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October 2, 2017 


The public health impact of the environmental pollution created by the healthcare sector is commensurate with the scale of hospital deaths due to preventable medical errors, recent research shows.  The operating room is an environmental hot spot and major generator of waste, and the greenhouse warming potential of inhaled anesthetics is of special concern.  Anesthesia providers can take some relatively simple steps to reduce the OR’s carbon footprint and become environmental leaders in their facilities.


Hospitals exist to protect health and treat illness, but healthcare has developed a culture of wasteful, environmentally unsound practices that actually causes harm, according to clinicians and scientists who have pioneered the emerging field of ecological sustainability in healthcare.  “The fundamental tenet of healthcare practice is ‘Do no harm,’ but ironically, the practice of healthcare itself causes significant pollution, and, consequently, indirect adverse effects on public health,” one of these pioneers, Yale University anesthesiologist Jodi Sherman, MD, said.

A 2016 study by Dr. Sherman and environmental engineer Matthew J. Eckelman, PhD, published in PLOS One reports that “these indirect health burdens are commensurate with the 44,000-98,000 people who die in hospitals each year in the U.S. as a result of preventable medical errors, but are not currently attributed to our health system.” 

The environmental damage wrought by healthcare is particularly evident in the operating room.  “Among environmental hot spots in healthcare, the OR is highly resource-intensive and a very large contributor to the pollution footprint,” said Dr. Sherman.  The healthcare organization Practice GreenHealth cites estimates that 20–30 percent of a hospital’s total waste originates in the OR.

According to Dr. Sherman, anesthetic gases are of particular concern.  More than one-third of the carbon footprint stemming from an average OR surgical procedure derives from anesthetic gases, and up to five percent of a hospital’s greenhouse emissions can come from inhaled anesthetics.  Practice GreenHealth notes that, during a procedure, a patient metabolizes only about five percent of administered anesthesia gas; the remaining 95 percent is exhaled as waste during respiration and vented by scavenging system into the atmosphere.

Drs. Sherman and Eckelman performed a “cradle to grave” Life Cycle Assessment (LCA) of common anesthesia drugs to quantify their environmental impact.  Their research shows that the atmospheric pollution impact of desflurane and nitrous oxide is more than 20 times that of sevoflurane and isoflurane.  It also shows that inhaled anesthetics have 40,000 times the atmospheric impact of intravenous propofol.  (The greenhouse gas impact of propofol comes primarily from the electricity required for the syringe pump and not from drug production or direct release into the environment.)

They recommend restricting desflurane and nitrous oxide to cases in which the agents are needed to reduce the likelihood of morbidity and mortality.  They also recommend avoiding unnecessarily high fresh gas flow rates for all inhaled drugs and using waste anesthetic gas capturing systems.  Techniques other than inhalation anesthetics, such as total IV anesthesia and neuraxial or peripheral nerve blocks, are also less environmentally harmful.

Natural Leaders

The fact that anesthesiologists interact with many other specialists in care delivery uniquely positions them to lead efforts to embed sustainability as a core patient care value, according to Dr. Sherman.  Anesthesiologists can easily expand their mission of delivering safe care throughout the perioperative period to include safety for the community and the environment.  “Resource conservation is not part of the clinical mindset, but it ought to be,” she said.  “While clinical conditions must dictate clinical care, waste reduction is a simple means to reduce pollution and conserve healthcare resources without altering patient safety.”

Practice GreenHealth recommends using the low-flow technique, which involves reducing the flow of anesthetic gases to the amount needed to maintain sedation after induction, with careful monitoring, in order to reduce the amount of unmetabolized gas released into the air.

The Department of Anesthesiology at the University of Wisconsin-Madison has developed a sustainable anesthesiology website with information on the environmental effects of anesthetic gases and other resources, and has created vaporizer label stickers (available for use freely without alterations) to remind anesthesia providers of the environmental impact of the agents they use.

