Final session - The Debate and close
Summary
This on-demand teaching session is relevant to medical professionals and provides a heated debate between an anesthetist and an intensive care specialist about whether nitrous oxide should be used in medical practice. The anesthetist argues that nitrous oxide is a great drug with a strong safety record and a fast, smooth induction. The intensive care specialist raises the point that nitrous oxide is a potent greenhouse gas, contributing to a global warming present in 20 years. The session discusses measures of quantifying the impact of nitrous oxide, putting it in context with other choices that can be made, and concludes that a nitrous free practice is responsible for much of the nitrous oxide released.
Learning objectives
Learning Objectives:
- Understand the history of nitrous oxide in anesthesia and its impact over the last 150 years.
- Analzye the current evidence pertaining to the safety and efficiency of nitrous oxide.
- Understand the global warming effect of nitrous oxide.
- Examine the impact that the use of nitrous oxide can have on reducing greenhouse gas emissions and the global environment.
- Become familiar with strategies to reduce nitrous oxide emissions in anesthesia.
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Good afternoon. All on my welcome to the final exacting session off this more it can. Ascetic meat. Uh, it's actually feeling quite woman key. Yeah, because the debate is going to be quite heated up on Dem. Last two years, we have been see in, oh, hearing about a couple of things. One most coveted. Another one was climate change. So we wanted to be a big trend, and we thought, Well, stay something that climate change. And then this topic came up about better. We should use nitro. So no on, Do we have, Ah, kind off debate, you know, in the corridors and things like that. Then we thought, or don't we bring it really and live so that we can we can have Ah ah, some information and we can reflect on the practice as well. So then we got stuck up. Whom can we get to do this talk? Um, Then it was unanimously decided we got to eminent speakers to fight for. This one Is Mark Dixon on the other one is Simon Fletcher. It makes my job easier because I don't have to introduce these too eminent speakers. Um, before I go into the details, uh, towards the end that it'll be a slide over which is a whole, um, you can walk down that hole, and then at the end, we can see how much wants to use nitrous and how much doesn't want nitrous. But the first stop is going to be, um, Markets, and he's going to come strongly with this. Be better. That on Actos is complete. Absolute necessity practice to introduce month Dixon. He's a regional anesthetist, the diva and two CS on Depakene cyclist. So whatever he does, he wanted to be pure and clean on on the other end. I got Doctor Fletcher, who is an intensive ist on. He's been the past president off the college wise president. I just wanted to make you a bit more of a greater Simon Onda. Uh, he's not, ah, gained sight This I think he's got he's liking car lover. I could see his from his live. He's got a very Proscar, but we'll come to that later. But I'm going to handle the topical that baby. It opens with the Mobic san over to you, Mom. Thank you, Santa. Thanks very much. And thank you to To the organizer. The meeting for bringing this debate Teo usual, I believe, is the first time the urine channel setting update has had a session on sustainability because that that heart is what this debate is all about. Drugs have come and gone in anesthetic practice over the years, and obsolescence has been driven by better alternatives or by change perceptions risk no more. Now, seriously, consider getting another. Set it with these exito drawer former office in on, uh, no one would use jittery or eus muscle relaxant toe upon us. Know Jesus. These drugs have all had their time in the sun. And, uh, what is different this time is that Nitrostat side remains a good drug. However, the world around that has changed, and so now, belatedly must our practice. This, Santosa said, is a debate on here to present by. But the counter argument is like colleagues, um, Fletcher. Those who know Simon nose amount of strongly held views on go. Any debate that seeks to prize his fingers from his blue no is likely to be, uh, less like one of boost Boris Johnson's drinks, events or works events on drinks and levels and more like a cage fight. So let's, um Let's get underway. Sure. Missing you, Mr. On that. Yeah. So been around a long time. Last induction. Excellent safety record. Was his son nausea? Maybe, but less than expected and often gone before the patient wakes up. Now this, of course, is true. Assignment or low? Could equally applied to mattress oxide, which, as I say, is a great drug. There's been around a long time. This is the kind of young man a Taurus twelves who first introduced a max oxide to work in the practice. 18. 