Session ESA10: Sustainable anaesthesia

Session ESA10: Sustainable anaesthesia

Monday 4 June, 1400-1530H – Turquoise room

A special session on sustainable anaesthesia will be held on this last day of Euroanaesthesia 2018, in conjunction with the French Society of Anaesthesiologists and Intensive Care (SFAR).

The first talk on “Let’s green the hospital! Why not starting with the operating room?” is by Dr Jane Muret, Institut Curie, Paris France, and Head of the Sustainability group of SFAR.

She will discuss the issue of greenhouse gases (GHG) and human emissions, and the Paris Agreement to limit global temperature increases to a maximum of 2°C compared with pre-industrial levels by reducing GHG emissions. A total of 195 countries including the European Union signed this agreement, although the USA has controversially pulled out.

“Climate change has an impact on health including food and water insecurity, increased transmission of infections, heat stress, more frequent and extreme weather events, threats to shelter and security, air pollution and population migration,” says Dr Muret. “The paradox is that healthcare itself contributes to climate change by producing huge quantities of GHG with massive energy and water consumption, large waste production and supply purchase, and frequent transportation of patients and hospital workforces among other issues.”

In the hospital, the operating theatre contributes to 30% of total GHG production, partly due to the GHG properties of inhaled anaesthesia (IA) with desflurane and N2O having the worst global warming potential.

Dr Muret says: “A contribution to the reduction of GHG can be performed in the OR by limiting energy and water use, sorting and recycling waste, efficient use (low flow and closed circuits) and appropriate IA selection and suppression of N2O. These strategies lead to a reduction of both direct and environmental costs. We now have the opportunity to craft sustainable, safe, evidence-based practice and to become responsible leaders in this area.”

Dr El Mahdi Hafiani, Pôle TVAR Hôpital Tenon, Paris, will then present on the carbon footprint analysis of perioperative products. He says: “Eco design in care is mastering its ecological and energy footprint for efficient use of natural resources to minimise its environmental impact.” He will explain that this consists of knowing precisely all the resources used to carry out a treatment, identifying the environmental and health impacts a treatment generates, analysing all the alternatives, and designing at each stage the prevention to be implemented.

Dr Hafiani says: “Perioperative care and operating room care contributes disproportionately to the production of waste with significant effects on human health and the environment, not to mention the additional institutional costs. The carbon footprint analysis collects and calculate greenhouse gas emissions, allowing us to plan and implement actions to reduce these emissions. The purpose is to ensure the long-term environmental sustainability of our health care system.”

Also speaking in this session is Dr Henrik Jörnvall, Senior Consultant in Perioperative Medicine and Intensive Care at the Karolinska University Hospital Solna, Sweden.

His talk will be on closed circuit inhalation anaesthesia (CCA), which is defined as inhalation anaesthesia using a minimal fresh gas flow (FGF) so that the expiratory valve of the circle system remains closed and without any exposure of the circuit to the atmosphere. Although minimal, FGF must provide oxygen to fulfil the metabolic needs of the patient, and thus the term metabolic flow anaesthesia can be used interchangeably with closed circuit anaesthesia. Finally, carbon dioxide must be removed by the means of an absorber, and an anaesthetic agent dosed to maintain adequate depth of anaesthesia.

“CCA offers several advantages to higher FGFs – most obvious and intuitively of course being environmental and economic benefits. For example, CCA with 200 ml/min of oxygen with 8% sevoflurane consumes 5.2 ml of sevoflurane per hour, versus 19.6 ml of sevoflurane per hour when using an FGF of 2000 ml/min and 3 % sevoflurane,” explains Dr Jörnvall.

Furthermore, given the low metabolism of modern anaesthetic agents, a steady state and equilibrium between alveolar and target tissue concentration is established; further and significantly lowering the need of externally administered anaesthetic agents.

There are also many other less well-known benefits of CCA; medical, procedural, technical, and pedagogical. Medical benefits include an indication of the current oxygen consumption of the patient – facilitating an early diagnosis of metabolic stress, sepsis and, in the extreme, malignant hyperthermia.

“Basically, all conditions or events that increase the oxygen consumption will immediately be detected when using CCA since they increase the required FGF,” explains Dr Jörnvall. “Furthermore, the development of atelectasis or the reverse, the recruitment of lung volume during a recruitment manoeuvre, can be quantified and confirmed.”

He adds that a rapid emergence from anaesthesia is a substantial benefit of CCA. The anaesthetic agent is turned off when the procedure is coming to an end, and anaesthesia is maintained by recruitment of anaesthetic agent from saturated tissue depots; a process termed coasting. He concludes: “When FGF is finally increased, the patient rapidly emerges from anaesthesia. The procedural and pedagogical benefits include early detection of a leaking airway device, and simplified training in anaesthesia administration using a clear and intuitive algorithm.”

The final presentation is by Nolwenn Febvre, Nurse Anaesthetist at Rennes University Paediatric Hospital, France (an SFAR Green Member). She will ask “how can we engage the caregivers to act and become environmentally responsible stakeholders?”

At Rennes University Hospitals, France, in 2011, the medical team created an association in the operating room, Les P’tits Doudous, to improve the support of children and act to decrease the anxiety of both the children and the parents. By recycling waste, funds were generated to provide toys and other gifts for the children, while also reducing waste.

Mrs Febvre says: “The engagement from all the actors in the operating room has then allowed us to reflect on the child’s journey. The association then created a serious game to make the child an actor of his journey. Today the game ‘Le Héros c’est toi’, is a medical prescription after significant studies found a decreased anxiety in the children.”

She concludes: “From their room all the way to the inhalation anaesthesia in the operating room. this game explains, reassures and accompanies the child and his parents. Today 40 associations of caregivers in France have developed this concept, based on sustainable development action. In 2017 alone, we were able to recycle of 40 tons of hospital waste.”