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Sustainable Anaesthesia Dr Kate Gardner Anaesthetic Consultant ESNEFTNHS England - October 2020 • NHS CO2 emissions reduced by 62% since 1990 • Net zero by 2040 for the NHS Carbon Footprint, aiming for an 80% reduction (cf 1990) by 2028 to 2032 • Net zero by 2045 for the NHS Carbon Footprint Plus, aiming for an 80% reduction (cf 1990) by 2036 to 2039Delivering a ‘Net Zero’ National Health Service - October 2020 NHS EnglandGlobal Warming Potential and CO2 equivalent GWP 100 The most commonly used metric to compare greenhouse gases The amount of heat trapped by a gas over 100 years • CO 21 • CH = 34 4 • N2O = 298 • CFCs, HFCs 1000s-10000s • Ie one tonne of nitrous oxide is equivalent to 298 tonnes of carbon dioxide • CO equivalents 2To reach net zero need to remove (from 2020) 6.1MtCO2e from NHS Carbon Footprint 24.9 MtCO2e from NHS Carbon Footprint Plus1 Megatonne CO2 = 1 billion Kg Co2 • 1 second • 1000 seconds = 16.7 minutes • 1 million seconds = 11.5 days • 1 billion seconds = 31.67 YearsAnaestheticsWhat does an anaesthetic involve? The word anaesthesia means ‘loss of sensation’. General anaesthetic Local anaesthetic Regional anaesthetic Spinal or epidural anaesthetic Sedation CombinationsGeneral anaesthetic Induction Injection into vein Inhaling anaesthetic gases/volatile agents Maintenance Injecting an infusion into the vein (TIVA) Inhaling anaesthetic gases/volatile agents Emergence occurs when these are stoppedVolatile Anaesthetics/GasesVolatile Anaesthetics/Gases 1 GWP100 Atmospheric lifetime Desflurane 2540 14 Years Isoflurane 510 3 years Nitrous Oxide 298 114 years Sevoflurane 130 1 year CO2 1 50-200 yearsReducing environmental impact • Desflurane – • Anaesthetists reduced use dramatically since 2019 (20%-3%) • With support of RCOA and Association of Anaesthetists, NHS England announced the decommissioning of desflurane by early 2024. • Stopping the use of desflurane across the NHS, with use allowed only in exceptional clinical circumstances, will further reduce harmful emissions by around 40 kilotonnes of carbon a year – the same as powering 11,000 homes every year. – NHS EnglandOther solutions • Volatile capture • Low flow anaesthesia • Machine designNitrous Oxide • Nitrous oxide alone contributes 2% of the total NHS England carbon footprint, and 75% of the total anaesthetic gas footprint. (CSH – Nitrous Oxide project) • Used in some anaesthetics – especially paediatrics and obstetrics • Used in ‘gas and air’Reducing environmental impact • Many anaesthetists no longer use nitrous oxide • The nitrous oxide project • Alifia Chakera –NHS Lothian/CSH • 16 sites – 95% of nitrous was wasted • Decommissioning of manifolds • Use of cylindersNitrous oxide destruction units – break nitrous oxide down into nitrogen and oxygenIntravenous Anaesthetics • Propofol Toxic to aquatic life Preservatives that have adverse effects eg changes to algae growth Soybean – 10% is soybean oil – environmental concernsTotal Intravenous Anaesthetic (TIVA)TIVA More environmentally friendly (1) 40 time less CO2e than a sevoflurane anaesthetic (2) Plastic waste accounts for nearly half of the carbon footprint per case Electricity to run pumps accounts for some of carbon footprint Estimates that an anaesthetist could use over 50,000 50ml syringes during their career (3) 1. White SM, Shelton CL. Abandoning inhalational anaesthesia. Anaesthesia 2020; 75: 451–4. 2. anaesthesia. Anaesthesia 2021; 76: 862-3.ental impact of inhalational anaesthesia and propofolbased intravenous 3. Tapley P, Patel M, Slingo M. Abandoning inhalational anaesthesia. Anaesthesia 2020; 75: 1257–8.TIVA comparisions 7 hour anaesthetic kgCO2e TIVA 3.2 Sevflurane 69.9 Desflurane 820 C Allen/I Baxter Newcastle upon Tyne• Regional anaesthesia • Dutch Approach ‘TIVA where possible, inhalational anaesthesia when necessary’Other projects • days - Sheffieldife of the anaesthetic breathing circuit form 7 to 30 • Reducing anaesthetic room use • Reusable hats, gowns, drapes • Improve efficiency of cell salvage • Stop unnecessary use of pneumatic compression boots -Swansea • Reduce inco pad use –Gloucs and Cheltenham Inco awareness week • Review instruments and equipment in preprepared packs • Gloves offOther issues • Energy consumption • Ventilators • Monitors • Pumps • Active warming• Reduce disposable equipment • Recycle • Laryngoscopes • LMA • ETT • Plastic trays • Waste streamsColchester anaesthetic departmentNitrous Oxide Project • In 2021 16 trusts who undertook the nitrous project found wastage of over 95% • A leak of 1 l/min = 43,000 l/month = 516,000 l/yearColchester Project • In the department there was known to be minimal use of nitrous oxide • The exceptions were in paediatrics and in obstetrics • oxide remained in the atmosphere – 35% of respondents were out by over 100 years • A survey was sent out regarding keeping the nitrous on delivery suite -64% of respondents wanted to keep it available • Audit afternoon on environmental issues and anaesthesia • Advice was asked from the paediatric anaesthetic lead regarding keeping nitrous available for paediatric cases – the general agreement was that it could be removed and was not necessaryColchester Project • Contacted other hospitals regarding delivery suite arrangements • Dame Clare Marx Centre,IRCA,MRI theatres designed without nitrous oxide supply • Notice was given by WhatsApp, email and notices in the anaesthetic rooms that nitrous oxide was to be removed from the anaesthetic machines. • Chance to use SPA time to update or change anaesthetic technique • Pipeline supply switched off in all three theatre suites in November 2022 • Manifold kept going to supply the two theatres on delivery suite as no capacity for cylinders on the machines Colchester project Delivery suite supplied with two large cylinders – one for each theatre, with Schrader valve connectors for those who want nitrous oxide for the general anaestheticsColchester project • September 2023 request for the manifold to be decommissioned • Environmental impact - up to 600,000Kg CO2 saved a year • Financial impact – Approx £5,500 saved a year plus mantainence costs • Ipswich Hospital followed suite – decommissioned ? Late 2024Engagement • Education • Training • Awareness • Priority among clinicians and managers • Procurement • Work together • Involve the whole patient pathwayThank you for listening, any questions?