44. He was This was watching a country show on saw a demonstration of the effect of natural socks side. And the very next day, you had one of his teeth removed under nitrous oxide. Use this on a few patient. It's in a month later. You like the Massachusetts General. Hospitals demonstrate his technique. Sadly, it wasn't a great success as surgeons that his knife, the patient cried out in pain. Wells was hustled out of the room, cried out of the Charlotte. Yeah, suicide. Three years later. Not a great start. The career much. But he started something on this, uh is the BBC World machine, designed in 1941 100 years after course swells. His first demonstration, so by 1941 standard on a CD. Yeah, it was not just oxide in a patient with a vapor of some sort, and you've got either on trying socks. I'd had useful anesthetic properties and orgies. It properties sped up induction or any cause it so health. It's fast, but also because of useful second gas effect, which was useful in the soluble slow acting. Draper's in use that time, from our perspective, now is really hard to come to terms with just how much of an impact nitrous oxide had 18 44. For that time, the options for patients with surgery were prodigious amounts of morphine, alcohol or leather strap, or, in a girly reform multimodal analgesia. A combination of all three. And just because my mattress is being in around a long time doesn't diminish. It is a drug after when we still have some very good uses for alcohol, morphine and occasionally for leather straps, and I should say I'm getting more details about that. The thankfully things have changed since 1941 c the floor in his cover Long on allows rapid smooths gas inductions. The predictable confusion characteristics of a problem for the fentanyl, together with the magic of Target controlled infusion, is made TVA much more accessible. This monitors don't get perfect. They're improving rapidly. I never helpful in our practice already. So practices moved on. How many of us still fiddles with Simon's Blue? No. One source of information on this is the most recently completed nap nap six. This slapshot off 2016 practice Gather data on 16,000 patients case in the states we're using now excited. 17% of these cases more convenient peed in about 30% and in cetera X in about 6%. Why I started on a seizure in the early 19 nineties. Venerable hello. Thing was still in wise for it. Use. It was a great drug, but still slow enough to justify using, like stock side with it. So when the new morphine or a hospital is being designed, revision of pipe night stock side wasn't a question exam must. It was exactly the same. Other side with world, um was meeting to agree away to limit greenhouse gas emissions that was 1997. It's now 2022. Quarter of a century is past sense of world news The nitrous oxide was a G determinant. By 1997 it was evident the greenhouse gas effect was leading to worry about climate changes in our weather patterns was recognized that time, with three biggest contributors to warming were carbon dioxide. Methane, yeah, nitrous oxide. The floor of compounds listed here. Release them ups with the confidence. But we have seen as without urinated on a set occasions to keep a desperate. These are very potent greenhouse gases. Nevertheless, much sock side has by far the largest greenhouse gas effect of the anesthetic gases in nuisance in clinical in a seizure in UK contributing to 80% greenhouse cancer effect. Anesthetic practiced in this country. How do you quantify this? So the relative potency off the different greenhouse gases is important Is a global warming present for the next 20 years of loopy, 20 gives her to about one. Then the relative value for nitrous oxide is 289. It's massive difference is partly due to the greater intrinsic potency of nights oxide itself. It's greenhouse gas partly to its effect on those, uh, in the stratosphere. That's the upper. They're over at Masefield. It catalyze is the depletion that's not great. Exposures to more ultraviolet light doesn't itself having if it doesn't in itself having effect on the greenhouse gas effect. However, in the troposphere, which is from ground, looked about four 19 floaters, reaction goes the other way. A nitrous oxide catalyze is the formation of those which in this lower atmosphere access a potent greenhouse gas. It's math, and you've seen American, one of the earlier talked by and boom from that. This one, that is, uh, rapidly Stangler in 2014 is That's when GW to 20 might be coming into play, uh, with a temperature rise of 2.4 degrees centigrade, which is what's predicted for running the cop 20 sales preservation. What I haven't shown in this map is London, which is just a disaster. Putting the choices we make into context is difficult. For example, there is a huge societal pressure to recycle stuff have releasing in terms of global warming. This has a pretty modest impact, really, with the the order of half a ton of two per person per year. But politicians, this is also quite difficult. Yeah, they're often seen is trying to take away the fun stuff. So, for