Anaesthetic gases, which have been exempt from Paris and other climate agreements, now coming under the spotlight.
As the COP26 Global Climate Conference in Glasgow, UK, gets underway this week, all areas of society are looking at the impact their activities have on the environment and, more specifically, global warming. Anaesthesia is an area of healthcare that uses medicines that are potent greenhouse gases and also produces substantial medical waste.
In a new Consensus Statement paper led by the World Federation of Societies of Anaesthesiologists (WFSA) and published in Anaesthesia (a journal of the Association of Anaesthetists), a broad global working group of anaesthesia providers agree that there are multiple areas of their practice in which they can substantially reduce their environmental impact. The authors include Professor Adrian Gelb, WFSA President, Dr Stuart White, a Consultant Anaesthetist based at University Hospitals Sussex NHS Foundation Trust, Brighton, UK, Dr Jodi Sherman, Yale University, New Haven, CT, USA, and colleagues. The overall process of bringing the statement together was managed by the WFSA.
Urgent and substantial annual reductions in greenhouse gas emissions are required to meet the 1.5°C target as set forth by the Intergovernmental Panel on Climate Change to avert the worst predicted harms to civilization from a rapidly changing climate. Global emissions will need to fall by approximately 7.5% annually between now and 2030 to achieve the recommended reduction of 45% of 2010 baseline by 2030. The goal is to reach “net zero” by 2050 or as soon as possible.
Globally, healthcare is responsible for nearly 5% of total global greenhouse gas emissions and similar fractions of harmful air pollutants. Estimates of global emissions stemming from anaesthesia practice are unavailable due to data gaps. However inhalational anaesthetic agents alone are estimated to contribute nearly 3% of these healthcare-related emissions in the UK, where the National Health Service (NHS) has been tracking its emissions for over a decade. Thus, regardless of the exact level of impact of anaesthesia gases in individual countries, their total global impact on the climate is substantial and can no longer be ignored.
Unlike other greenhouse gases, inhalational anaesthetic agents are ignored in international regulation and reporting under the Kigali Amendment of the Montreal Protocol, the Kyoto Protocol and the Paris Agreement, possibly due to their perceived medical necessity. As a result, there is an absence of accurate production and consumption data, making challenging to engage policymakers, professional societies, healthcare organisations, and health professionals in practice improvements.
The authors of the WFSA Global Consensus Statement also focus attention on waste, highlighting that operating theatres produce 25% of all hospital waste, of which 25% arises from anaesthesia care. Approximately 25% of all operating room waste is readily recyclable, yet overall recycling rates remain very low.
What was more difficult for the group to agree upon was whether single-use disposable equipment should be used preferentially over sterilising and reusing devices, since single-use devices can appear to be more wasteful, yet high amounts of energy and water can be used in the sterilisation process for reuse of devices. The authors noted that the ‘single-use vs. reuse’ debate requires a nuanced understanding, balancing the needs of the individual patient with those of the anaesthesia provider, the hospital (financially) and the population as part of wider environmental health considerations. They say: “There is also considerable scope for further exploration into improving the energy efficiency of device manufacture, transport and disposal, single-use device reprocessing and reusable device sterilisation.”
The WFSA Global Working Group on Environmental Sustainability in Anaesthesia
agreed on seven principles that any anaesthesia provider in the world should strive to achieve:
- Minimise the environmental impact of their clinical practice.
- Use environmentally preferable medications and equipment when clinically safe to do so
- Minimise the overuse/waste of medications, equipment, energy and water.
- Incorporate environmental sustainability principles within formal anaesthesia education.
- Embed environmental sustainability principles within anaesthesia research and quality improvement programmes.
- Lead environmental sustainability activity within their healthcare organisations
- Collaborate with industry to improve environmental sustainability.
The WFSA Working Group noted that the mission to reduce the environmental impact of anaesthesia must align with three underlying fundamentals: patient safety should not be compromised by sustainable anaesthetic practices; high-, middle- and low-income countries should support each other appropriately in delivering sustainable healthcare (including anaesthesia); and healthcare systems should be mandated/monitored to reduce their contribution to global warming.
The authors conclude: “We suggest that the above seven consensus principles form the basis of sustainable anaesthesia practice. Our expert opinion is that these recommendations are achievable globally, with minimal material resources and financial investment. A number of resources already exist on how to implement the recommendations made in this paper, which anaesthesia providers should discuss regularly at institutional and national meetings. This work is iterative, with opinion forming much of the basis for the recommendations, informed by published evidence. We suggest that these principles undergo re-evaluation and updates as better evidence is published, and we strongly encourage institutions to sponsor anaesthesia providers in undertaking the necessary research as a matter of urgency.”
WFSA President Professor Adrian Gelb says: “The climate crisis is as great, if not a greater threat than the COVID pandemic and both must be confronted urgently. Time will not allow us the luxury of dealing with one first and then the other. All sectors of society, including anaesthesia providers, must play our part in addressing climate change, the biggest threat to society.”
Dr Stuart White, who led the Consensus Group adds: “As anaesthesia providers, we are often appalled by the pollution we cause at work compared to the environmental care we take at home. We have to tackle climate change, together. I’m really encouraged to see how much consensus there is around the world about what we need to do to reduce the climate impact of anaesthesia and surgical care. Changing practice can be difficult, but never was it more essential, and the WFSA Consensus Statement should help anaesthesia providers do this”.