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ANZCA Bulletin articles

Hegedus J, Wyssusek K. Medical waste increasing during pandemic. ANZCA Bulletin; 2020; 29(3); 54-55.

Jones C. Searching for the gold in garbage. ANZCA Bulletin; 2020; 29(3); 52-53.

Grobler S, Davies J.Clean up theatre day –“reduce bluey use”. ANZCA Bulletin; 2020; 29(2); 54-55.

Zanker A. Flinders' recycling initiative. ANZCA Bulletin; 2020; 29(1); 29.

Crossley A. Environmental sustainability working group (ESWG). ANZCA Bulletin. 2019; 28 (4): 50.

Owen T. Sunshine Coast University Hospital. ANZCA Bulletin. 2019; 28 (4): 51.

Ma S. College to develop guidelines on sustainability. ANZCA Bulletin. 2017; 26(1): 12.

Kissane K. The accidental greenie. ANZCA Bulletin; 2017; 26(1): 41.

Jones C. Climate smart anaesthesia. ANZCA Bulletin; 2017; 26(4): 52-53.

Ewart S. Hospital staff welcome recycling scheme. ANZCA Bulletin; 2016; 25(1): 38.

Yaman E. Greening your gases. ANZCA Bulletin; 2013; 22(4): 46-47.

Lightfoot S. Anaesthesia and the environment: how big is our footprint?ANZCA Bulletin; 2009; 18(1): 32-33.

Kayak E, McGain F. Doctors for the Environment Australia. ANZCA Bulletin; 2009; 18(1): 28-30.

McGain F. Personal experience: initiating operating theatre plastic recycling programs.ANZCA Bulletin; 2009; 18(1): 29-30.

Latest articles of interest

Last updated: 23 March 2023

Heenan M, Rychetnik L, Howse E, et al. Australia's political engagement on health and climate change: the MJA-Lancet Countdown indicator and implications for the future. Med J Aust. 2023;218(5):196-202. Keywords: Climate change; Politics; Public health; Public policy.
Davies JF, Seglenieks R, Cameron R, et al. Operation clean up: A model for eco-leadership and sustainability implementation [epub ahead of print, 2023 Jan 31]. Anaesth Intensive Care. 2023;310057X221102469. doi:10.1177/0310057X221102469
Kampman JM, Sperna Weiland NH. Anaesthesia and environment: impact of a green anaesthesia on economics [epub ahead of print, 2023 Jan 24]. Curr Opin Anaesthesiol. 2023;10.1097/ACO.0000000000001243. Review - No abstract available
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The excessive growth of the health sector has created an industry that, while promoting health, is now itself responsible for a significant part of global environmental pollution. The health crisis caused by climatechange urges us to transform healthcare into a sustainable industry. This review aims to raise awareness about this issue and to provide practical and evidence-based recommendations for anaesthesiologists
Tang MSS, McGain F, Bramley DE, Sheridan NM, Seglenieks R. Evaluation of propofol wastage and disposal in routine anesthesia care [epub ahead of print, 2022 Dec 15]. Anaesth Intensive Care. 2022;310057X221121832. No abstract available - correspondence
Chambrin C, de Souza S, Gariel C, Chassard D, Bouvet L. Association Between Anesthesia Provider Education and Carbon Footprint Related to the Use of Inhaled Halogenated Anesthetics [epub ahead of print, 2022 Aug 19]. Anesth Analg.
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Background: Inhaled halogenated anesthetics are responsible for half of operating room total greenhouse gas emissions. Sustainable anesthesia groups were set up in 4 Lyon, France, university hospitals (Hospices Civils de Lyon) in January 2018 and have supported a specific information campaign about the carbon footprint related to the use of inhaled halogenated anesthetics in June 2019. We aimed to assess whether implementing such information campaigns was associated with a decrease in the carbon footprint related to inhaled halogenated anesthetics.

Methods: This retrospective cohort study was conducted from January 1, 2015, to February 29, 2020, in 4 hospitals of the Hospices Civils de Lyon in France. Information meetings on sustainable anesthesia practices were organized by sustainable anesthesia groups that were set up in January 2018. In addition, a specific information campaign about the carbon footprint related to inhaled halogenated anesthetics was conducted in June 2019; it was followed by a questionnaire to be completed online. The monthly purchase of sevoflurane, desflurane, and propofol was recorded, and the estimated monthly carbon footprint from desflurane- and sevoflurane-related perioperative emissions was calculated. The interrupted time-series data from January 2015 to February 2020 were analyzed by segmented regression, considering both interventions (setting up of the sustainable anesthesia groups and specific information campaign) in the analysis and adjusting for 2 confounding factors (seasonality of the data and number of general anesthesia uses).

