 10.1007/s12630-022-02393-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 10/28/2022] [Accepted: 10/31/2022] [Indexed: 02/24/2023] Open
Abstract
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.
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Affiliation(s)
- Marie-Luise Rübsam
- Department of Anaesthesia, Intensive Care, Emergency and Pain Medicine, University Medicine of Greifswald, Greifswald, Germany
| | - Philippe Kruse
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Yvonne Dietzler
- Department of Anaesthesia, St. Marienhospital Vechta, Marienstraße 6-8, 49377, Vechta, Germany
| | - Miriam Kropf
- Department of Anaesthesia, Intensive Care, Emergency and Pain Medicine, BG Klinikum Hamburg, Hamburg, Germany
| | - Birgit Bette
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Alexander Zarbock
- Department of Anesthesiology and Critical Care, University Hospital of Muenster, Münster, Germany
| | - Se-Chan Kim
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Christian Hönemann
- Department of Anaesthesia, St. Marienhospital Vechta, Marienstraße 6-8, 49377, Vechta, Germany.
- Department of Anesthesiology and Critical Care, University Hospital of Muenster, Münster, Germany.
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7
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Cleland J, Bill V, Williams E, Shelton C. Retained desflurane in decommissioned vaporisers: a national problem? Anaesthesia 2022; 78:651-652. [PMID: 36437774 DOI: 10.1111/anae.15930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 11/30/2022]
Affiliation(s)
- J Cleland
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - V Bill
- North West School of Anaesthesia, Health Education England North West, Manchester, UK
| | - E Williams
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - C Shelton
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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8
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Devlin-Hegedus JA, McGain F, Harris RD, Sherman JD. Action guidance for addressing pollution from inhalational anaesthetics. Anaesthesia 2022; 77:1023-1029. [PMID: 35729804 PMCID: PMC9543086 DOI: 10.1111/anae.15785] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 02/04/2023]
Abstract
Climate change is a real and accelerating existential danger. Urgent action is required to halt its progression, and everyone can contribute. Pollution mitigation represents an important opportunity for much needed leadership from the health community, addressing a threat that will directly and seriously impact the health and well‐being of current and future generations. Inhalational anaesthetics are a significant contributor to healthcare‐related greenhouse gas emissions and minimising their climate impact represents a meaningful and achievable intervention. A challenge exists in translating well‐established knowledge about inhalational anaesthetic pollution into practical action. CODA is a medical education and health promotion charity that aims to deliver climate action‐oriented recommendations, supported by useful resources and success stories. The CODA‐hosted platform is designed to maximise engagement of the global healthcare community and draws upon diverse experiences to develop global solutions and accelerate action. The action guidance for addressing pollution from inhalational anaesthetics is the subject of this article. These are practical, evidence‐based actions that can be undertaken to reduce the impact of pollution from inhalational anaesthetics, without compromising patient care and include: removal of desflurane from drug formularies; decommissioning central nitrous oxide piping; avoidance of nitrous oxide use; minimising fresh gas flows during anaesthesia; and prioritising total intravenous anaesthesia and regional anaesthesia when clinically safe to do so. Guidance on how to educate, implement, measure and review progress on these mitigation actions is provided, along with means to share successes and contribute to the essential, global transition towards environmentally sustainable anaesthesia.
