Jan 31, 2019, 10:57 AM by Timur J.P. Ozelsel, MD; Rakesh Sondekoppam Vijayashankar, MBBS, MD; Vivan H.Y. Ip, MBChB, MRCP, FRCA

 

World Anesthesia Day is recognized annually on October 16 and marks a significant day for acknowledging and celebrating the discoveries and advancements made in the international practice of anesthesia. This is a day to commemorate the birth of our specialty and to honour not only those who have come before, but also those who represent the present and future of our specialty.

---

In 2017, our Edmonton anesthesiology practice purchased 1,211,250 mL of sevoflurane, 593,280 mL of desflurane, and 54,600 mL of isoflurane. This is the equivalent of 6,430,365 kg of CO₂ resulting from volatile anesthetic agent administration—before considering the impact from nitrous oxide.

---

As anesthesiologists, we have made significant advancements in clinical care that have resulted in tremendous benefits for our patients. However, our practice also represents a significant contributor to the production of greenhouse gas via the administration of volatile anesthetic agents. As shown in Table 1, different volatile agents have different global warming potential, with sevoflurane being the least harmful to the environment and desflurane being the most potent greenhouse gas.^[1-3] Nitrous oxide, in addition to acting as a greenhouse gas, also possesses ozone depleting potential.^[4],[5]

The volatile agent repertoire has seen no advancements since the 1990s when sevoflurane was introduced. This may be secondary to a lack of health care-related carbon footprint regulation and therefore a lack of interest to explore other newer, inert gases with no global warming potential (eg, xenon).^[6] Furthermore, our soil and water are being polluted by solid and liquid waste production in the operating room that results from abundant single-use product packaging and drug disposal.

The World Health Organization described climate change as one of the biggest threats to human health in the 21^st century.^[7] As physicians whose primary goal is to save humanity and do no harm, we must pay more attention and act to reduce the amount of carbon dioxide (CO₂) we produce.

This year, we celebrated World Anesthesia Day in style in Edmonton, Canada. In partnership with the Edmonton-based Canadian Anesthesia Society Environmental Sustainability Section, we invited anesthesiologists in Edmonton to sponsor reforestation efforts in Fort McMurray, Alberta. This act served to partially offset the carbon footprint related to the provision of anesthesia and to rebuild the environment of Fort McMurray where a huge forest fire devastated the community in 2016. The forest fire was the result of unseasonable and extreme heat and wind, which many speculate was caused by climate change. A registered company (A Living Tribute) managed the reforestation effort by using the gathered funds from our event to plant native tree species in dedicated copses (groups of trees). Satellite imaging will allow for sponsors to track the progression of the copses over time. Each tree has a 22 kg (48 lb) carbon offset per year, and our event sponsored the planting of 256 trees.

In 2017, our Edmonton anesthesiology practice purchased 1,211,250 mL of sevoflurane, 593,280 mL of desflurane, and 54,600 mL of isoflurane. This is the equivalent of 6,430,365 kg of CO₂ resulting from volatile anesthetic agent administration—before considering the impact from nitrous oxide. Although many more trees are required to totally offset our carbon footprint, do not despair: there is hope! Through education, Edmonton is moving away from the use of desflurane and increasing the use of regional anesthesia in our practice, which has already decreased our CO₂ emissions by two tons from 2016.

On World Anesthesia Day, we also launched an awareness campaign where we set up an exhibit at the University of Alberta Hospital to inform the public about our initiative (see Figure 1). We educated the public on the impact of anesthesia on the environment and ways to decrease our carbon footprint, such as reducing our use of desflurane and employing more regional anesthesia techniques where appropriate, recycling our plastic waste, segregating solid waste and separating sharps only waste from glass ampule waste, and reusing our equipment as much as possible rather than using disposable equipment. People from all walks of life visited the exhibit, including a 10-year-old girl who told us she would request environmentally sustainable anesthesia when she needed surgery.

Our innovative initiative with planting trees for Fort McMurray and awareness campaign will not offset our practice; however, as a specialty, we can make a public statement: “Primum non nocere”—first do no harm. We are health care providers, and we care for humanity.

 

Figure 1: Exhibit for the Sustainable Anesthesia Awareness Campaign

From left to right: Dr. Cheryl Mack (anesthesiologist at the Stollery Children’s Hospital), Dr. Vivian Ip, Dr. Timur Ozelsel (both are anesthesiologists at the University of Alberta Hospital), and Justine Klaverkibria (epidemiologist with special interests in climate change)

 

Table 1: GWP20 and Equivalent of Distance for Driving a Car for Selected Anesthetic Volatile Agents or Gas

Agent	GWP20a	Km per OR-Dayb
Sevoflurane	795	145
Isoflurane	1,800	181
Desflurane	5,550	2,554
Nitrous oxide	264	350

GWP20—global warming potential over 20 years; OR-day—7-hour workday in the operating room using 0.5 liters/minute of fresh-gas flow

 References

1. Sulbaek Andersen MP, Nielsen OJ, Karpichev B, Wallington TJ, Sander SP. Atmospheric chemistry of isoflurane, desflurane, and sevoflurane: kinetics and mechanisms of reactions with chlorine atoms and OH radicals and global warming potentials. J Phys Chem A. 2012;116:5806–5820. https://doi.org/10.1021/jp2077598
2. Climate change 2014: synthesis report. contribution of working groups I, II and III to the fifth assessment report of the Intergovernmental Panel on Climate Change. Core writing team, Pachauri RK, Meyer LA, eds. Geneva, Switzerland: IPCC; 2014. https://www.ipcc.ch/report/ar5/syr
3. Sherman J, Le C, Lamers V, Eckelman M. Life cycle greenhouse gas emissions of anesthetic drugs. Anesth Analg. 2012;114:1086–1090. https://doi.org/10.1213/ANE.0b013e31824f6940
4. Portmann RW, Daniel JS, Ravishankara AR. Strtosperic ozone depletion due to nitrous oxide: influences of other gases. Philos Trans R Soc Lond B Biol Sci 2012;367:1256–1264. https://dx.doi.org/10.1098%2Frstb.2011.0377
5. Parn J, Cerhoeven JTA, Butterbac-Bahl K, et al. Nitrogen-rich organic soils under warm well-drained conditions are global nitrous oxide emission hotspots. Nat Commun. 2018;19:1135. https://doi.org/10.1038/s41467-018-03540-1
6. Xia Y, Fang H, Xu J, et al. Clinical efficacy of xenon versus propofol: a systematic review and meta-analysis. 2018;97(20):e10758. https://doi.org/10.1097/MD.0000000000010758
7. Climate change and human health. World Health Organization website. http://www.who.int/globalchange/global-campaign/cop21/en. Accessed October 26, 2018.