example, if you avoid one return transplanted flight, for example, to Jamaica, that might avoid 1.5 tons of seeing to counter over a year. Nevertheless, we can't avoid the fact the choices will make individually. Do you have an impact? That impact is higher in the richer parts. The world in the poorer pass the world at the top of the leaderboard in Australia, with a carbon cost off 17 tons per person per year. Driven, I think, really, by the CO2 from the cold fire past Asians driving a electric conditioning unit, the average see here to, uh, consumption per person per year. It's about 4.8 on a global scale in the UK, it throughout 10 tonnes purpose for you. Let's put that in the context decision. We make our hands harbor. Oh, that the fresh gas flow choice we make for, um, aches and ascetic. One hour. This is the's. The figures from the AGB I carbon cost calculated using figures from Tom Pierce in his Group one hour of nitrous oxide. Flying a one liter a minute has a global warming. You perfect equivalent of 33 kg to see you too. So the niece disuse. Um, what is two liters a minute for eight hours of anesthesia? Three days a week. 44 weeks in a year is making a choice equivalent for the 70 tons of CO2 in there, and we'll practice if we go back to this slide. The biggest impact you can typical UK person can have is to live car free, saving 2.5 tons of two year. We knew that long. And finally we can work out that it's true. A niece just have superpowers. We can save 70 tons of Sears to a year just by using fresh air. Now, that will be amazing enough. Sadly, is only part of the story because anyway, you work Just having pipe. Nitrous oxide of age is responsible for much of the nitrous oxide we release. The damage sphere isn't natural. Still 25 years old, you still look shining on the outside, but you're just getting a little bit shabby on the inside. And this is a new most hospitals in the UK a considerably older A study by any chest Lothian across 16 sites indicator that 95% a mattress oxide supplied hospitals was lost in pipeline. There are good reasons why this is the case. If there's a leak from water pipe, it causes damage. Leak is very quickly repaired. Leaking a nitrous oxide is different, delivery merrily for years without being until some would it, like this comes up and shows that discrepancies between volumes used in the mornings. All right, so I understood how important it will be for you to have the data from nourished and, I gather will be available data to give to, you know, here it is. There is no data. It's five nights oxide responsibility of seconds. Danger that manifolds lie in the hospital still in supply. Maintain to contracted level. There is no or bit of use. We have no records of use. A little local theater, information system or sauce holds information on the primary, and it said occasion. No information is gained. One where the nitrous or air or used. So you may think there's a reasonable argument to be made to continue the use in that side in selected patient use. Asian groups, for example, having cylinders, uh, as a transition from apart mind supply to stopping using mattress a little better may consider having cylinders in P 10, a separate room and mercy theaters in the center. It's for where there previously been heavy users when this would reduce the fact the nitrous oxide used by factor approximately 20. Uh huh. Soon let's have problems of the room. Most of those return to the suppliers by the part or even complete. Full mhm regulations. Stipulate that alone Medical gasoline does have two event it airport for refilling. There is at present little vacation on supplies to make that much subsided homeless before in teeny syllables. Of course, As a niece, this are used to not socks. I'd another volatile it on a setting. Agents is only a tiny part of the whole global warming picture, not just outside accounts or 6% the total greenhouse gas effect and medical much outside account through any 1% of that. However, if we're gonna meet, the challenge is present about global warming. We're gonna have to do everything, and the sooner the better. This is what Netzer Row looks like from the chair of Deanna Chest X active, the NHS is mandated to be net zero by 2040 and 80% of that has to reach for 2030. Unit tests has divided the emissions related to an excess activities into three steps. Scoot one is all those emissions that directly controlled by the NHS itself scope, too. And schedule three of where there's indirect religion control tool. Okay, maybe to see in this line, there are four categories within the scope. One. Direct control. When it's the first few months Bentyl teaching buildings. Another is thie embedded carbon cost with the natural buildings themselves. The third is thie, any chairs, vehicle fleet least vehicles and the fourth his anesthetics. So the only clinical component of Skirt one for any chest zero is anesthesia and 80% of the carbon cost fallacy easier is nitrous oxide. So what can we do? How do we respond to all this bad