Just Breathe

Here's how you can make the case for environmental stewardship in anesthesia care.

By Kaeleigh Sheehan, Practice Greenhealth Member Engagement Manager, Greening the OR Initiative on October 25, 2016

greening-the-orAnesthesia and the use of anesthetic agents are not new to the health care sector. However, their direct impact on the environment, patients and community health is quickly becoming a major area of focus for the anesthesia provider and health care community due to their global warming potential.

The use of anesthesia and analgesia to improve patient safety and provide patient care is pervasive. Typically associated with inpatient and ambulatory surgical settings, anesthesia can be used in cardiac catheterization labs, gastrointestinal endoscopy, diagnostic imaging procedures, labor and delivery, pediatrics and other departments.

An estimate from the Sustainable Development Unit in the U.K. indicates that anesthesia is responsible for 5 percent of an acute care hospital’s environmental footprint.1 This is a conservative and imperfect estimate and only represents the percentage from acute-care inpatient hospitals, so it’s likely that anesthesia’s footprint is actually greater. Here in the United States, hospitals are directly responsible for 8 percent of greenhouse gas emissions.2 In fact, anesthetic gases used for patient care (most commonly desflurane, sevoflurane and isoflurane) are greenhouse gases, as is nitrous oxide. In many health care settings, waste anesthetic gases—those gases that are exhaled or unused by the patient—are trapped from the immediate clinical setting through scavenging systems and vented directly off the roof of the building into the local community and atmosphere. Sevoflurane, isoflurane and desflurane have high 20-year global warming potentials of 349, 1,401 and 3,714 respectively.3

While an essential clinical practice, anesthesia has financial implications for health care institutions as well. The anesthetics themselves are costly: Desflurane, the worst environmental offender, happens to be the most expensive. Health care organizations that have worked to educate their clinicians and reduce desflurane consumption have seen considerable cost savings. For example, Johns Hopkins Hospital provided education and saw costs for inhalational anesthetics go from $12,500 to $8,500 per OR annually, or a savings of more than $226,000.

Beyond these environmental and financial implications, adverse health impacts from exposure to waste anesthetic gases are cause for concern, both for the health and safety of health care staff and their surrounding communities. Potential adverse health risks range from dizziness and nausea to sterility, miscarriage, birth defects, cancer, and liver and kidney disease.4

New Practices

A survey of more than 780 anesthesia providers from the U.K., Australia and New Zealand found that 95 percent of providers support increasing recycling and sustainability efforts in their clinical environments.5 A similar survey was conducted in the United States with more than 2,000 responses, indicating that 91 percent of anesthesia providers surveyed are interested in recycling and sustainability programs.6 One common takeaway from both surveys is that despite interest, clinicians believe they lack adequate education around these practices.

It’s clear that developing and providing education to anesthesia providers and key stakeholders is imperative. When presented with peer-reviewed research, clinicians are able to review their practices without adversely affecting patient care.

For example, the low-flow technique is a practice consideration for anesthesia providers that has both environmental and financial benefits. After induction and with careful patient monitoring, an anesthesia provider can lower the flows of anesthetic gases to an amount that’s needed to maintain sedation while being more fully metabolized by the patient. This practice helps reduce excessive, unnecessary gas flow that would otherwise be unused by the patient and vented into the environment.

Waste Not

A number of waste streams are generated through the provision of anesthesia, but strategies are available to mitigate that waste. Opportunities include proper waste segregation at the anesthesia cart; recycling clinical plastic, including packaging material and empty containers; utilizing reusable laryngeal mask airways, endotracheal tubes and laryngoscope blades instead of disposable products; utilizing reprocessed single-use medical devices when possible; and proper pharmaceutical waste disposal.

Waste also occurs in the form of wasted anesthesia drugs. Ordering an excessive amount of emergency or on-hand drugs that have a limited window of use before needing to be disposed of leads to a waste of the supply. Also, these additional pharmaceuticals can enter and pollute waterways after disposal.

The “Price” of Purchasing

Purchasing opportunities include investing in reusables and reprocessed equipment and choosing materials that minimize DEHP and PVC. Anesthesia machines can have lifespans of 15-plus years, so it is beneficial to choose more energy-efficient options and models that help clinicians track flow rates and practice low-flow techniques. Additionally, emerging technologies for waste anesthetic gas capture are making their way into the market. These capture systems go beyond the standard scavenging systems, capturing, separating and preventing the waste anesthetic gases from exiting the hospital.