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Affiliation(s)
- J A Devlin-Hegedus
- Department of Anaesthesia, Wollongong Hospital, Wollongong, NSW, Australia.,Graduate School of Medicine, University of Wollongong, NSW, Australia
| | - F McGain
- Departments of Anaesthesia and Intensive Care, Western Health, Footscray, VIC, Australia.,Department of Critical Care, University of Melbourne, VIC, Australia
| | - R D Harris
- School of Medicine, University of Sydney, NSW, Australia.,Department of Intensive Care, Royal North Shore Hospital, Sydney, NSW, Australia
| | - J D Sherman
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT, USA.,Department of Environmental Health Sciences, Yale School of Public Health, CT, USA
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Lachowska S, Antończyk A, Tunikowska J, Godniak M, Kiełbowicz Z. Reduction of greenhouse gases emission through the use of tiletamine and zolazepam. Sci Rep 2022; 12:9508. [PMID: 35681078 PMCID: PMC9184519 DOI: 10.1038/s41598-022-13520-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/25/2022] [Indexed: 11/30/2022] Open
Abstract
Isoflurane is an anaesthetic gas widely used in both human and veterinary medicine. All currently used volatile anaesthetics are ozone-depleting halogenated compounds. The use of total intravenous anaesthesia (TIVA) allows to induce the effect of general anaesthesia by administering drugs only intravenously without the use of anaesthetic gases. This allows you to create a protocol that is safe not only for the patient, but also for doctors and the environment. However, so far, no anaesthetic protocol based on induction of anaesthesia with tiletamine-zolazepam without the need to maintain anaesthesia with anaesthetic gas has been developed. Our study showed that the use of this combination of drugs for induction does not require the use of additional isoflurane to maintain anaesthesia. Thanks to Dixon's up-and-down method we proved that with the induction of anaesthesia with tiletamine-zolazepam at a dose of 5 mg/kg the use of isoflurane is not needed to maintain anaesthesia in minimally invasive surgical procedures. Until now, this dose has been recommended by the producer for more diagnostic than surgical procedures or for induction of general anaesthesia. The maintenance was required with anaesthetic gas or administration of another dose of the tiletamine-zolazepam. The results obtained in this study will allow for a significant reduction in the consumption of isoflurane, a gas co-responsible for the deepening of the greenhouse effect, having a negative impact on patients and surgeons. These results are certainly the first step to achieving a well-balanced and safe TIVA-based anaesthetic protocol using tiletamine-zolazepam, the obvious goal of which will be to maximize both the safety of the patient, people involved in surgical procedures, and the environment itself. Being aware of the problem of the greenhouse effect, we are committed to reducing the consumption of anaesthetic gases by replacing them with infusion agents.
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Affiliation(s)
- Sonia Lachowska
- Department and Clinic of Surgery, Faculty of Veterinary Medicine, Wroclaw University of Environment and Life Sciences, Pl. Grunwaldzki 51, 50-366, Wroclaw, Poland.
| | - Agnieszka Antończyk
- Department and Clinic of Surgery, Faculty of Veterinary Medicine, Wroclaw University of Environment and Life Sciences, Pl. Grunwaldzki 51, 50-366, Wroclaw, Poland
| | - Joanna Tunikowska
- Department and Clinic of Surgery, Faculty of Veterinary Medicine, Wroclaw University of Environment and Life Sciences, Pl. Grunwaldzki 51, 50-366, Wroclaw, Poland
| | - Martyna Godniak
- Royal (Dick) School of Veterinary Studies, The University of Edinburgh, Midlothian, EH25 9RG, UK
| | - Zdzisław Kiełbowicz
- Department and Clinic of Surgery, Faculty of Veterinary Medicine, Wroclaw University of Environment and Life Sciences, Pl. Grunwaldzki 51, 50-366, Wroclaw, Poland
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Qin RX, Velin L, Yates EF, El Omrani O, McLeod E, Tudravu J, Samad L, Woodward A, McClain CD. Building sustainable and resilient surgical systems: A narrative review of opportunities to integrate climate change into national surgical planning in the Western Pacific region. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2022; 22:100407. [PMID: 35243461 PMCID: PMC8881731 DOI: 10.1016/j.lanwpc.2022.100407] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Five billion people lack access to surgical care worldwide; climate change is the biggest threat to human health in the 21st century. This review studies how climate change could be integrated into national surgical planning in the Western Pacific region. We searched databases (PubMed, Web of Science, and Global Health) for articles on climate change and surgical care. Findings were categorised using the modified World Health Organisation Health System Building Blocks Framework. 220 out of 2577 records were included. Infrastructure: Operating theatres are highly resource-intensive. Their carbon footprint could be reduced by maximising equipment longevity, improving energy efficiency, and renewable energy use. Service delivery Tele-medicine, outreaches, and avoiding desflurane could reduce emissions. Robust surgical systems are required to adapt to the increasing burden of surgically treated diseases, such as injuries from natural disasters. Finance: Climate change adaptation funds could be mobilised for surgical system strengthening. Information systems: Sustainability should be a key performance indicator for surgical systems. Workforce: Surgical providers could change clinical, institutional, and societal practices. Governance: Planning in surgical care and climate change should be aligned. Climate change mitigation is essential in the regional surgical care scale-up; surgical system strengthening is also necessary for adaptation to climate change.