stuff when nitrous oxide has been such a nisi drug use? Maybe we can hide behind the defense that it's still the best drug for patients. This is how robs lead human gonorrhea on David pension respond to that. And, yes, you look carefully. This is back in 2010. Ropes needed human gonorrhea. Well known trust man. It's easier. David Pension. Who's a public health doc? Abscess. Oh, in 2020. He won the BMJ outstanding contribution to Health Ward for his working, making climate change and sustainable development. Health issues just They advocate that we in making acceptable sponsor 30 for environmental stewardship. We've got our patients first. But what about patients? What did they think? It's fair to say they're pretty concerned about change, which is important when you come to come get a patient's consent. This is information from that so summary whole taken in August 2021. Previously under the bottom tests, you could rest assured that there's evidence of 17% of your colleagues. Also use nitrous oxide. No pulling the Montgomery. Really. Doctors must provide information about material risks. They must disclose any risk to. It's a reasonable burst in the patient's position where attached difference. The judgment therefore, means doctors must share ulcer material risks is where there's any too, which would be reasonable for them to think that the individual patient would attacks if a third of new K population things. Climate changes. The most important issue facing broken today is reasonable to assume many patients with attached difference to your choice of anesthetic if the material risk you trust much stock side. If the big guns and anesthesia in the views your patients aren't enough, please allow me to invite 44th president of the United States to come to make some closing currents. This is the first generation to feel the impact of climate change. Where the last generation do something about it. You only get one home. You only got one planet has Low. Plan B is a comments of rock a warmer mate. United um Climate change summit in 2014, 8 long years ago As a nation. Eustis we can do something about climate change, and we must all think about what we do. The impact it has is individuals as departments is hospitals, and it's a specialty you just stop using. Not so so, but little time has passed since we first knew about this. Brought on. Even so, it's not too late. Indeed, 11 years early is it is loud. Thank you. Oh, that's not. That was mind blowing. What a minor, precise details. Years even. I think I'm going to stop Nitrostats Cycling. Two words. Cut all of my holidays. I don't know how Simon is going to come up under against pain. Um, let me pass on this, too. Simon on. Get me give marks presentation again. All right, let me force on this. Okay, We're going to get into the Simon. There you go. Good off. But I'm I guess separating you from your first glass of wine of the day. Ah, excellent presentation up. Thank you. I have trouble disagreeing with a single word you said, but my role is not to, uh, Teo disagree with markets to actually make a case for the continued use of nitrous oxide. I'm not trying to convince any of you to use it when I have my job. Here is to absolutely to actually make a presentation that that that satisfies enough for you. That nitrous oxide still has a place in modern anesthesia. While we're at that, this is not a debate about modern versus old about intravenous first gases. Anesthesia. It's not a debate about whether I should retire is an anachronism. It's a debate about whether nitrous oxide is still off some value toe us in 2020 to anesthesia. Just aside, I noticed the title of the debate was a volatile debate where it's not a voluntary, it's a gas, but we go. That's just semantics. Sure makes me move it. Okay. There. Okay. Okay. Bit more history. You had some history from Mark. I'm going to go do a little bit more detail just to put these things in perspective. So John Priestly, who was a we know, a clergyman scientist first isolated nitrous oxides back in the latest 16th century. Interestingly, he also identified oxygen. We're not suggesting that we stopped using oxygen in medical practice just because it was identified 250 years ago. Ah, again. Interestingly, nitrous oxide waas ah, used for almost a century from principally recreational purposes. And nothing has changed. There has it because it's still now the main use of abuse of nitrous oxide is getting high, apparently hot, more than ketamine and all the other drugs. It's used for that purpose. So little changes over over 2.5 centuries. So priestly identified it and did nothing with it apart. from sniff it, Humphrey. Davy also abused it. And we all know Humphrey Davy for his eminent work in science. He was the chaplain did with the mind safety and things like that. He studied the physiological effects informal detail of nitrous oxide on. He was the first one to identify it's allergies effects as a side effect for for abusing it and getting high on it. You notice that got his