Sustainability

Most would argue that since you don't need to know much more than 'don't chuck stuff away if you can avoid it and use low flow where possible' to be a perfectly proficient consultant anaesthetist, it is simply baffling that the examiners in FRCA land would dedicate entire CRQ questions to this topic.

However since they have done this, we thought it prudent to arm you with some factoids that might come in useful.

Choosing those factoids was rather tricky, given this is an endlessly large topic that steadily relates even less to the practice of anaesthesia the further down the rabbit hole you go, but no matter.

Let's dive in, and heads up, this is not a very happy post.

Deep breath

Here we go.

Humans have fairly unequivocally demonstrated themselves as being terrible for the environment in a variety of different ways, with carbon emissions being just one of them.

• If you only look at healthcare, you're already looking at 4% of the carbon emissions worldwide
• If 'healthcare' were a country, it would produce the fifth highest carbon emissions worldwide
• If the NHS were a patient on a ventilator with a respiratory rate of 12, it would have an end tidal CO2 of 3.96 tonnes

The last one is probably not examinable material.

Burn baby burn

The NHS incinerates nearly half of the waste it produces, and only manages to recycle around 15%.

Then COVID came along and plastic PPE waste shot up nearly four-fold in a number of countries.

And then there's us

You'll struggle to find an anaesthetist that doesn't agree that anaesthesia is terrible for the environment. You will however find anaesthetists that drive their Land Rover to the airport and then fly long distances to exotic places to attend sustainability conferences discussing just how bad the impact is.

• Approximately 5% of a major hospital's carbon emissions are caused by anaesthesia alone
• Of all the different departments in the hospital, operating theatres generate a disproportionate amount of hospital waste.

Some spheres

Who knows what the FRCA will throw at you if a question about sustainability comes up, so may we interest you in some spheres?

• Biosphere - where all the life is happening
• Lithosphere - the land bits
• Hydrosphere - the watery bits
• Atmosphere - the gaseous bits

Plastics

This is probably the highest yield section of the post, given the major argument against TIVA being the holiest of anaesthetic techniques is just how much plastic it uses.

Plastic is made from petrochemicals including crude oil and natural gas. To obtain these resources, processes such as fracking (hydraulic fracturing) literally blow the earth apart to find it.

• Fracking wastewater contains metals, organic material and radioactive compounds
• This water washes merrily into the drinking water supply
• It can cause liver disease, cancer and developmental disorders in children

Then you have to take your hard-won crude oil and gas and process it into meaningfully useful plastics, which in turn produces all manner of carcinogens and neurotoxins.

• So while sevoflurane is destroying the air above us, the TIVA plastics are killing all the plankton
• If you did a blood gas on the ocean, the pH is currently 8.1
• If it drops below 7.95, nearly everything dies.

This is currently expected to happen in approximately... 2045.

And no - 8.4% bicarbonate is not an option here.

If the phytoplankton continue to decline, we lose even more of our ocean's ability to store CO2, and enter a disastrous positive feedback loop of warming and acidification that won't end well for anyone.

Ocean failure is like liver failure - bad news for every other system in the body.

The only difference is you can't do an ocean transplant.

But we can recycle right?

Yes, but it's not that simple.

Recycling is usually better for the environment than just burning stuff and using the heat to produce energy, however it is not without its own drawbacks.

• Processing and transporting waste produces CO2
• The whole recycling process consumes vast quantities of energy
• It can't be done forever

Some stuff, like aluminium and glass, you can essentially recycle indefinitely, so once you've made it you can keep using it again and again, and the only environmental cost is the energy and waste associated with the recycling process.

Plastics are different. They degrade every time you recycle them so you're on a one-way train to releasing microplastics into the environment no matter how conscientiously you recycle them.

• Recycling plastic is still three times better than incinerating them in terms of green house gas emissions
• Glass, metal or paper are better options wherever possible
• The best option is to use as little as possible in the first place

Maybe use that propofol syringe twice?

Moving around

Transporting stuff costs energy however you choose to move it.

