Medical Technology

Anesthesiology Needs to Be Greener, Multinational Group Says

An international group of anesthesiologists has written a consensus statement emphasizing the need to reduce greenhouse gas emissions and medical waste in daily practice, as well as promote environmental sustainability in education, research, and quality improvement initiatives. Published online November 1 in Anaesthesia, the document lays out seven general principles that are “achievable globally, with minimal material resources and financial investment.”


Dr Jodi Sherman

Healthcare contributes nearly 5% of global greenhouse emissions. Although every medical specialty has a role to play in increasing environmental sustainability, anesthesiology undoubtedly has a large environmental footprint, said Jodi Sherman, MD, an associate professor of anesthesiology at Yale School of Medicine and medical director for sustainability for Yale New Haven Health, in Connecticut, in an interview with Medscape Medical News. She is one of the authors of the statement. “If you look at how much resource is spent or therefore consumed [in healthcare], perioperative services and also critical care — which is also a subspecialty of anesthesiology and of surgery — are amongst the largest areas of consumption of resources,” she said.

Commonly used inhalational anesthetics, such as desflurane and sevoflurane, are recognized greenhouse gases, and operating rooms alone produce one fourth of all medical waste.

Although professional groups such as the American Society of Anesthesiologists and the European Society of Anaesthesiology have previously released sustainability guidelines, the authors note, the recommendations were mainly applicable to anesthesia practitioners in high-income countries.

The working group, led by the World Federation of Societies of Anesthesiologists, included 45 anesthesia practitioners from 29 countries across all continents except Antarctica. Emphasizing that patient care should never be compromised by sustainable practice, the participants reached consensus on seven main principles to promote environmental sustainability in anesthesia and critical care:

  1. Clinical practice should have minimal effect on the environment.

  2. Medications and equipment that are less damaging to the environment should be preferred when doing so is clinically safe.

  3. The overuse/waste of medications, equipment, energy, and water should be minimized.

  4. Environmental sustainability principles should be incorporated within formal anesthesia education.

  5. Environmental sustainability principles should be incorporated into anesthesia research and quality improvement programs.

  6. Local healthcare organizations should support environmental sustainability.

  7. The field of anesthesia and critical care should collaborate with industry to improve environmental sustainability.

Under each principle, the group included more descriptive, actionable points to guide practitioners. To reduce emissions, for example, the group recommends use of single inhalational anesthetics that have the lowest global warming potential. Halothane or sevoflurane should be considered before isoflurane, the authors write, and isoflurane is preferable to desflurane. (Desflurane is 20 times more powerful than sevoflurane at trapping heat in the atmosphere.) In countries where it is available, high-emission inhalational agents such as nitrous oxide and desflurane should only be used in “specific agreed cases.” The authors also endorse the use of low air flows during sedation and general anesthesia when appropriate and reducing unnecessary preoperative investigations.

The principles are “intentionally not prescriptive,” Sherman said, because high- and low-income countries have different aims in improving the sustainability of their health systems. Lower-income countries should improve the sustainability of care while they continue to build up their health systems, she noted, and high-income countries need to focus on mitigating emissions and consuming less.


Dr Harriet Hopf

“This is really an actionable document,” said Harriet Hopf, MD, a professor of anesthesiology at the University of Utah School of Medicine, Salt Lake City, Utah, in an interview with Medscape. She was not involved with the study and conducts research on sustainable anesthesiology. “No matter where you are in thinking about environmentally sustainable anesthesia, you can read this and immediately implement things that will make your practice better,” she said.

But Gail Van Norman, MD, an anesthesiologist and clinical ethicist at the University of Washington Medical Center, Seattle, Washington, who was unaffiliated with the research, believes the principles fall a little bit flat. “They’re nice, comforting statements that we should do things for the environment, but the group didn’t come out with much in the way of really concrete measures,” she said. She noted that broad guidelines such as these are typical for large, multinational groups — often with many differing motives and interests — and that she would have liked to have seen more directives and suggested interventions in the document. She mentioned as examples prioritizing the use of total IV anesthesia over inhalational agents or outlining in what specific circumstances nitrous oxide or desflurane should be used.

However, Norman emphasized that these guidelines do acknowledge anesthesiology’s role in climate change. “Getting the conversation going is a vital and early important step in making an impact. So, what they’ve done is extremely important,” she said. “The disappointment that I express is not disappointment that they did this; it’s disappointment that they didn’t do more.”

Sherman is co-chair of the American Society of Anesthesiologists’ Subcommittee on Environmental Health. Hopf and Norman disclosed no relevant financial relationships.

Anaesthesia. Published online November 1, 2021. Full Text

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