headaches. So he suggested back in, uh, back in 1800 that it was a potential of surgical benefit. Didn't do anything about it. Move on to Horace Wells. We've already discussed New England dentist. So stuff moved across the Atlantic. Uh, dentists, then and now, mainly motivated by the bottom line there. Pecuniary motivation on da Horace was spotted. This being used as a sort of a safari ground demonstration realized that it may help him getting more people into his chair to pull teeth out if it was effective. Anagesic Ondas Mark said here he, uh, failed a demonstration a target medical school in January of 80 and 45 killed himself. Three years later, not a dentist killed themselves. They do now. The high suicide rate of all professions. I think William Morton, who was another New England dentist instructed by Wells. He then used ether to provide surgical anesthesia a few years later. So they're the early, early, uh, sort of a history of of anesthesia. We moved back to the UK well, to remember in principle with James Simpson, who is an obstetrician he gave. He gave Laura form in to deliver babies. Then Jon Snow Clover and Frederick you. It then, actually, for the first three recognized anything tests in medical practice, and they really developed the art of international anesthesia. The principal used Ethan chloroform, a nitrous oxide, a little bit. The nitrous oxide wasn't actually involved in what was called a balanced anesthetic until the late 19th century. Yeah, Okay, so what's the benefits of nitrous oxide? And this is where, where I think we have to look carefully on DNA, not try and get herself to dwelling on the motive issues of of the environment, which I will come to in some detail a bit later on. So it has a significant allergies effect. So 60% in oxygen is included, too nanograms per mil of remifentanil. So It's a significant effect on, like remifentanil when you switch it off, it goes away quickly, so it is really equivalent to really offensive. Normal. In that respect, physiologically has many of the many of the, uh, many of the features of an ideal anesthetic Asians. Those of us that back in the day did the old part to anesthetic example to learn about a lot. A lot of factors of these if these are these drugs, and there was a list of ideal anesthetic agents and it was to have no effect on cerebral blood flow, minimal respiratory depression, no effect on the cardiovascular system safe generally in cardiac disease, member effect on the uterus. And and that's some of the list. But nitrous oxide for pills, all those criteria. Okay, what else have notes? More recent is an NMDA antagonist. It, like, kept him in, and it doesn't affect by spectral index. So if you use nitrous oxide with a with A with A with a scan on your head, you're going to be giving tumor on a statin because it is negating that effect. Most other anesthetic agents, intravenous and gauge, particularly propofol, are GABA agonists on have on that. Maybe it be why there's association with a delirium, POSTOP and agitation after some intravenous anesthesia. Because Gap gap Bragan agonist, which we know is not good for you. Okay, so what's wrong with it? Whether quite a lot wrong with it, really. But not as much as we used to think it was wrong with it. So it's a week anesthetic agent, so you can only given anesthetic under hyperbaric conditions. The max is 105. Uh, however it is is, and Waas on is widely used as a sparing agent for potent, volatile anesthetic agent. So because it's Mac is about 100 it's about 10% 100.1 of Mac for every 10% of off nitrous oxide. Interestingly, many years ago, when we were first moving to this hospital, we had a little trip. Some of us to lose back to look at a draeger work because we're buying drag around aesthetic machines and in the Draper Work Museum was a a old anesthetic machine that just deliver nitrous oxide, and they used to give nitrous oxide 100% until the patient fitted, then do the operations. So it's called high popped it jactitation. So nitric oxide's been used as a sole anesthetic. Asians dictate in Germany. The other interesting thing I discovered that was that Met Doctor mentally was from New Becca's. Well, okay, so what else is an irreversible inhibition of my methionine synthetase? This is the sub acute combined the B 12 deficiency that has been noted again in dentists because dentists or the principal abusers of nitrous oxide through most of the 20th century because it was used in the dental chair, uh, frequently to have to help to extract teeth. So, dentist, we're not allowed to use nitrous oxide any more after that. But they were the main problems. There is no evidence of miscarriage or birth defects in theater exposure. That's been a popular myth that's been put around for years. But there's no evidence to support that mark. A little nausea and vomiting. Yes, there's a significant increase in north and vomiting, but that increase is substantially reduced if, uh, the, uh, the patient is induced with propofol on if they'll give you an