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Key Words
- CO2, Carbon dioxide
- Climate change
- DALY, Disability-adjusted life year
- FEMAT, Fiji Emergency Medical Assistance Team
- GHG, Greenhouse gas
- HICs, High-income countries
- HVAC, Heating, ventilation, and air conditioning
- IPCC, Intergovernmental Panel on Climate Change
- LCA, Life-cycle analysis
- LCoGS, Lancet Commission on Global Surgery
- LED, Light-emitting diode
- LMICs, Low- and middle-income countries
- NSOAP, National Surgical, Obstetric, and Anaesthesia Plan
- National health planning
- Natural disasters
- OR, Operating Room
- SOA, Surgical, obstetric, and anaesthesia
- SUD, Single-use device
- Surgical system strengthening
- WASH, Water, sanitation, and hygiene
- Western pacific
- kgCO2e, Kilograms of carbon dioxide equivalent
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Affiliation(s)
- Rennie X. Qin
- The Program in Global Surgery and Social Change, the Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, USA
| | - Lotta Velin
- Centre for Teaching and Research in Disaster Medicine and Traumatology (KMC), Department of Biomedical and Clinical Sciences, Linköping University, Johannes Magnus väg 11, Linköping 583 30, Sweden
| | - Elizabeth F. Yates
- Center for Surgery and Public Health, Brigham and Women's Hospital, 1620 Tremont St, Boston, MA 02120, USA
| | - Omnia El Omrani
- Faculty of Medicine, Ain Shams University, Ramsis Street, Abbassia Square, Cairo, Egypt
| | - Elizabeth McLeod
- Department of Neonatal and Paediatric Surgery, Royal Children's Hospital, 50 Flemington Rd, Melbourne, VIC 3052, Australia
| | - Jemesa Tudravu
- Ministry of Health and Medical Services of Fiji, Dinem House, 88 Amy St, Suva, Fiji
| | - Lubna Samad
- Center for Essential Surgical and Acute Care, IRD Global, 4th Floor, Woodcraft Building, Plot 3 & 3-A, Sector 47, Korangi Creek Road, Karachi, Pakistan
| | - Alistair Woodward
- School of Population Health, Faculty of Medical and Health Sciences, The University of Auckland, 22-30 Park Ave, Auckland 1023, New Zealand
| | - Craig D. McClain
- The Program in Global Surgery and Social Change, the Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, USA
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
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11
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Müller‐Wirtz LM, Behne F, Kermad A, Wagenpfeil G, Schroeder M, Sessler DI, Volk T, Meiser A. Isoflurane promotes early spontaneous breathing in ventilated intensive care patients: A post hoc subgroup analysis of a randomized trial. Acta Anaesthesiol Scand 2022; 66:354-364. [PMID: 34870852 DOI: 10.1111/aas.14010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Spontaneous breathing is desirable in most ventilated patients. We therefore studied the influence of isoflurane versus propofol sedation on early spontaneous breathing in ventilated surgical intensive care patients and evaluated potential mediation by opioids and arterial carbon dioxide during the first 20 h of study sedation. METHODS We included a single-center subgroup of 66 patients, who participated in a large multi-center trial assessing efficacy and safety of isoflurane sedation, with 33 patients each randomized to isoflurane or propofol sedation. Both sedatives were titrated to a sedation depth of -4 to -1 on the Richmond Agitation Sedation Scale. The primary outcome was the fraction of time during which patients breathed spontaneously. RESULTS Baseline characteristics of isoflurane and propofol-sedated patients were well balanced. There were no substantive differences in management or treatment aside from sedation, and isoflurane and propofol provided nearly identical sedation depths. The mean fraction of time spent spontaneously breathing was 82% [95% CI: 69, 90] in patients sedated with isoflurane compared to 35% [95% CI: 22, 51] in those