ASRA Pain Medicine Update

Living in a clean situation is essential to the health of all beings, and yet humans are the only species that choose to destroy its environment. One major contributor is plastic, and therefore any proposed solution for environmental preservation must involve sustainable production, use, and disposal of plastics. Dramatic reductions in single-use disposable products, increased use of reusable products, improved retention and management of plastics for recycling and repurposing, and increased use of bio-based plastics are needed across all sectors of the economy. The health care sector is an enormous consumer of plastics and must begin to use sustainably produced products or demand them where they do not yet exist.

Every product contributes to resource depletion, and we must manage our resources wisely to benefit current and future generations.

Plastics have unarguably revolutionized medical care. Unfortunately, the environmental destruction and public health effects of plastic waste are growing at an unprecedented rate. In an effort to minimize transmission of communicable diseases and increase workflow and cost efficiency, many hospital administrators have supported widespread adoption of single-use disposable plastic products. This wasteful strategy has little data to support its implementation, benefits a minority of patients, is tragically short sighted, and adds to the growing ecologic and humanitarian crisis of climate change. We must find a way to minimize transmission of disease, maximize fiscal and labor efficiency, and minimize environmental destruction. Finding a balance will be difficult, but they do not need to be mutually exclusive.

Benefits of Reusable Products

A product’s environmental impact is a calculation of the energy consumption associated with raw material acquisition, product production and transport, autoclave and other sterilization procedures, premature device loss, landfill use, and eutrophication. The results are then compared for various devices and many times reported in carbon dioxide equivalents to yield the carbon footprint for a particular product or process.

We can examine particular products that have single-use disposable and reusable varieties. Some examples include laryngeal mask airways (LMAs), laryngoscope blades, and surgical textiles. Reusable LMAs have fewer negative environmental effects in nearly all categories (ie, carcinogenesis, global warming potential, acidification, air pollutants, eutrophication, ecotoxicity, smog, water intake, ozone depletion), typically contributing less than 50% of the effects of disposable LMAs.^[1] Reusable rigid laryngoscope handles and blades have a significantly lower environmental impact compared to single-use disposable alternatives.^[2] Furthermore, disposable metal handles and blades are worse than their plastic counterparts, secondary to significantly higher greenhouse gas emissions associated with their production.^[2] Reusable surgical textiles offer substantial sustainability benefits over the same disposable product in energy usage (200%–300% less), water usage (250%–330% less), carbon footprint (200%– 300% less), volatile organic production from degradation, solid waste production (750% less), and improved instrument recovery.^[3]

Typically, the environmental benefits of reusable products are a consequence of their intrinsic reusability and reduced energy expenditure associated with transportation. For regional anesthesia, neuraxial blockade, or perineural catheter insertion, reusable gowns and drapes can be used to create a sterile field while increasing the likelihood of reducing the environmental footprint of regional anesthesia. Every product contributes to resource depletion, and we must manage our resources wisely to benefit current and future generations.

Is Disease Transmission a Risk?

Intuitively, preferential use of single-use disposable products should decrease the risk of transmission of communicable diseases and life-threatening pathogens. Indeed, they are a good solution for indwelling devices and to prevent transmission of highly virulent communicable diseases. For example, prion diseases are cited as a major infection concern thereby favoring single-use disposable products for those patients. Although use of single-use products in the setting of infectious disease processes may seem reasonable, a paucity of data supports those conclusions. Critics of reusable devices highlight the documentation of proteinaceous material remaining on reusable LMAs. In addition, iatrogenic transmission of Creutzfeldt-Jakob disease has been reported in more than 250 patients worldwide, with six cases attributed to contaminated neurosurgical equipment, but all were prior to current sterilization procedures and standards. Of note, no reported cases of iatrogenic infection of any type are linked to a reusable LMA.^[1]