anti emetic and the relative risk is said to be 1.1. But the the common it is across equivalent, so I think we can put that one to sleep it. It has, uh, seven. Effect is not a huge effect. And then there's an issue of the developing brain with all anesthetics, which was which was very, very poor, very, very topical about 45 years ago. Do neonate have significant cognitive cognitive minutes? Have had multiple anesthetics have significant, significant cognitive delay compared with their their peer group. Now nobody knows where. That's a factor of the neonate, whether it's an anesthetic or whatever that will or because they've been here is near next. But actually, nitrous oxide is not implicated any more than any other agent in that. The other thing I was going to mention The reason I put it up at the beginning is it doesn't burn. It doesn't, uh, doesn't explode, but clearly it does support combustion. Hence it's usin supercharging the drag drag racer I stuck on the front so there is a potential to support the combustion of the virus. I understand six, but it's but it's under very specific situations. So obviously the topic of this talk and it's a significance earned all of us. The incentives debate is the environment and I I'm not a mad car user. I run most places. I I have a really issue with the environment as we all do want. One thing I would question There is the issue of Grey over warming in the UK If we get some different global warming, where the main effects in the UK will be loss of the Gulf Stream ago, stream will. London is on the same same latitude as Moscow and some John's new fan lens on we are only protected from winters of mine is 30 by the Gulf Stream. It's a girl stream stopped, will become cold, not warm. So I think that's that. That's an issue we will need to look at. So okay, so yes, let's put her hands up. Nitrous oxide is a significant greenhouse. Gas sits in the atmosphere for more than 100 years on. His global warming potential is 300 or thereabouts through, compared with the molecule perm article compared to the molecule off carbon dioxide. Looking at some figures from 2019, nitrous oxide was 7% of greenhouse gas emission in the states Onda, 40% of the total nitrous oxide emissions of human activity. That other 60% comes from natural course. You taking nothing about thunderstorms. Every time there's a lightening flash, it oxidizes nitrogen to tonight. Nitrogen oxides in the vast quantities s a global warming itself is producing more nitrous oxide. It's these temperate storms in the summer that doing it main sources Agriculture, fuel in your car, much less catalytic converters have really stopped the emission of nitrogen night jock sides from your from your exhaust fumes industry and, interestingly, foul water processing. So the sewage farms produce vast amounts of nitrous oxide. Uh, the figures suggest that 5% of the atmosphere it warming is caused by nitrous oxide going up a little bit, but it's relatively stable. Uh, methane is falling. That's been a success. And ah, and and there is a as mark pointed out in ozone depletion effect as well. But it's not as big as lot, not that large. The contribution from medicine to the output of nitrous oxide is very small. So all anesthetics and one of the other fixed things I found recently was all anesthetic vapor. Pollution across the world is roughly equivalent to the output from one cold fired power station. So they just put things a little bit perspective. I'm not saying it's not a problem just saying, Actually, let's get really about the problem. What about us anesthetic gas emissions? About 5% of the CT frequent of NHS? We don't disagree on that. 90% of this is from nitrous oxide. We don't agree about disagree about that. Two thirds of that. Whoever is on the label ward from from enter knocks from cylinders, so only a third of it is from anesthesia on. I think they're not about to remove and knocks from the labor wards. I don't think, uh, if we if we have to look at balance, you don't intravenous. That anesthesia does have a global warming potential Now, the figures wrote from um from Tom Pierce, with Mark Talked about. Also looked at looked at the rate if contribution of ah of non gaseous anesthetic, their calculations that 25% or that the use of an anesthetic not using vapors. In other words, a total intravenous and it's a thick contributed about 25% of the desert, a desperate nitrous anesthetic. Now it's interesting that you desperate I haven't no. I give no support. The use of desperate. It should be removed. It is completely scandalous. It's still being used. There are plenty of alternatives to desperation. It doesn't doesn't confer any benefit. And 111, report, I said one bottle of desperation. Approximate to 3000 miles in your car. That's I'm justifiable. See both floor in is by far in a way, say the best anesthetic on if you're going to use a volatile, and I will probably do this myself move to using CVA. It's been a bit more expensive, but still my anesthetics cost about 50 p. So if