assigned to propofol: median difference: 61% [95% CI: 14, 89], p < .001. After adjustments for sufentanil dose and arterial carbon dioxide partial pressure, patients sedated with isoflurane were twice as likely to breathe spontaneously than those sedated with propofol: adjusted risk ratio: 2.2 [95%CI: 1.4, 3.3], p < .001. CONCLUSIONS Isoflurane compared to propofol sedation promotes early spontaneous breathing in deeply sedated ventilated intensive care patients. The benefit appears to be a direct effect isoflurane rather than being mediated by opioids or arterial carbon dioxide.
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Affiliation(s)
- Lukas M. Müller‐Wirtz
- Department of Anaesthesiology Intensive Care and Pain Therapy Saarland University Medical Center Saarland University Faculty of Medicine Homburg Germany
- Outcomes Research Consortium Cleveland Ohio USA
| | - Florian Behne
- Department of Anaesthesiology Intensive Care and Pain Therapy Saarland University Medical Center Saarland University Faculty of Medicine Homburg Germany
| | - Azzeddine Kermad
- Department of Anaesthesiology Intensive Care and Pain Therapy Saarland University Medical Center Saarland University Faculty of Medicine Homburg Germany
| | - Gudrun Wagenpfeil
- Institute for Medical Biometry Epidemiology and Medical Informatics (IMBEI) Saarland University Faculty of Medicine Homburg Germany
| | - Matthias Schroeder
- Department of Anaesthesiology Intensive Care and Pain Therapy Saarland University Medical Center Saarland University Faculty of Medicine Homburg Germany
| | - Daniel I. Sessler
- Outcomes Research Consortium Cleveland Ohio USA
- Department of Outcomes Research Anesthesiology Institute Cleveland Clinic Cleveland Ohio USA
| | - Thomas Volk
- Department of Anaesthesiology Intensive Care and Pain Therapy Saarland University Medical Center Saarland University Faculty of Medicine Homburg Germany
- Outcomes Research Consortium Cleveland Ohio USA
| | - Andreas Meiser
- Department of Anaesthesiology Intensive Care and Pain Therapy Saarland University Medical Center Saarland University Faculty of Medicine Homburg Germany
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12
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Liang M, Yu C, Dai S, Cheng H, Li W, Lai F, Ma L, Liu X. Reactivity and kinetics of 1,3-butadiene under ultraviolet irradiation at 254 nm. BMC Chem 2022; 16:4. [PMID: 35180888 PMCID: PMC8857861 DOI: 10.1186/s13065-022-00800-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/14/2022] [Indexed: 12/03/2022] Open
Abstract
The reaction process of gaseous 1,3-butadiene following ultraviolet irradiation at the temperature range from 298 to 323 K under nitrogen atmosphere was monitored by UV–vis spectrophotometry. A gaseous mini-reactor was used as a reaction vessel and could be directly monitored in a UV–vis spectrophotometer. We investigated the reactivity and kinetics of 1,3-butadiene under non-UV and UV irradiation to evaluate its photochemical stability. A second-order kinetic model with 50.48 kJ·mol–1 activation energy fitted the reaction data for non-UV irradiation, whereas a first-order kinetic model was appropriate in the case of UV irradiation with activation energies of 19.92–43.65 kJ mol–1. This indicates that ultraviolet light could accelerate the photolysis reaction rate of 1,3-butadiene. In addition, the reaction products were determined using gas chromatography-mass spectrometry (GC–MS), and the reaction pathways were identified. The photolysis of 1,3-butadiene gave rise to various volatile products by cleavage and rearrangement of single C–C bonds. The differences between dimerization and dissociation of 1,3-butadiene under ultraviolet irradiation were elucidated by combining experimental and theoretical methods. The present findings provide fundamental insight into the photochemistry of 1,3-butadiene compounds.