Reusable metal laryngoscope blades are associated with significantly higher success rates with rapid-sequence intubation compared to single-use plastic alternatives.^[4] It logically follows that reusable metal blades may be associated with a decreased risk of pulmonary aspiration and iatrogenic infection by minimizing intubation attempts and the amount of time that a patient is anesthetized with an unprotected airway. With regard to surgical textiles, the Centers for Disease Control and Prevention and others concluded that no data suggest important differences in reusable versus disposable gowns and drapes in preventing surgical site infections. General lack of any bacterial contamination from permeation of a gown barrier reflects the similarity of reusable and disposable textiles in protecting health care workers and patients.^[3] Clearly, disposable barrier devices may have a role for patients with highly infective or particularly virulent infectious agents. However, data do not support selecting disposables for all patients to prevent any possible risk of infection.^[1]

Cost Savings

No discussion of proposed sustainability initiatives is complete without addressing their financial implications. Certain products should be reused because of financial cost and technologic composition. Unfortunately, a minority of health care items are available as reusable products, and the number of disposable product options is growing rapidly. Cost analysis has been performed for single-use disposable and reusable varieties of LMAs, laryngoscopes, and surgical textiles. Eckelman and colleagues demonstrated, assuming full use, that a $200 reusable LMA costs $5 per use, plus $3 per cleaning for a unit cost of $8, excluding utility and hospital overhead costs, whereas the cost of disposable LMAs is 20% higher at $9.60 per unit.^[1] A study at a single institution demonstrated that transitioning to use of disposable laryngoscope handles increased overall costs by $495,000–$604,000 per year relative to reusable handles, depending on the cleaning scenario. The same study found that single-use disposable blades increased costs by $180,000–$265,000 per year relative to reusable blades, depending on the cleaning scenario.^[2]

Cost differences between reusables and disposable textiles may be overshadowed by personnel garment preferences. These preferences could explain the higher reusable use percentages in Europe (50%) versus the U.S. (10%), rather than any fundamental cost differences. Neither disposable nor reusable systems have eliminated the other product type. This suggests similar costs because significant cost differences would have driven the market to essentially zero for the expensive option.^[3]

Collectively, we are at a pivotal point in history where we have an opportunity to make an incredibly positive impact on environmental health. To accomplish this, we can no longer consider environmental destruction an externality but rather an ever-present factor to consider when making purchasing decisions. Looking forward, we can strive for new biomedical ethics, by which we remain faithful to preserving patient care without compromising ecologic health. Adopting those ethics requires a profound reorganization of our professional priorities and our standards of daily practice.^[5] The environmental and humanitarian crisis of climate change demands such a reorganization. With collaboration, awareness, and hard work, we can preserve patient care and improve ecologic health.

References

1. Eckelman M, Mosher M, Gonzalez A, Sherman J. Comparative life cycle assessment of disposable and reusable laryngeal mask airways. Anesth Analg. 2012;114(5):1067–1072. https://doi.org/10.1213/ANE.0b013e31824f6959
2. Sherman JD, Raibley LA 4th, Eckelman MJ. Life cycle assessment and costing methods for device procurement: comparing reusable and single-use disposable laryngoscopes. Anesth Analg. 2018;127(2):434–443. https://doi.org/10.1213/ANE.0000000000002683
3. Overcash M. A comparison of reusable and disposable perioperative textiles: sustainability state-of-the-art 2012. Anesth Analg. 2012;114(5):1055–1066. https://doi.org/10.1213/ANE.0b013e31824d9cc3
4. Amour J, Le Manach YL, Borel M, et al. Comparison of single-use and reusable metal laryngoscope blades for orotracheal intubation during rapid sequence induction of anesthesia: a multicenter cluster randomized study. Anesthesiology. 2010;112(2):325–332. https://doi.org/10.1097/ALN.0b013e3181c92111
5. Ahuja NK. Health and high water. N Engl J Med. 2019;381:2196– 2197. https://doi.org/10.1056/NEJMp1909480