The stickers indicate the Global Warming Potential (GWP) of the various gases relative to carbon dioxide.  The department has been able to save more than $20,000 monthly by reducing desflurane use, a change that has yielded emission reductions that are the equivalent of 875 cars being taken off the road for one year.

Dr. Sherman and her colleagues in Yale University’s Department of Anesthesiology have developed a free app, Yale Gassing Greener, that allows anesthesia providers to enter amounts and flow rates of inhaled anesthetics and obtain their carbon emission equivalents.  The app includes a facility calculator that allows perioperative staff to enter amounts of purchased inhaled anesthetics and receive a comprehensive report on their facility’s carbon emissions.

The American Society of Anesthesiologists has challenged clinicians internationally to reduce their inhaled anesthetic carbon emissions by 50 percent by 2020.  The initiative, known as Project Draw Down, invites participants to anonymously compare their facilities’ inhaled anesthetic procurement volumes to inspire performance improvement and reduce healthcare carbon emissions globally.

Anesthesia gases are only one of many sources of waste and pollution in the OR.  To help anesthesia providers become better environmental stewards, the ASA Environmental Task Force offers the following checklist of other strategies to create a more environmentally responsible environment.   

  1. Reduce Inhaled Anesthetic Atmospheric Waste
    Utilize low fresh gas flows
    Avoid high impact inhaled anesthetics: Desflurane, Nitrous Oxide
    Consider intravenous and regional techniques
    Invest in waste anesthesia gas (WAG) trapping (for volatiles only) or WAG destroying (all inhaled anesthetics, including Nitrous Oxide) technology for the anesthesia machine
  2. Reduce IV Pharmaceutical Waste
    Use prefilled syringes
    Use appropriate sized vials for an individual patient
    Dispose of unused medications and vials according to regulations (and not exceeding)
  3. Reduce Anesthesia Equipment Waste
    Only open equipment intended for immediate use
    Consider purchase of reusable or reprocessed equipment over disposable
    Reprocess or recycle suitable disposable equipment
    Adjust stock levels to minimize discarding expired items
    Reformulate prefabricated kits to eliminate unnecessary items
    Reformulate anesthesia supply carts to eliminate unnecessary items
    Donate expired or unused open equipment
  4. Solid Waste Segregation
    Segregate waste according to type (pharmaceutical, solid, biohazard, etc.) 
    Avoid default of placing all waste into a biohazard or sharps bins
    Recycle batteries
    Consider intraoperative recycling program for clean plastics, paper and cardboard
  5. Linens
    Consider reusable linens
    Minimize excessive use of reusable and disposable towels and blankets
  6. Electronics
    Avoid excess electronics without proven benefit to patient care
    Use a certified sustainable electronics recycling vendor to dispose of old equipment
    When negotiating equipment upgrades/contracts, request vendors take back old equipment for refurbishment and donation, or request vendor use a certified sustainable electronics recycling vendor
  7. Leadership
    Develop/join a Sustainability Committee at a department, hospital, or society level and advocate for a sustainability officer
    Collaborate with hospital leadership to embed pollution prevention as part of the core business mission, to improve the health of our patients, employees and the surrounding community
    Become involved in environmental preferable purchasing
    Educate staff regarding the health, safety and cost benefits of environmental projects
    Evaluate new equipment, facility and behavior options for improved sustainability
    Consider strategic sustainability research projects that will lead to financial and environmental savings for the hospital.   

Dr. Sherman sums up this important issue nicely in a March article in Anesthesiology News

A critical knowledge gap exists in the medical community regarding the indirect health consequences of wasteful, non-value-added practices in all their forms, and anesthesiologists can play a role in narrowing this gap.  Anesthesiologists can model conservation practices, through leading by personal example, as well as through education of students, residents, patients, and other health professional colleagues and support staff.  We can also influence change by taking on leadership roles in our own institutions and in our communities.  It’s time to broaden the scope of our thinking about our health care duties as anesthesiologists, and embrace our role in global health.

With best wishes,

Tony Mira
President and CEO