Using purchasing data to track the volume of anesthetic gases has been the first step for Practice Greenhealth to establish a usage benchmark for the United States, with a goal of developing metrics and a reduction challenge.

Energy Use

There are also opportunities for energy savings directly related to anesthesia care. Besides choosing more energy-efficient equipment, savings are also reported from the use of waste anesthetic capture systems that reduce the energy consumed from the waste energy disposal system and extend the life of the medical vacuum pump.7

Global Impacts

The international community of anesthesia providers has shown mounting interest in the environmental footprint of anesthesia. In the United States, the American Society of Anesthesiologists has organized the Green Initiatives Task Force to support and lead its members, has established a liaison between its committee and Practice Greenhealth, and has developed numerous resources for anesthesia providers.8 Part of NHS England and Public Health England, the Sustainable Development Unit has developed a report on the greenhouse gas footprint of anesthetics and developed a carbon footprint calculator.9 Doctors for the Environment Australia has developed a position statement and collected some research on anesthetics and the environment.10 In August at the World Congress of Anesthesiologists in Hong Kong, the presentation “Going green while maintaining quality of care in the operating room” was delivered to more than 9,000 delegates in attendance.11

Future Directions

It’s a common belief across the anesthesia community that appropriate education for clinicians to safely provide more environmentally friendly anesthesia care is lacking, despite the existence of considerable literature. This is one barrier that sustainability managers can overcome. Many position statements12-17 from varied clinical groups support environmental stewardship, and the impressive amount of advocacy and education that has already occurred points to a receptive and eagerly awaiting audience, with the trailblazers already off and running.

Education for key stakeholders is critical. Thirty-four percent of Practice Greenhealth award winners reported providing staff education on environmental impacts of inhaled anesthetics and reduction strategies for clinicians in 2015. Just as important is the delivery of this education. Because of its complex, clinical and direct patient impact, it is imperative that anesthesia providers and experts are leaders and advisors in this space. Anesthesia providers educating their peers will go much further than non-clinician-led efforts. Educating support staff and ensuring ready access to tools and resources is also a key component to spreading this work.

Beyond education, gaining a better understanding of best practices in tracking anesthesia usage to establish a more definitive greenhouse gas footprint for current practice is necessary in order to benchmark and track reduction efforts and impact. For example, only 49 percent of Practice Greenhealth award winners attempted to enter anesthetic gas purchasing data on the award application in 2015.

Still, momentum toward environmental stewardship in anesthesia care has been building and is reaching a critical tipping point. To date, an impressive wealth of research, education and advocacy has already occurred. The health care community needs only to take advantage of these opportunities to provide more sustainable anesthesia, with the potential for enormous impact across the United States and among international health care communities.


  1. www.sduhealth.org.uk/areas-of-focus/carbon-hotspots/anaesthetic-gases.asp
  2. J.W. Chung and D.O. Meltzer, “Estimate of the carbon footprint of the U.S. Health Care Sector.” JAMA, 2009.
  3. S.M. Ryan and C.J. Nielsen, “Global warming potential of inhaled anesthetics: application to clinical use.” Anesthesia & Analgesia, July 2010.
  4. www.osha.gov/SLTC/wasteanestheticgases
  5. J.L. Ard Jr., et al, “A Survey of the American Society of Anesthesiologists Regarding Environmental Attitudes, Knowledge, and Organization.” AA Case Rep, April 1, 2016.
  6. Forbes McGain, et al, “A survey of anesthesiologists’ views of operating room recycling.” Anesthesia & Analgesia, May 2012.
  7. www.mazzetti.com/blog/dynamic-gas-scavenging-systems-saving-energy-and-money
  8. www.asahq.org/resources/resources-from-asa-committees/greening-the-operating-room#49
  9. www.sduhealth.org.uk/areas-of-focus/carbon-hotspots/anaesthetic-gases.aspx
  10. dea.org.au/news/article/green_doctors_anaesthetic_life
  11. b-com.mci-group.com/eventportal/information/eventprogramme.aspx
  12. www.asahq.org/resources/resources-from-asa-committees/greening-the-operating-room#49
  13. www.aorn.org/-/media/aorn/guidelines/position-statements/posstat-safety-environmental-responsibility.pdf
  14. www.aana.com/resources2professionalpractice/Documents/PPM%20Management%20Waste%20Gas.pdf
  15. www.ast.org/uploadedFiles/Main_Site/Content/About_Us/SOP_Environmental_Practices_in_the_OR.pdf
  16. www.osha.gov/dts/osta/anestheticgases
  17. www.cdc.gov/niosh/docs/2007-151