The United States health care sector is responsible for 10% of the nation’s greenhouse gas emissions and generates costs of up to 470,000 disability-adjusted life years in terms of excess morbidity and mortality. , Anesthesiology in particular contributes a third of health care’s greenhouse gas emissions due to inhaled anesthetic atmospheric waste, pharmaceutical waste, and solid waste. Furthermore, anesthesiologists play a crucial role in the operating room, one of the most resource-intensive and polluting care settings. For these reasons,the specialty is poised to play a significant role in promoting sustainability in their care settings, with considerable potential savings and boons to patient care.
Waste Generated by Anesthesiology:
In 2014, the American Society of Anesthesiologists Environmental Task Force published sustainability guidelines that directly target specific waste streams, including inhaled anesthetic atmospheric waste, pharmaceutical waste, electrical waste, and solid waste. The guidelines include a call for anesthesia specialists to increase their involvement in their respective communities and become sustainability leaders.
Some of the guidelines are immediately salient to anesthesiology, including those which address inhaled anesthetic gases.Of all inhaled gases, desflurane and nitrous oxide are particularly high-risk as emissions: desflurane has the largest carbon dioxide equivalence (in global warming potential)of any inhaled anesthetic gas, and nitrous oxide’s reactivity leads to toxic downstream products that are later released into the ambient air, often without treatment. What’s more, desflurane takes up to 14 years to degrade, while nitrous oxide takes 114.ASA Guidelines, along with Jeffrey Feldman, MD, of the University of Pennsylvania,advise that these high impact gases be substituted when possible for less reactive gases, or that their use be limited through semi-closed or closed circuit anesthesia. Regional techniques should also be considered whenever possible, and investments in waste anesthetic gas capture (WAG) can provide a long term solution in limiting the amount of anesthetic gas released into the atmosphere.
Another major concern relates to the waste of pharmaceuticals. For instance, infusion waste stems from two major issues: physicians do not mix infusions with scarcity in mind, and containers are not made for single-patient use. In 2017, Tera Cushman, MD, an adult cardiothoracic anesthesiology fellow from the Duke University Medical Center, found that infusions were being wasted when trainees systematically mixed infusions as a part of their training, regardless of whether they were appropriate for the patient’s condition or treatment. This practice resulted in up to 39% of primed epinephrine being wasted and 22% of primed vasopress in being wasted. The cost of wasted infusions per case was $110. Cushman sought to cut down the amount of non-recyclable infusions and to increase the rate of return of recyclable infusions through tracing of spiked and used infusions, managing a per-case waste decrease of 70%. Alternative solutions to decreasing the waste of infusions include the cost-neutral measure of favouring pre-filled syringe use and splitting large infusion vials between patients.
Waste Generated by Anesthesiology:
In 2014, the American Society of Anesthesiologists Environmental Task Force published sustainability guidelines that directly target specific waste streams, including inhaled anesthetic atmospheric waste, pharmaceutical waste, electrical waste, and solid waste. The guidelines include a call for anesthesia specialists to increase their involvement in their respective communities and become sustainability leaders.
Some of the guidelines are immediately salient to anesthesiology, including those which address inhaled anesthetic gases.Of all inhaled gases, desflurane and nitrous oxide are particularly high-risk as emissions: desflurane has the largest carbon dioxide equivalence (in global warming potential)of any inhaled anesthetic gas, and nitrous oxide’s reactivity leads to toxic downstream products that are later released into the ambient air, often without treatment. What’s more, desflurane takes up to 14 years to degrade, while nitrous oxide takes 114.ASA Guidelines, along with Jeffrey Feldman, MD, of the University of Pennsylvania,advise that these high impact gases be substituted when possible for less reactive gases, or that their use be limited through semi-closed or closed circuit anesthesia. Regional techniques should also be considered whenever possible, and investments in waste anesthetic gas capture (WAG) can provide a long term solution in limiting the amount of anesthetic gas released into the atmosphere.
Another major concern relates to the waste of pharmaceuticals. For instance, infusion waste stems from two major issues: physicians do not mix infusions with scarcity in mind, and containers are not made for single-patient use. In 2017, Tera Cushman, MD, an adult cardiothoracic anesthesiology fellow from the Duke University Medical Center, found that infusions were being wasted when trainees systematically mixed infusions as a part of their training, regardless of whether they were appropriate for the patient’s condition or treatment. This practice resulted in up to 39% of primed epinephrine being wasted and 22% of primed vasopress in being wasted. The cost of wasted infusions per case was $110. Cushman sought to cut down the amount of non-recyclable infusions and to increase the rate of return of recyclable infusions through tracing of spiked and used infusions, managing a per-case waste decrease of 70%. Alternative solutions to decreasing the waste of infusions include the cost-neutral measure of favouring pre-filled syringe use and splitting large infusion vials between patients.
These strategies are not only reasonable and culminate in lives and dollars saved from environmental impact, but they can help steer healthcare institutions toward sustainability-motivated purchasing. In an age of rising costs and frequent drug shortages, allocating drugs and resources with a scarcity mindset ensures that anesthesia providers are less likely to run out of emergency drugs (e.g. epinephrine) and curbs waste generated along the upstream production and supply chain processes. That said, leadership from hospitals, practices, and management service organizations can make key systemic adjustments to facilitate waste efficiency and in the process, increase their competitiveness in an increasingly ecology-conscious market by:
1. Where applicable, transitioning from flat-rate waste management to volume-based waste disposal to directly incentivize waste minimization;
2. Utilizing apps such as the Yale Gassing Greener to evaluate the environmental impact of inhaled anesthetics and to collect research data so that monitoring can be conducted over time;
3. Building institutional spaces, such as task forces and commissions, that encourage interested health practitioners to cultivate leadership in healthcare sustainability; and
4. Being supportive of efforts to decrease waste when it is not financially onerous to do so.
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