[I can’t even…charles]
Inhaled anaesthetic gases are potent greenhouse gases, with effects up to thousands of times more potent than carbon dioxide; • In most cases, there is no reason why intravenous or regional anaesthesia cannot be safely used in its place
THE EUROPEAN SOCIETY OF ANAESTHESIOLOGY AND INTENSIVE CARE (ESAIC)
A review presented at this year’s Euroanaesthesia Congress will address the environmental impact of inhaled anaesthetic agents and how we can and should manage without them – or at least massively reduce their use. The presentation will be given by anaesthesiologist Dr Niek Sperna Weiland, Amsterdam University Medical Center, The Netherlands, founder of the centre’s Sustainable Healthcare Team.
All volatile (gaseous) anaesthetics are potent greenhouse gases, ranging in global warming potential (GWP) from 440 to 6810 relative to carbon dioxide (CO2,) which has a reference GWP of 1. The anaesthetic sevoflurane has a GWP of 440, isoflurane 1800, and desflurane 6810. These are all extremely high. Methane, emitted by livestock around the world and other processes, has a GWP of 86, and Nitrous oxide (emitted by agriculture, but also used in anaesthesia) is 289, and this gas has an extremely long atmospheric lifetime (around 120 years).
“Reduction of emission of these gases is a quick win in combatting climate change,” explains Dr Sperna Weiland. “After use, these substances are emitted into the atmosphere and rising concentrations have been registered even in very remote areas such as Antarctica and high in the Alps.”
There are several ways to reduce emissions, which include ending the use of nitrous oxide, desflurane and isoflurane immediately, though a combination of efficient use of the only other available alternative (sevoflurane), and switching to other modes of anaesthesia such as TIVA (total intravenous anaesthesia) and regional anaesthesia (spinal/epidural/nerve blocks); and also capturing volatile anaesthetics from the exhaust air piping. “It is also hopeful that a complete ban on desflurane is now being prepared by the European Commission*, which would come into effect on 1 January, 2026,” explains Dr Sperna Weiland.
He will explain that while some indications for inhaled anaesthesia will remain, there is no reason why a patient could not be switched to TIVA or regional anaesthesia in most instances. “There is no evidence that volatile anaesthesia results in more favourable patient outcomes. That said, we cannot do entirely without these inhaled agents. The most common indication may be the continued need for mask induction of anaesthesia for children,”
He will also present the successful sevoflurane reduction campaign of Amsterdam UMC, which has seen annual cannisters used fall by 70% from above 2500 per year to below 1000. In line with previous recommendations, Amsterdam UMC also completely abolished nitrous oxide, desflurane and isoflurane.
This success has come without the hospital yet implementing capture and recycle technology. He explains: “In Amsterdam, we do not capture and recycle and yet we reduced our emissions by 70%. This seems almost as low as you can go with using sevoflurane efficiently and switching to regional/TIVA. For the remaining 30%, capture and recycling will be the only option. While technology that can do this is coming onto the market, there are some legal issues with marketing the recycled substance which must still be overcome before this can become widespread practice.”
Dr Sperna Weiland will address overall energy use in operating rooms (ORs), explaining “hospitals generally do not seem to have any clear policy on this, and indeed energy saving technology only tends to be introduced when operating theatres are refurbished, or entirely new hospitals are built. But as we ourselves have demonstrated, you really can save a lot of energy by switching off most ORs during evenings, through the night and over weekends. In Amsterdam, we save around 360.000 kWh per annum by doing this”.
For waste materials, Amsterdam UMC uses the apply the ‘reduce, reuse, recycle’ paradigm. A lot of the materials in ORs are disposed of unused, just because it was unwrapped due to protocol. Dr Sperna Weiland explains: “We are critically reviewing these protocols and also the sets that we use. Moreover, we have developed a washable surgical headcover that is being implemented this year. We will go from 100,000 disposable headcovers to just 500 per year, and save around 60% of our carbon footprint for headcover use. Lastly, we implemented a full recycling program of plastic packaging materials on all our operating rooms recycling around 4000 kg per month.”
He concludes: “Climate change has really come to the top of the agenda in many countries, in both developed and developing countries, especially in the last couple of years. Every sector must play its part in reducing both emission of harmful gases and overall energy use. It is clear that much can be achieved with relatively little effort, such massively reducing use of inhaled anaesthesia and general power saving techniques. Some national and international policies may be required to target remaining emissions, especially those associated with our supply chain, but at Amsterdam UMC we have shown what is possible with our own effort first.”
Dr Niek Sperna Weiland, University Medical Centre Amsterdam, The Netherlands. Please e-mail with questions and interview requests. E) n.h.spernaweiland@amsterdamumc.nl
Alternative contact in the Euroanaesthesia Media Centre. Tony Kirby of Tony Kirby PR. T) +44 7834 385827 E) tony@tonykirby.com
Notes to editors
Dr Sperna Weiland declares no conflict of interest
This press release is based on a presentation at Euroanaesthesia 2022 in Milan, 13ME1 Reducing the carbon footprint of anaesthetics, at 1630H Milan time in room Amber 7 on Saturday 4 June.
As it is an oral presenation there is no abstract.
*Desflurane ban information: planned date January 1 2026. Reference: https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX%3A52022PC0150, see page 24.
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No more laughing gas for you.
