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10 Expert tips for reducing volatile anesthetic emissions

Topic
Operating Room
Topic
Operating Room

Why reducing volatile anesthetic emissions matters

Volatile anesthetics are potent greenhouse gases. Their targeted reduction is not only economically sensible, but also an important step toward environmental sustainability. We asked Prof. Dr. Jan Hendrickx, an expert in the kinetics of inhaled anesthetics and carrier gases, to share his recommendations on how hospitals can minimize the environmental impact of anesthesia gases.

Volatile anesthetics account for up to 35% of greenhouse gas emissions in hospitals [1] and are a significant environmental factor. The greenhouse effect of sevoflurane and the even more environmentally damaging desflurane, is many times stronger than that of CO₂.[2] In addition to their climate impact, they pose potential health risks to OR staff and generate substantial costs. Therefore, the administration of inhaled anesthetics should aim to minimize their release into the environment.[3]

The “ESAIC Glasgow Declaration on Sustainability in Anaesthesiology and Intensive Care,” adopted in 2023, provides a detailed three-year roadmap to reduce emissions from volatile anesthetics and promote environmentally friendly alternatives. The roadmap emphasizes the urgent need to reduce the use of fluorinated gases—calling for a 98% reduction by 2050 in accordance with EU regulations and a ban on desflurane from 2026[4].

Measures to reduce environmental impact

Prof. Dr. Jan Hendrickx from OLV Hospital in Aalst, Belgium, recommends the following actions:

  1. Apply minimal-flow anesthesia.
  2. Do not use desflurane.
  3. Minimize the use of N₂O.
  4. Use propofol instead of inhalation agents before securing the airway, in order to deepen anesthesia during intubation or laryngeal mask insertion.
  5. Minimize the use of fresh gas flow (FGF) above the minute ventilation interval; exceptions only during washout at specific workstations.
  6. During wash-in, use a low FGF (1 L/min or less) with a high vaporizer setting, and monitor anesthesia depth using tools such as MAC Brain, EEG, indices, and/or PK/PD visualization tools.
  7. Use target control flow to precisely manage gas flow.
  8. Minimize the concentration of expired agent to 0.8 MAC and ensure age correction.
  9. Titrate opioids appropriately and use the synergy between opioids and inhalation agents to maintain 0.8 MAC. Higher concentrations delay emergence and waste anesthetic gases.
  10. Coasting.[5]

Achieving impact with Low-Flow Anesthesia and AGC

Low-flow anesthesia, supported by Automatic Gas Control (AGC), can safely reduce the consumption of anesthetic gases by up to 58%.[6],[7] Reports from various hospitals show that the consumption of anesthetics was significantly reduced and that substantial cost savings were achieved. One hospital predicts annual savings of €30,394 for its anesthesia equipment and expects that the investment in the software upgrade will pay off in less than a year.[8] Another hospital was able to reduce the ecological footprint of its anesthesia department by over 1,600,000 kg of CO₂ equivalent.[9]

Automatic Gas Control (AGC) is a software function for regulating the supply of fresh gas flow and the concentration of anesthetic vapor in order to achieve the specified target values for inspired oxygen  (FIO₂) and the end-tidal concentration of the anesthetic agent (EtAA). Once the target is reached, AGC automatically reduces the fresh gas flow and anesthetic vapor supply to a minimum. A speed and prediction tool provides information about the expected course of anesthesia and facilitates the safe administration of low-flow anesthesia. This allows clinicians to minimize fresh gas flow (FGF) and waste of anesthetic gases. 
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The German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Professional Association of German Anesthesiologists (BDA) also provide specific action recommendations for ecological sustainability in anesthesiology and intensive care medicine.[10] This includes the consistent use of minimal-flow anesthesia. The national report "Green OR Barometer" in the Netherlands also includes low-flow anesthesia in its action plan for reducing CO2 emissions from Dutch operating rooms.[11]

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  1. 1. Karliner J SS, et al. ARUP – Health Care Without Harm. September: 1-48

  2. 2. Richter H, Weixler S, Schuster M: Der CO2-Fußabdruck der Anästhesie. Wie die Wahl volatiler Anästhetika die CO2-Emissionen einer anästhesiologischen Klinik beeinflusst. Anästh Intensivmed 2020;61:154–161. DOI: 10.19224/ai2020.154

  3. 3. Schuster M,Richter H, Pecher S, Koch S, CoburnM (2020) Positionspapier mit konkreten Handlungsempfehlungen: Ökologische Nachhaltigkeit in der Anästhesiologie und Intensivmedizin. Anasth Intensivmed 61:329–339

  4. 4. Gonzalez-Pizarro P. et al.; the Sustainability National Representatives. European Society of Anaesthesiology and Intensive Care consensus document on sustainability: 4 scopes to achieve a more sustainable practice. European Journal of Anaesthesiology 41(4):p 260-277, April 2024. | DOI: 10.1097/EJA.0000000000001942

  5. 5. J.F.A. Hendrickx 1, S. De Cooman, A.A.J. Van Zundert, R.E.J. Grouls, E Mortier, A M De Wolf; Coasting: worth the effort? Acta Anaesthesiologica Belgica, 2011;62(3):147-50.

    https://pubmed.ncbi.nlm.nih.gov/22145256/

  6. 6. Carette R, De Wolf AM, Hendrickx JF. Automated gas control with the Maquet Flow-i. Journal of Clinical Monitoring and Computing 2016;30(3):341-6)

  7. 7. Kalmar A. et al. Minimizing sevoflurane wastage by sensible use of automated gas control technology in the flow-i workstation: an economic and ecological assessment. J Clin Monit Comput. 2022 Jan 3. doi: 10.1007/s10877-021-00803-z

  8. 8. 'Kostenbesparend, comfortabel en duurzaam dankzij Automatic Gas Control'

    https://www.getinge.com/nl-be/insights/nieuws/gezondheidszorg/Kostenbesparend-comfortabel-en-duurzaam-dankzij-automatic-gas-control/

  9. 9. 'Getinge's Flow-i met AGC draagt bij aan het verminderen van de uitstoot van broeikasgassen in het Imeldaziekenhuis'

    https://www.getinge.com/nl-be/insights/nieuws/gezondheidszorg/milieubewuste-anesthesie/

  10. 10. Schuster M,Richter H, Pecher S, Koch S, CoburnM (2020) Positionspapier mit konkreten Handlungsempfehlungen: Ökologische Nachhaltigkeit in der Anästhesiologie und Intensivmedizin. Anasth Intensivmed 61:329–339

  11. 11. Nieuwenhuizen, van Kim, et al. ‘Landelijke rapportage Barometer Groene OK’, juni 2024.

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