Environmental Sustainability
SUS-01
A Quality Improvement discussion
Benjamin Stam, MD
Anesthesia Practice Consultants
Grand Rapids, MI
No financial disclosures
What impact does anesthesia have
on the environment?
● Modern healthcare is a leading producer of environmental pollutants.
○ Responsible for 10% of national greenhouse gases.
● Scavenged volatile agents are vented out the back or top of facilities.
○ Remain in the atmosphere for years.
■ Sev (1.1y), Iso (3.2y), Des (14y), N
2
O (114y)
● 1 hr of sevo = driving a modern car 30 miles.
1
● 1 hr of des = driving a modern car 230 miles.
1
Adapted from a presentation by Jodi Sherman, MD.
● GWP (Global Warming Potential) represents the
(1) ability of a gas to trap heat combined with its
(2) atmospheric lifetime and its (3) infrared absorption.
● Used to calculate CO
2
equivalencies over 20 years
(CDE
20
)
● Anesthetic gases
2
:
○ Sevo 349 GWP
20
6,980 g CDE
20
○ Des 3,715 GWP
20
187,186 g CDE
20
○ Iso 1,401 GWP
20
15,551g CDE
20
○ Nitrous as a carrier worsens Sevo and Iso profiles
What impact does anesthesia have
on the environment?
Ryan, Susan M. MD, PhD*; Nielsen, Claus J. CSc† Global Warming Potential of Inhaled Anesthetics,
Anesthesia & Analgesia: July 2010 - Volume 111 - Issue 1 - p 92-98
SUS-01 and beyond
● SUS-01: Mean Fresh Gas Flows ≦ 3 LPM between intubation and extubation.
○ Does not take into consideration the type or concentration of gas used
○ Cannot account for benefit of ultra low-flow anesthesia (<1 LPM FGF)
● SUS-04: Mean Fresh Gas Flows ≦ 2 LPM between intubation and extubation.
○ Significantly harder to achieve than SUS-01
● SUS-02: Mean “efficiency” of anesthetic gas
usage during maintenance.
○ Each gas measured in total CO
2
E per hour.
○ Goal: beat 2.58 kg CO
2
/hr .
■ Equivalent to 2% sevo @ 2LPM FGF
https://spec.mpog.org/Measures/Public
What can we do about this?
● Avoidance of general
inhaled anesthesia.
○ TIVA
○ Regional + MAC
○ Neuraxial
○ WALANT (wide
awake, local anesthesia, no tourniquet)
Sherman, Tunceroglu, Parvatker, Sukumar, Dai , Eckelman
What can we do about this?
● Provider Education & Systems processes
○ Create a culture of stewardship
● Sustainability metrics with cost pairing
○ SUS-01, SUS-02, SUS-04
○ MPOG/ASPIRE tracking
● Specific provider feedback
○ MPOG/ASPIRE reporting
What can we do about this?
● “Pause FGF” button during intubation
● Ultra low-flow anesthesia during maintenance
○ Low-flow sevoflurane
■ Compound A
■ Package insert: 1LPM for 2h, then 2LPM
○ “Increase your FiO
2
, overgas your agent”
● Avoid using nitrous oxide enriched anesthetics
○ This is the single most impactful contribution
● Avoid using desflurane unless expected to reduce morbidity/mortality
Adapted from a presentation by Jodi Sherman, MD.
What can we do about this?
● Anesthesia Impact Calculator
○ On iOS and Android (Kevin Scott)
● Real-time CO
2
E calculator on-screen
○ conversion to modern car miles driven
● Scavenging devices
● New tech to destroy waste anesthetic gases
Adapted from a presentation by Jodi Sherman, MD.
University of Michigan Health West
University of Michigan Health West
● Culture of stewardship
● Always seeking to improve practice
● High proportion of CAAs in the
care team model.
○ Anecdotally ran FGF very low
in training
● Historically close relationship with
pharmacy
○ Emphasis on keeping costs to
a minimum
References
1. Charlesworth M, Swinton F. Anesthetic gases, climate change and sustainable practice. Lancet
Planet Health 2017;1(6):e216-17.
2. Ryan, Susan M. MD, PhD*; Nielsen, Claus J. CSc† Global Warming Potential of Inhaled
Anesthetics, Anesthesia & Analgesia: July 2010 - Volume 111 - Issue 1 - p 92-98; doi:
10.1213/ANE.0b013e3181e058d7
3. Sherman, Tunceroglu, Parvatker, Sukumar, Dai , Eckelman, Yale University
4. https://spec.mpog.org/Measures/Public
Thanks!
