RESEARCH AND QI PERSPECTIVES ON
SUSTAINABILITY
SEEMA GANDHI, MD
CLINICAL PROFESSOR, DEPARTMENT OF ANESTHESIA AND PERIOPERATIVE CARE
UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
The harmful environmental impacts of volatile anesthetics are
well documented.
Strategies to minimize these impacts include:
Avoiding desflurane and nitrous oxide use
Reduction of fresh gas flow (FGF) rates
Total intravenous anesthesia (TIVA)
Regional anesthesia
Background
Ryan, S. M., & Nielsen, C. J. (2010). Global warming potential of inhaled anesthetics: application to clinical use.Anesthesia & Analgesia, 111(1), 92-98.
Sher m an , J., Le , C ., Lamers, V. , & Eckelman, M. (2012). Life cycle greenhouse gas emissions of anesthetic drugs.Anesthesia & Analgesia, 114(5), 1086-1090.
Education
• Grand rounds
• Resident didactics
• Sustainability newsletter
Personalized feedback reports
Desflurane vaporizer only available in the workroom
Clinical Decision Support (CDS) tool
UCSF’s Journey
Personalized “Hall of Fame” Report
Active Non-interruptive BPA for FGF
Results
Baseline Intervention Difference (95% CI) P Value
Sevoflurane
n cases
44,899 (62.5%) 26,911 (37.5%)
Duration (hours)
2.0 ± 1.7 2.1 ± 1.8 0.1 (0.1 to 0.1) < 0.0001
Fresh Gas Flow (L/minute)
2.0 ± 0.6 1.2 ± 0.5 -0.8 (-0.8, -0.8) < 0.0001
Mean End-tidal Agent
Concentration (volume %)
1.6 ± 0.6 1.5 ± 0.5 -0.1 (-0.1, -0.1) < 0.0001
MAC
0.9 ± 0.3 0.9 ± 0.3 0.0 (-0.1, 0.0) < 0.0001
Total mL/hour
13.8 ± 6.8 8.2 ± 4.8 -5.5 (-5.6, -5.4) < 0.0001
mL/MAC-hour
14.5 ± 5.3 9.3 ± 6.9 -5.2 (-5.3, -5.1) < 0.0001
$/MAC-hour
$5.82 ± $2.11 $3.72 ± $2.77 -$2.10 (-$2.13, -$2.06) < 0.0001
"Maintenance" is defined as procedure start to procedure end.
CI, confidence interval; MAC, minimum alveolar concentration
Baseline period was from July 22, 2015 to July 10, 2018. Intervention was implemented on August 29, 2018. Data during the transition period (July 11, 2018 to August 28, 2018) were excluded.
MacNeill, A. J., Lillywhite, R., & Brown, C. J. (2017). The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems.The Lancet
Planetary Health, 1(9), e381-e388.
Describe patterns of volatile agent and nitrous oxide use and trends over time
Identify factors associated with agent consumption including patient characteristics,
airway type and procedure
Estimate variation in agent consumption at provider and institutional level that is
not explained by patient level variables
Study Aims
Practice Patterns of Volatile Anesthetic Use During General Anesthesia
MPOG Study Overview
Describe patterns of volatile agent and nitrous oxide use and trends over time
Identify factors associated with agent consumption including patient characteristics,
airway type and procedure
Estimate variation in agent consumption at provider and institutional level that is
not explained by patient level variables
Data Sources:
MPOG database SUS 1 metrics)
> 5 million cases
Across 61 centers
SUS-O1 metrics
Survey of MPOG institutions
To understand behavioral changes
Primary Outcomes:
Estimated anesthetic agent
consumption (mL/min) during
general anesthesia
Reported by each agent
Convert to CO
2
equivalent
based on LCA*
Descriptive analysis of volatile anesthetic agent use across US
o Variabilities by providers and institution
o Presence or absence of nitrous oxide
Quantify the excess carbon emissions from “wasteful” practice patterns
Identify ongoing mitigation efforts by various institutions (via survey)
Provide guidance for future SUS metrics
Study Significance