Sea vs Air

Air travel is quite obviously disastrous for the atmosphere, as thousands of aluminium tubes paint the sky with CO2 and kerosene every day.

Floating heavy things on a big boat makes more logical sense than trying to lift them up 35 000 feet in the air, however sea transport isn't without its ecological perils.

• Oil spills and discharge from ships kill aquatic life
• Waste water contains a pungent mix of sewage, plastics, detergents and drugs
• Even the paint on the underside of the ship is toxic to prevent build up of marine organisms on the hull
• The engines burn around 14 tonnes of fuel per hour, and the propellers chop the water with such thunderous vigour that animals struggle to communicate and navigate through the deafening turbulence for many miles around

On the road

Over 3% of all road journeys in the UK are NHS related, generating toxic fumes and particulate emissions that, if you churn the stats, probably contribute to over a thousand extra deaths per year.

"Ah but we're going to have electric vehicles soon"

Yes, however there's still the small matter of the battery production, fuels used to charge the damned things and the enormous quantities of rubber and microplastics sheared off tyres of each vehicle, however it's powered.

Drugs

We act as if all of the drugs we give just magically disappear after the patient has woken up. We also celebrate when a drug undergoes 'minimal metabolism' because that means it doesn't matter so much if they have renal or hepatic impairment.

But what this actually means is the drug is just free to go and harm other living things further down the line.

• 90% of all the oral medications taken by patients end up in wastewater in some active form
• The treatment plants aren't able to remove all of these, so they end up in the water and farmers' fields
• Exhaled anaesthetic gases end up unchanged in the atmosphere acting as potent greenhouse gases

Propofol

I mean you only have to take one look at a vial of propofol to be able to guess that it's probably not great for the environment.

When left in soil and water through unsafe disposal down the sink, it will sit there for over a year.

Propofol has a variety of harmful effects including algae growth inhibition and acute toxicity in small crustaceans and freshwater fish.

And that's before you take into account all of the plastic waste and other emissions required to produce and administer it in the first place.

TIVA divas not looking so smug now.

The main examinable point from the 2024 paper seems to be that propofol isn't fully destroyed until around 1000°C, so you need to put your unused syringes in the sharps bin for incineration, not down the sink.

Otherwise the fishes will be sleeping...with the fishes.

Nitrous and Des

The deadly duo of greenhouse gases, nitrous oxide and desflurane have been shown unequivocally to be absolutely horrendous for the environment, and there is a general trend towards not using them at all.

One key issue is that much of the harm from nitrous oxide occurs from it simply leaking out of the pipeline system, allowing it to still poison the atmosphere even if you're being a terribly virtuous anaesthetist and not using it.

How low can you go?

Reducing FGF from 6 L/min to 1 L/min reduces volatile consumption by around 80%.

Low flow anaesthesia has other benefits such as improving the humidity and warming of inspired gases, which benefits the patient enormously.

Remember that scavenging simply protects theatre staff from exhaust gases, and doesn't prevent them tearing a hole in the atmosphere.

You can find our whole post on scavenging here:

Scavenging

A dry topic.

AnaestheasierAnaestheasier ltd.

Some of those toxins in detail

We're guessing entirely here at what the examiners in FRCA land will question you on, but here are some of the commonly mentioned specific toxins that cause lots of nasty damage to the environment (and people).

So what can we do?

We can start by instigating all the little, easy things that have been shown to reduce the environmental impact of our work

Then we need to audit our practice to see what we can reasonably improve within the department in a cost-effective manner.

It is probably a good idea also to accept that whatever we do, anaesthesia (and humans in general) are likely to have an adverse effect on the environment, and not compromise good patient care in the pursuit of overly optimistic environmental metrics.

Here is how your colleagues felt about the exam at the time:

Useful Tweets and Resources

References and Further Reading

Primary FRCA Toolkit

While this subject is largely the remit of the Final FRCA examination, up to 20% of the exam can cover Primary material, so don't get caught out!

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Just a quick reminder that all information posted on Anaestheasier.com is for educational purposes only, and it does not constitute medical or clinical advice.