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Affiliation(s)
- Min Liang
- School of Chemistry and Chemical Engineering, Guangxi University, Nanning, 530004, China
| | - Chang Yu
- School of Chemistry and Chemical Engineering, Guangxi University, Nanning, 530004, China
| | - Suyi Dai
- School of Chemistry and Chemical Engineering, Guangxi University, Nanning, 530004, China
| | - Haijun Cheng
- School of Chemistry and Chemical Engineering, Guangxi University, Nanning, 530004, China
| | - Weiguang Li
- School of Chemistry and Chemical Engineering, Guangxi University, Nanning, 530004, China
| | - Fang Lai
- School of Chemistry and Chemical Engineering, Guangxi University, Nanning, 530004, China
| | - Li Ma
- School of Chemistry and Chemical Engineering, Guangxi University, Nanning, 530004, China.
| | - Xiongmin Liu
- School of Chemistry and Chemical Engineering, Guangxi University, Nanning, 530004, China.
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Wu S, Cerceo E. Sustainability Initiatives in the Operating Room. Jt Comm J Qual Patient Saf 2021; 47:663-672. [PMID: 34344594 DOI: 10.1016/j.jcjq.2021.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/25/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Operating rooms (ORs) contribute up to 30% of a hospital's waste, are very resource-intensive, and thus provide an opportunity for improvement. METHODS A narrative review was conducted, searching MEDLINE, EMBASE, and ProQuest databases. The study included 78 of the 108 published articles. RESULTS The researchers identified and categorized articles according to the following major themes: Committee and Leadership; Waste Reduction; Segregating OR waste; Minimizing unnecessary devices and packaging; Reducing energy consumption; Choosing anesthetic gases; Education; Reducing water consumption; Different surgical venues; Donating medical supplies. Formation of an OR committee or a hospital Green Team dedicated to environmentally sustainable initiatives can significantly improve health care's impact on the environment while saving money. Changes in supply chain with preferences for reusable devices, effective recycling, repurposing instruments, and donating items can all be effective means of diverting waste away from landfills. Reducing unnecessary packaging and instruments would eliminate excess in the waste stream. Curtailing energy and water usage results in cost and environmental savings. Surgical venue (inpatient vs. outpatient surgical center) can also contribute to waste. Transitioning away from certain inhaled anesthetics can minimize greenhouse gas impact. Education to all levels in the health care system is important to drive change and maintain change. CONCLUSION Optimizing efficiency and decreasing waste generation can have a positive impact on the environment and can be accompanied by cost reduction. Because the field of sustainability in health care is young but burgeoning, increased research is needed to support evidence-based approaches.
