Anesthesia Alert: Go Green With Anesthesia Gases

The impact inhalational anesthetics have on the environment is probably greater than you realize. Consider these planet-polluting realities:

• Administering the inhalational agent desflurane at 10.0 liters per minute for 1 hour has the same global warming potential as driving a car from Outpatient Surgery's home office in suburban Philadelphia to AORN's headquarters in Denver, Colo.
• Inhalational anesthetics are responsible for half of the life cycle of greenhouse gas emissions coming from perioperative services.
• Waste anesthesia gas is responsible for more than 5% of a hospital's carbon footprint.
• The U.S. healthcare system accounts for 10% of the nation's greenhouse gases.
• If our healthcare system were a country, it would rank 13th in the world for greenhouse emissions.

Unfortunately, capturing and evacuating waste anesthetic gas in the OR is not an environmentally friendly option. OSHA regulations that call for protecting surgical team members from exposure to inhalational anesthetics by mandating the use of scavenger systems don't go far enough.

"The systems suction waste gas out of the room, but often send it up through vents on facility roofs and out into the atmosphere in unregulated amounts," says Jodi Sherman, MD, director of sustainability and the department of anesthesia at Yale-New Haven Health System in New Haven, Conn. What can you do to go green with anesthesia gases? Here are 3 straightforward interventions.

• Sevoflurane instead of desflurane. Desflurane and nitrous oxide have the highest potential impact on global warming. When it comes to reducing how much gas is distributed into the environment, Dr. Sherman says minimizing or avoiding the use of desflurane and nitrous oxide is the most effective.

Desflurane is also the most expensive of the inhalational agents. Anesthesia providers might not be aware of those drawbacks associated with desflurane and, besides, patients who receive the anesthetic emerge faster and recover more quickly — factors that are said to offset the additional cost of the agent.

However, improved clinical efficiencies have not been definitely linked to desflurane in the literature, says Dr. Sherman. Plus, you can replicate the positive properties of desflurane with other agents. "It's not an essential drug," says Dr. Sherman. "No matter which anesthetic you use, you can titrate the drug to wake up patients as quickly as possible." Consider using sevoflurane over desflurane, says Dr. Sherman. Sevoflurane has the smallest carbon footprint among commonly used anesthesia gases, and administering it instead of desflurane will not impact the quality or safety of patient care.

Limiting the amount of anesthesia gases your facility emits is low-hanging fruit that can have a positive impact on the environment.
— Jodi Sherman, MD

• Opt for regional anesthesia. We all know that spinal epidurals and peripheral nerve blocks reduce the need for inhaled anesthetics. They also result in better pain management for patients. But what if your surgeons don't like regional anesthesia because they feel it takes too long to place blocks and wait for them to take effect?

"Work on systems factors to improve block placement efficiency instead of avoiding regional anesthesia altogether," says Dr. Sherman.

Her pointers to improve the efficiency of a regional program: Ask patients who'll receive regional anesthesia to arrive earlier than normal to allow extra time for block placement and onset. And form a dedicated block team of anesthetists and nurses who know how to place various blocks quickly and effectively.

• Raise awareness. Track the monthly usage of anesthetic agents and present the findings to your anesthesia providers to help them realize how the decisions they make at the head of the table impact the environment.

You can also prompt eco-friendly choices at the point of care. One idea is to use vaporizer labels — designed with a tree graphic for placement on environmentally friendly gases and an air pollution graphic for placement on environmentally harmful gases — to remind providers to use low-flow anesthesia and administer sevoflurane whenever it's clinically appropriate.

Data doesn't hurt either. Researchers at the University of Wisconsin School of Medicine in Madison used scientific data that backed the benefits of low-flow anesthesia and the environmental impact of anesthetic choice in an attempt to influence which agent anesthesia providers chose to administer. The efforts lowered per-case carbon dioxide equivalent emissions by 64% over a 3-year period and resulted in an estimated $25,000 in monthly savings (osmag.net/JYe9Vw).

The positive change realized at the University of Wisconsin relied on changing the practice of individual providers. Those type of efforts are often effective in the short term, but wane over time as providers revert back to clinical habits, says Dr. Sherman. To achieve a more sustained practice improvement, you can remove desflurane from your formulary altogether. Dr. Sherman says a healthcare system reportedly realized $300,000 in annual savings by eliminating desflurane. Her own health system removed the drug from its formulary in 2013.

Anesthesia providers are becoming increasingly aware of the significant impact waste anesthesia gases have on the environment, according to Dr. Sherman. But, she says, there are plenty more who need to understand how their everyday practices affect the planet.

"Climate change is considered by some as the top public health issue of the 21st century," says Dr. Sherman. "Limiting the amount of anesthesia gases your facility emits into the atmosphere is low-hanging fruit that can have a positive impact on the environment." OSM