they cost 75 years, not a huge amount One word about propofol it persisted the environment for more than 1000 years. If it's flushed down the drain and it's toxic to Marine, the marine environment, so it is not without its problems. So what's the answer? Fish. What could we do? Mitigating? We can stop using nitrous, but I think it remains a flexible and very safe anesthetic. Agent Mark mentioned using See Boto to use gas induction, but the second gas effect is still extremely beneficial in induction of pediatric anesthesia, and most of my pediatric anesthetic coding still use nitrous oxide. See, both is an induction agent. Not all but most. We can minimize the usage, least it, but it's a low for anesthesia. Yeah, but it just said the vast majority and knocks vast majority of doctors from introduction. The label ward. Well, we can scrub waste gas is now. We haven't talked about this, but I think it's important we do. All the potential is there, and it is to remove vapors from the anesthetic circuits before vented them into the environment. In Canada, using assumed, which absorbs isoflurane, there are there are commercially available cylinders, mainly activated charcoal that will remove. See they Florida's well. The problem with that is there not reclaimed at the moment, but they can easily be reclaimed. But also there is now commercially available system to remove nitrous oxide from anesthetic circuits, and this is in use in in Germany and in the in the in the Scandinavian countries. Is a German company produced this it It is actually a very small catalytic converter that sticks on the waste. Gas is your machine. There's no does not interfere with any other way and removes 99.9% of nitrous oxide. It's not cheap, I suspect. But if in reality, if you actually balance the cost off a vapor anesthetic to the cost of a non vapor around aesthetic and add in the cost of these these extraction options, it's still going to be cheaper. I know if I try and suggest that we buy this by this this see a but catalytic converter. People tell me it's too expensive, but actually we're not looking in the right place, so I have no kwab or quarrel whatsoever about the environmental issues of nitrous oxide. What I'm trying to suggest is it still has a place in modern anesthesia. It's still a good drug. There are is not for everybody. I'm not suggesting you will start using it again. The problem I have is that it's 61 I of old to teach new tricks, and I don't give that many anesthetics because I do a lot of critical care. I can give a safe, uh, gastro sound aesthetic. I think I might find myself standing in the court with lots of awareness. We try and give too many TV around on aesthetics, so I think I think not socks. I'd still has a definite place in modern medicine, but I think what we need to do is start treating the environmental aspect of it seriously and introduce the available scavenging for or both papers and for nitrous oxide. Thank you. That's what I have to state. Oh, thank you. Same one that was well argued. But I'm not surprised because Simon can argue against anything and everything, and you can come into people now. I have now. I'm just now. I usually I thought I shouldn't use go tonight. Is it all? But now it looks like it might have a place. I'm slightly confused now, but I'll come to the walking pool at the end because I'm keeping I'm aware off the timing constraints. So I'm just going to quickly I have a question to mark on the question to Simon on Ben a lot. Let me know what the whole said on then. Uh, then a quick thank you. And then we should finish your fault, and then you can have Ah, early weekend. Um, first to you, uh, Mark, uh, hypothetically speaking, say, because I know your how How King, a purist you are in terms off in my mental issues Say, if you're one off those high running dies in the chest and who goes to number 10 Downing Street for a different reason when you're giving press release on things, if you're in that cushion and you got the old opposed to do change the rules and laws off this country, what are things you do, including medicine on a way from medicine as well? Is that anything you impose us a lot? Gosh, Um Well, carbon taxation is the thing that it will dry behavior. So if you introduce carbon tax and all these things that we're doing would stop incurring a charge that would change behavior. And until you change behavior across the board, you aren't gonna have an impact. So that's that's what's gonna happen. But at the moment just isn't a physical for it. On personally what you're doing. I know your cycle. I know you do a lot. So I know your liver. What about holidays? Do you fly in law? Uh oh, no, You said the family. We're not going for oldest. Just a cycle. Ah, my daughter has been offered a fellowship in Harbour. Won't take it because she doesn't want to fly. Does that give you an idea? Okay. Yeah, I think you take it there. There are alternatives to find, um, on, uh, but it's very hard to find alternative flight in states. Yeah, I