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Lopes R, Shelton C, Charlesworth M. Inhalational anaesthetics, ozone depletion, and greenhouse warming: the basics and status of our efforts in environmental mitigation. Curr Opin Anaesthesiol 2021; 34:415-420. [PMID: 33958528 DOI: 10.1097/aco.0000000000001009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Following their use for medicinal purposes, volatile inhalational anaesthetic agents are expelled into the atmosphere where they contribute to anthropogenic climate change. We describe recent evidence examining the benefits and harms associated with their use. RECENT FINDINGS The environmental harms associated with desflurane and nitrous oxide likely outweigh any purported clinical benefits. Life cycle analyses are beginning to address the many gaps in our understanding, and informing choices made on all aspects of anaesthetic care. There is, however, an urgent need to move beyond the debate about anaesthetic technique A vs. B and focus also on areas such as sustainable procurement, waste management, pharmacological stewardship and joined-up solutions. SUMMARY There is now compelling evidence that anaesthetists, departments and hospitals should avoid desflurane completely, and limit nitrous oxide use to settings where there is no viable alternative, as their environmental harms outweigh any perceived clinical benefit. Life cycle analyses seem supportive of total intravenous and/or regional anaesthesia. There are many other areas where choices can be made by individual anaesthetists that contribute towards reducing the environmental burden of healthcare, such as prioritising the reduction of inappropriate resource use and over-treatment. However, this all requires joined up solutions where all parts of an organisation engage.
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Affiliation(s)
- Rita Lopes
- Department of Cardiothoracic Anaesthesia, Critical Care and ECMO
| | - Cliff Shelton
- Department of Anaesthesia, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester.,Department of Anaesthesia, Lancaster Medical School, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
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Varughese S, Ahmed R. Environmental and Occupational Considerations of Anesthesia: A Narrative Review and Update. Anesth Analg 2021; 133:826-835. [PMID: 33857027 PMCID: PMC8415729 DOI: 10.1213/ane.0000000000005504] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
With an estimated worldwide volume of 266 million surgeries in 2015, the call for general inhalation anesthesia is considerable. However, widely used volatile anesthetics such as N2O and the highly fluorinated gases sevoflurane, desflurane, and isoflurane are greenhouse gases, ozone-depleting agents, or both. Because these agents undergo minimal metabolism in the body during clinical use and are primarily (≥95%) eliminated unchanged via exhalation, waste anesthetic gases (WAGs) in operating rooms and postanesthesia care units can pose a challenge for overall elimination and occupational exposure. The chemical properties and global warming impacts of these gases vary, with atmospheric lifetimes of 1-5 years for sevoflurane, 3-6 years for isoflurane, 9-21 years for desflurane, and 114 years for N2O. Additionally, the use of N2O as a carrier gas for the inhalation anesthetics and as a supplement to intravenous (IV) anesthetics further contributes to these impacts. At the same time, unscavenged WAGs can result in chronic occupational exposure of health care workers to potential associated adverse health effects. Few adverse effects associated with WAGs have been documented, however, when workplace exposure limits are implemented. Specific measures that can help reduce occupational exposure and the environmental impact of inhaled anesthetics include efficient ventilation and scavenging systems, regular monitoring of airborne concentrations of waste gases to remain below recommended limits, ensuring that anesthesia equipment is well maintained, avoiding desflurane and N2O if possible, and minimizing fresh gas flow rates (eg, use of low-flow anesthesia). One alternative to volatile anesthetics may be total intravenous anesthesia (TIVA). While TIVA is not associated with the risks of occupational exposure or atmospheric pollution that are inherent to volatile anesthetic gases, clinical considerations should be weighed in the choice of agent. Appropriate procedures for the disposal of IV anesthetics must be followed to minimize any potential for negative environmental effects. Overall, although their contributions are relatively low compared with those of other human-produced substances, inhaled anesthetics are intrinsically potent greenhouse gases and pose a risk to operating-room personnel if not properly managed and scavenged. Factors to reduce waste and minimize the future impact of these substances should be considered.
