Climate change – anaesthesia’s part in the problem

1. Climate change – anaesthesia’s part in the problem Dr Stuart White Royal Sussex County Hospital, Brighton

2. Climate change is a fact.

3. Man is responsible for climate change.

5. Why? • Less/more expensive food • Fewer/more expensive car journeys • No air travel • Higher taxes and costs • Less ‘stuff’ • Population restriction

8. Anaesthetists • Professional life • Personal life

9. Professional life • Do anaesthetic drugs harm the environment? • Does the conduct of anaesthesia harm the environment? • How can we minimise the impact of anaesthesia on the environment?

10. Anaesthetic gasses • Evidence limited • Langbein T et al. Volatile anaesthetics and the atmosphere: atmospheric lifetimes and atmospheric effects of halothane, enflurane, isoflurane, desflurane and sevoflurane. BJA 1999; 82: 66-73 • IPCC • Summarised in Axelson U. Climate impact of anaesthetic gases 2008.http://www.miljo.skane.se/eng/U2237_translation.pdf

11. Langbein Inhalational anaesthetic agents contribute to two environmental problems • Direct depletion of the ozone layer • Infrared absorption and global warming

12. Oxygen-ozone cycle OO O O O OO OOO OO OOO OO OO UV UV

13. l 100 400 MESOSPHERE STRATOSPHERE TROPOSPHERE

16. Ozone depletion potential Ozone depletion dependent on: • chlorine and bromine content • amount of agent that reaches the stratosphere • longevity of agent remains in the stratosphere Calculated contribution to stratospheric ozone depletion • halothane 1%, • isoflurane 0.02% • sevoflurane 0% • desflurane 0%

18. Health effects of global warming • Extreme weather • Rising sea levels • Drought • Crop failure • Resource conflict • Disease • Ozone depletion

19. Greenhouse gasses Global warming potentials (GWPs) • Measure of relative contribution to global warming of a mass of gas to equivalent mass of CO2 (GWP 1) • Calculated according to - (high) absorption of infrared radiation - (wide) spectral location of absorbing wavelengths - (long) atmospheric lifetime • Absorption not always linear

20. Greenhouse gasses

21. Anaesthetic gasses

22. BUT ... Axelson

23. So N2O is most pollutant, BUT Greenhouse gasses 6% Nitrous oxide 20% Anthropogenic N2O 4% Specific manufacture 90% Medicinal N2O

24. So N2O is most pollutant, BUT Greenhouse gasses 6% Nitrous oxide 20% Anthropogenic N2O 4% Specific manufacture 90% • ... equivalent to approximately • 1% atmospheric nitrous • 0.07% global warming Medical N2O

25. So not much, BUT ... • Avoidable • Secondary health benefits • I’ve stopped using it • BUT, have to use nasty gasses at higher MAC • + more oxygen/air

26. Adapted from Charlesworth M. How green is your gas? Anaesthesia News 2009; 267: 22-23.

27. Oxygen production CO2 cost of liquid oxygen • Air liquefaction • Cooling • Transport = 0.4g CO2 per litre of oxygen • RAFT: Average amount of oxygen used per case is 594 litres = 238g CO2 • Hip # (GA) = 340 L = 136g CO2

28. Advice • Avoid nitrous oxide • Avoid desflurane (+ energy cost of warming) • Care prescribing oxygen • Active scavenging? • Low flow anaesthesia • TIVA

29. Low flow anaesthesia Lockwood GG, White DC. Measuring the costs of inhaled anaesthetics. BJA 2001; 87: 559-63. • NARKUP • Hip#, 50kg, SV, CO 4.5, MV 4.5, FRC 1500ml

30. TIVA Stockholm county council • janusinfo.se, pbtprofiler.net

31. TIVA (EPA)

33. What about regional anaesthesia?

34. RA v GA Also cheaper! Hip #

36. Medical waste • double/triple/quadruple packaging! Argh! • Costs of waste storage set to increase • Incinerator £753/tonne • Domestic £83/tonne • Recycled cardboard, plastic, glass +£17/tonne

37. Some figures • Europe 1.3 bn tonnes solid waste (3.5t/person) • UK 100 million tonnes solid waste • 85%  9901 landfill sites • Incineration limited by EU Directive • NHS waste 408,000t/year (4%) • 29% is clinical waste • < 10% of total NHS waste is recycled.

38. Hutchins DCJ, White S. Coming round to recycling. BMJ 2009; 338: 609 • 2300kg of anaesthetic waste/theatre/year • 40% of anaesthetic theatre waste is potentially recyclable • 4% of sharps bin waste was appropriate

39. Barriers Social Logistical Legal environment and wastes health and safety transport

40. 6R • Responsibility • Reduce • Reuse • Recycle • Rethink • Research

41. Responsibility Central Professional Personal

42. Travel 2010 update of NHS Carbon Reduction strategy (NHS SDU) • 2004 18.6Mt CO2 (25% public sector, 3% UK) • 2007 21 Mt CO2 • 2008 Climate Change Act - reduce by 10% 2015 (19Mt!) - reduce by 80% 2050 (4.2Mt)

43. 22%

44. RAFT environmental audit Patient + theatre staff + anaesthetists = 108.7 miles of car usage = 17.2kg CO2 (+ the rest!)

45. Cycle/walk/run to work

46. ESA Milan 2009 • From LGW (BA)= 225kg CO2 (stratosphere) • Mean SE UK = 8.8t CO2/person @ • ie 2.5% of @ production in 0.0006% of a year • ie 43 times the usual rate

47. ESA Amsterdam 2011

48. Research • Update inhalational work • Evaluate inhalational vs TIVA vs regional • Life cycle analysis of anaesthetic equipment • Evaluate the monetary and environmental cost of recycling equipment • Fully calculate the carbon cost of oxygen/air • Green alternatives • Decontamination and sterilisation

49. BUT 1 year Brighton East REC paper audit • 68 REC applications + research conduct of successful 55 • 176,150 sheets of A4 paper - 879kg, £658, + £2078 PC • equivalent national annual estimate - 11.5m sheets A4 - 88 tonnes - 2100 trees

50. Top tips • Don’t use nitrous oxide • Use low flow anesthesia • Use regional anaesthesia • REDUCE, reuse, recycle, responsibility • Cycle to work • Stay informed • Agitate