Ditching Desflurane Could Help Reduce Carbon Footprint of Surgical Procedures

Climate change and greenhouse gas typically bring to mind gridlock traffic, coal plants, and Big Oil, but a new study is pointing a finger at the carbon footprint of surgical procedures, including cardiac surgery.

According to a study of three large hospitals in the United States, Canada, and the United Kingdom, the choice of gases used for anesthesia during surgery can an “appreciable source” of greenhouse gas emissions. The two North American hospitals, which preferentially used desflurane, had anesthetic gas emissions over a 1-year period that were 10 times higher than those of the UK hospital, which used primarily isoflurane or sevoflurane.

Lead author Andrea J. MacNeill, MD (University of British Columbia, Vancouver, Canada), and colleagues say multidisciplinary action is needed to reduce the adverse effects of surgery on the environment. Avoiding desflurane, the most expensive volatile anesthetic, is one step toward improving the situation, they suggest, adding that “higher surgical case volumes can be done at a fraction of the cost” by choosing not to use desflurane.

In an interview with TCTMD, MacNeill said emerging research showing the disproportionate impact of desflurane from a global-warming perspective has already begun to inspire a shift in practice patterns, undermining its place as the anesthetic of choice at her institution and others.

“This is something that has been evolving and been disseminated among the anesthesiology community for the past couple of years, but I would not at all be surprised that outside of that community this is still a relatively unknown area,” she said.

The popularity of desflurane in North America is attributed to its faster induction and emergence in surgical patients compared with other agents, but it’s also significantly more expensive, which is the primary reason it is not preferentially used in the United Kingdom.

Sevoflurane Comes Out on Top

For the study, published online yesterday in Lancet Planetary Health, MacNeill and colleagues measured direct greenhouse gas emissions such as volatile gases, indirect emissions such as electricity consumption, and other emissions, including surgical waste.

Taken together, operating theatres at the three hospitals had carbon dioxide emissions per square meter that were three to six times larger than that of the hospitals as a whole. Assuming that the emissions from the three hospitals represent the average in their respective countries, the researchers estimated that overall the operating rooms in those countries are contributing 9.7 million tons of carbon dioxide equivalents each year.

The authors also report that energy consumption from heating and air conditioning was another large contributor to greenhouse gas emissions at the hospitals. They suggest that cutting back on heating and cooling in the operating rooms overnight and on weekends could make a difference, and could be done in a way that allows for a minimum number of properly heated and cooled rooms to be available for emergencies.

MacNeill said another important measure that is just starting to emerge, and that should help reduce carbon footprints of operating rooms, is the use of capture technology to prevent the gases from escaping into the atmosphere.

As for the alternatives to desflurane, MacNeill said sevoflurane is considered to have the lowest impact on the environment—130 times the impact of carbon dioxide, which pales in comparison to the 2,500 times the impact of carbon dioxide contributed by desflurane.

Going for ‘Triple Wins’

In an accompanying editorial, Tim Taylor, PhD (University of Exeter Medical School, Exeter, England), and Phil Mackie (Scottish Public Health Network, Edinburgh, Scotland), say carbon management in the healthcare sector can no longer be ignored. In an email, Taylor said while healthcare is not the largest polluter, it does play a significant role.

By providing estimates of the carbon output of surgical suites, which has not been studied so systematically before, nor across different countries, Taylor said the current study helps shed light on the importance of improving our understanding of that footprint, which could help in refining the processes in surgical suites.

“Patient care is clearly paramount, but by considering solutions that reduce carbon emissions it is often possible to identify so-called ‘triple wins.’ Carbon savings can be made alongside cost savings and improved patient choice or satisfaction,” Taylor said. “In work we have done in the past on dentistry in Scotland, options have been found which fulfill this criteria—and there is no reason to believe the same could not be true for surgical suites.”

MacNeill added that the changes can be done with virtually no up-front cost to healthcare systems.

“I think there’s a common conception that any sort of green initiative requires up-front investment, and that it’s going to be inherently more expensive than the usual way of doing things, and that’s not the case at all,” she observed.