Too funny
Is it time to say goodbye to that most potent of greenhouse gases dihydrogen monoxide?
stupid woman!
fools like her will push price to soaring levels, for veterinary use especially birds. theyre fiddly enough to work on at the best of times
the local vet here insists on ONLY inhaled anaesthetics for surgeries which pushes prices sky high
they state that injectables arent as safe, the vet I use? uses injectables low dose (monitored by me usually, yes a vet who allows you to be there holding the animal while the ops are done) and a fast reversal. and at least 1/3 less cost
And no lead bullets to chomp on either!
“…But as we ourselves have demonstrated, you really can save a lot of energy by switching off most ORs during evenings, through the night and over weekends. In Amsterdam, we save around 360.000 kWh per annum by doing this”.
Because there are no emegencies in Amsterdam during the nights, evenings or weekends?
This is the latest directive from Davos. One by one, all the benefits to the general population of the technological advances of recent centuries, are being deliberately withdrawn. First affordable energy for living, heating and transportation. Now surgery with anaesthesia. It will remain fully available to the Davos elites of course.
Soon to follow are sewage systems and water supply – wait for an academic with an ugly name like “Sperma-Weiland” to discover that laying pipes for sewage and water is way too carbon-polluting. So that will have to stop too. Back to bucketing sewage into the streets and walking miles to a well for dirty water.
I’m surprised that they’re not already scavenging used anaesthetic gas with charcoal filters. That’s easy to do and preclinical systems all scavenge used isofluorane in that way.
You’re going to enjoy your next surgery.
There are several factors governing what anaesthetic is used.
There is safety. There is a hierarchy with different types. For example, TIVA or Desflurane were introduced with fractional improvements in survival for example.
There are side effects. IV anaesthetics are not safe in some situations, and have a higher anaesthetic mortality (a poor outcome).
There is Time. Local/regional anaesthetics are relatively cheap. But they take time to set up, potentially halving the number of cases that can be done. Waiting times blow out. See below.
Then there is cost. Desflurane is expensive. TIVA/intravenous anaesthesia is expensive, particularly with the extra monitoring to make it safe. Moving to IV anaesthetics can potentially cripple the hospital budget. The result will be longer wait times.
So adopting the articles recommendations will result in an increase in complication, and a blow out in waiting times.
Anaesthetic gas quantities used are tiny. We used a fair bit of nitrous, but it degrades in the environment. Anaesthetic gases effect on the atmosphere are irrelevant.
An example of public waiting times is a neighbour. One to Two years waiting for a surgical consultation. Then one to two years wait time to get done. Every six months they ring to see if you are dead from your condition yet so they can take you off the lists. Welcome to free health care, Australian style.
As mentioned by others, the big issue is medical waste. A lot of equipment could be/used to be reused. A lot of waste could be recycled, at a profit, or donated to disadvantaged countries. (we used to steal a bit for use at home). Single use came in to cut costs, not for any other reason, in every hospital I worked in, but honestly, the cost savings were a con.
Instead, it all goes to landfill.
About the time you think there will never be a more ridiculous example of otherwise intelligent people not being able to look at things quantitatively something like this comes along. Amazing.
I’ve been an anaesthesiologist for almost 40 years.
Over that time, we have seen a strong shift away from inhaled fluorinated volatile hydrocarbon anaesthesia to intravenous and regional anaesthesia. This has been better for patients. Low-flow gas delivery methods with better monitoring of gas/vapour composition have become normal, mostly for overall cost savings, but also because modern equipment makes those techniques much safer than in the past.
Fluorinated volatile hydrocarbon anaesthetics are a very blunt tool compared to propofol, modern synthetic opioids, and ultrasound-guided local anaesthetic blocks.
Walking around our post-operative recovery unit, most patients are comfortable and quickly alert. Nothing like the old days of volatile anaesthesia with nitrous oxide, where it was full of vomiting people groaning in discomfort.
The main reason that nitrous oxide has fallen out of favour is that it is associated with hypoxaemia, pressure changes in the middle ear, and post-operative nausea. Its usage was falling well before global warming was a consideration.
I still use a small amount of volatile anaesthetic vapour in almost every anaesthetic I perform, but the total amount of agent released into the atmosphere, per patient, having the same surgery, has probably fallen by about 10-20 times from the amount released when I was a young man.
Having said that, I’d resist moves to stop me using that small amount of volatile agent. Just a little bit reduces the likelihood of awareness should the IV delivery system fail, reduces the amount of intravenous agents required significantly, and reduces opiod ‘windup’ that can occur with high doses of intravenous opioids.
The majority of anesthesiologists will not change their practice significantly because of the environmental impact of waste volatile agents. In significant part that is because they are mindful that no judge would accept, in a case of awareness under anaesthesia, an explanation that no volatile agent was given to save the world from global warming.
So don’t be too concerned. You’ll probably get a better anaesthetic if it isn’t primarily delivered by volatile anaesthetic agent.
Having said that, wastage in medicine is unbelievable. Every central venous line we place comes with a scalpel, stainless steel scissors, stainless steel forceps, and a line trimmer tool, all of which are just thrown away, along with sundry plastic jars, trays, drapes, wipes, syringes, needles, polyurethane and PVC tubes, disposable plastic coated paper gowns, and so on. The amount of waste is staggering.