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Affiliation(s)
- Shane Varughese
- From the Global Medical Affairs, AbbVie Inc, North Chicago, Illinois
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Gaya da Costa M, Kalmar AF, Struys MMRF. Inhaled Anesthetics: Environmental Role, Occupational Risk, and Clinical Use. J Clin Med 2021; 10:1306. [PMID: 33810063 PMCID: PMC8004846 DOI: 10.3390/jcm10061306] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/14/2021] [Accepted: 03/18/2021] [Indexed: 12/17/2022] Open
Abstract
Inhaled anesthetics have been in clinical use for over 150 years and are still commonly used in daily practice. The initial view of inhaled anesthetics as indispensable for general anesthesia has evolved during the years and, currently, its general use has even been questioned. Beyond the traditional risks inherent to any drug in use, inhaled anesthetics are exceptionally strong greenhouse gases (GHG) and may pose considerable occupational risks. This emphasizes the importance of evaluating and considering its use in clinical practices. Despite the overwhelming scientific evidence of worsening climate changes, control measures are very slowly implemented. Therefore, it is the responsibility of all society sectors, including the health sector to maximally decrease GHG emissions where possible. Within the field of anesthesia, the potential to reduce GHG emissions can be briefly summarized as follows: Stop or avoid the use of nitrous oxide (N2O) and desflurane, consider the use of total intravenous or local-regional anesthesia, invest in the development of new technologies to minimize volatile anesthetics consumption, scavenging systems, and destruction of waste gas. The improved and sustained awareness of the medical community regarding the climate impact of inhaled anesthetics is mandatory to bring change in the current practice.
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Affiliation(s)
- Mariana Gaya da Costa
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, 9713GZ Groningen, The Netherlands;
| | - Alain F. Kalmar
- Department of Anesthesia and Intensive Care Medicine, Maria Middelares Hospital, 9000 Ghent, Belgium;
- Department of Basic and Applied Medical Sciences, Ghent University, 9000 Ghent, Belgium
| | - Michel M. R. F. Struys
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, 9713GZ Groningen, The Netherlands;
- Department of Basic and Applied Medical Sciences, Ghent University, 9000 Ghent, Belgium
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McGain F, Muret J, Lawson C, Sherman JD. Environmental sustainability in anaesthesia and critical care. Br J Anaesth 2020; 125:680-692. [PMID: 32798068 PMCID: PMC7421303 DOI: 10.1016/j.bja.2020.06.055] [Citation(s) in RCA: 157] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/29/2020] [Accepted: 06/13/2020] [Indexed: 01/17/2023] Open
Abstract
The detrimental health effects of climate change continue to increase. Although health systems respond to this disease burden, healthcare itself pollutes the atmosphere, land, and waterways. We surveyed the 'state of the art' environmental sustainability research in anaesthesia and critical care, addressing why it matters, what is known, and ideas for future work. Focus is placed upon the atmospheric chemistry of the anaesthetic gases, recent work clarifying their relative global warming potentials, and progress in waste anaesthetic gas treatment. Life cycle assessment (LCA; i.e. 'cradle to grave' analysis) is introduced as the definitive method used to compare and contrast ecological footprints of products, processes, and systems. The number of LCAs within medicine has gone from rare to an established body of knowledge in the past decade that can inform doctors of the relative ecological merits of different techniques. LCAs with practical outcomes are explored, such as the carbon footprint of reusable vs single-use anaesthetic devices (e.g. drug trays, laryngoscope blades, and handles), and the carbon footprint of treating an ICU patient with septic shock. Avoid, reduce, reuse, recycle, and reprocess are then explored. Moving beyond routine clinical care, the vital influences that the source of energy (renewables vs fossil fuels) and energy efficiency have in healthcare's ecological footprint are highlighted. Discussion of the integral roles of research translation, education, and advocacy in driving the perioperative and critical care environmental sustainability agenda completes this review.
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Affiliation(s)
| | - Jane Muret
- French Society of Anaesthesia and Intensive Care (SFAR), Institut Curie PSL Research University, Paris, France
| | - Cathy Lawson
- Newcastle upon Tyne Hospitals, Newcastle upon Tyne, England, UK
| | - Jodi D. Sherman
- Department of Anesthesiology, Yale School of Medicine, Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA
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