drive to places lower carbon costs, but you there's a massive change coming. Thanks much. I think I need to stay away from March because I can't cycle that far on da 11 last question to Simon. Simon. Uh, what in your in your definition, in your books? What is that? Balanced anesthesia without having environmental effects without having environmental effects? Well, all everything we do has can't avoid it. Manufacturer. Everything cost is called because carbon procurement, cost card and putting in their putting in and stuff using a van cost carbon using using intravenous anesthesia. Little the stuff that gets thrown in the trash can cost carbon or the single use rubbish. Really? Using what? What's wrong with red rubber tubes? They work fine or uses carbon. Say so. So I think so. I think there is no such thing as a balanced anesthesia with no carbon, nothing is not not possible. The route of the world we live in. This that is not possible we need to do is minimize it. I don't So I said, I'm not trying to defend the use of high use of off the's these comp greenhouse gases. What I'm saying is that is that the nitrous oxide has a still has a benefit. Still has a use in our practice is it's a safe, well Provent drug that's cardio stable. That doesn't cause chaos. All the side effects that were attributed to really, actually negligible. Why don't we just employ the the available technology to remove the environmental factor of the stuff we use? It's there. Let's use it. Uh, it's a set of my my job wasn't to defend common docks, night stock times, the nose and the ozone depleted gas in the greenhouse gas. My job is to defend it as a as a valuable tour. In there anesthetic, drug covered and and at the same time show you how you could minimize it's problems. Thank you. Thanks so much for that reflection. And also I heard that they're Sinus taking that New Year old that is going to cycle the work or rest office life in Norfolk. A knowledge? Uh, that's correct, Simon. Thank you. Um, Thanks. Mark on banks Diamond. For your valuable thoughts about nitrous oxide on the world I was. And I think that's so that's that Just created some ah, reflection on your on your practice and your thoughts about nitros under other world. I was in practice on diet. Just got this lighter holding up on here. 75% off them. Have said I have stopped using nitro. Sucks it for maintenance off a seizure, but would like to have cylinder supply available for certain circumstances. I think that sums up all, um, still still, the warning is going on. Still, the 70% better pair off. People would like to have my trusty just for certain circumstances, but they don't want to take it completely out of practice on, but that that's the majority things in this region. By the looks of it on D. I take that as well, and I want it for the same same one. So, uh, thank you all for, uh, walking in this slider. Um, on without wasting time. We are closing those section on But we have just caught last few minutes on, um of this meeting and need to ah inform you about the training prices. Uh, first of all, all the judges would like to thank all these trainings who have taken so much off time and effort to do all these presentations in spite off all his own going well, commitments. So well done, you all on. Also for the order presentations, it has been neck to neck. They had a difficult time that this is not just for the sake of time saying you really, really have a difficult time, they have to brainstorm. And that they always just missed the, um uh the other price just by a very, very narrow margin. And the first place is for ah, get tablet for her organization off drugs on it, Onda. A second place is for Zarah, for her biggest analgesia on the third. One is for Christmas. Party for is a less and the other way. Thank you all. And for the poster prices for the big fiberoptic information on by J piece on. But I had chair if I promised it. Right. Well, the no thank you for getting all of presentations on the last few minutes. Uh, thank you. On behalf off the organism can be on the anesthetic department. African origin. We like to say a big thank you for the delegates, the speakers, the judges on everybody who has helped out with this meeting. Thank you very much for the sponsors. You maybe, uh, even going really well on thanks to l. A and Dental on for a medal for the technical support for this meeting on the I, like, excellent. Thanks to the Royal College of an Issue is as well for their, uh, 0.70 points for this Onda, uh, apologies for ah. Only technical glitch is we have with the some of slides and registration. But we all expected that this Kobe era on few things um, please don't feel any of feedback forms so that you can get your certificated see pretty points on brick orders will be available for future, but I think at least for the next three months on next year we are hoping on We are very, uh, but very, very, very confident that it will be live meeting rather than, uh which will one. Thank you all. See you next year.