Results: Among the 641 anesthesia providers from the study hospitals, 121 (19%) attended the information meetings about the carbon footprint of inhaled halogenated anesthetics, and 180 (28%) completed the questionnaire. The anesthetic activity from all 641 providers was considered in the analysis. After the sustainable anesthesia groups were set up, the carbon footprint of sevoflurane and desflurane started decreasing: the slope significantly changed (P < .01) and became significantly negative, from -0.27 (95% confidence interval [CI], -1.08 to 0.54) tons.month-1 to -14.16 (95% CI, -16.67 to -11.65) tons.month-1. After the specific information campaign, the carbon footprint kept decreasing, with a slope of -7.58 (95% CI, -13.74 to -1.41) tons.month-1 (P = .02), which was not significantly different from the previous period (P = .07).

Conclusions: The setup of the sustainable anesthesia groups was associated with a dramatic reduction in the carbon footprint related to halogenated anesthetics. These results should encourage health care institutions to undertake information campaigns toward anesthesia providers so that they also take into account the environmental impact in the choice of anesthetic drugs, in addition to the benefits for the patient and economic concerns.
Narayanan H, Raistrick C, Tom Pierce JM, Shelton C. Carbon footprint of inhalational and total intravenous anaesthesia for paediatric anaesthesia: a modelling study [epub ahead of print, 2022 Jun 18]. Br J Anaesth. 2022;S0007-0912(22)00224-0. [REQUEST VIA Keywords: climate change; inhalation anaesthesia; intravenous anaesthesia; paediatric anaesthesia; sustainability.
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Abstract
Background: Tackling the climate emergency is now a key target for the healthcare sector. Avoiding inhalational anaesthesia is often cited as an important element of reducing anaesthesia-related emissions. However, evidence supporting this is based on adult practice. The aim of this study was to identify the difference in carbon footprint of inhalational and i.v. anaesthesia when used in children.

Methods: We used mathematical simulation models to compare general anaesthetic techniques in children weighing 5-50 kg for TIVA, i.v. induction then inhalational maintenance, inhalational induction then i.v. maintenance, and inhalational induction and maintenance. We simulated inhalational induction with sevoflurane alone, and co-induction with sevoflurane and nitrous oxide, and both remifentanil-propofol and propofol-only i.v. anaesthesia. For each technique, we drew on previously published life-cycle data to calculate carbon dioxide equivalents for anaesthetic durations up to 480 min.

Results: TIVA with propofol and remifentanil had a smaller carbon footprint over a typical anaesthetic duration of 60 min (1.26 kg carbon dioxide equivalents [CO2e] for a 20 kg child) than i.v. induction followed by inhalational maintenance (2.58 kg CO2e) or inhalational induction and maintenance (2.98 kg CO2e). Inhalational induction followed by i.v. maintenance only had a lower carbon footprint than inhalational induction and maintenance when used in longer procedures (>77 min for children 5-20 kg; >105 min for children 30-50 kg).

Conclusions: In a simulation study, i.v. anaesthesia had climate benefits in paediatric anaesthesia. However, when used after inhalational induction, benefits were only achieved in longer procedures. These findings provide evidence-based guidance for reducing the environmental impact of paediatric anaesthesia, but these will require confirmation using real-world data.
Hanning SM, Hua C, Baroutian S, et al. Quantification and composition of pharmaceutical waste in New Zealand [epub ahead of print, 2022 May 10]. J Mater Cycles Waste Manag. 2022;1-9. Keywords: Pharmaceutical waste; Waste production; Waste stream composition.
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Abstract
This study aimed to quantify the amount of pharmaceutical waste produced in New Zealand, and determine the composition of pharmaceutical waste from community pharmacies in Auckland, New Zealand. Pharmaceutical waste collected in New Zealand is increasing, peaking at 542 tonne in 2019. Pharmaceutical waste collected from hospitals and pharmacies in Auckland increased by more than fourfold from 2016 to 2020. An audit of the types of pharmaceutical waste collected from community pharmacies revealed that the most common classes of drugs identified in this waste stream belonged to the nervous system, cardiovascular system and alimentary tract, and metabolism. Following examination of the contents of 12 pharmaceutical waste bins, 475 different pharmaceutical products were identified, highlighting the breadth of drugs in this waste stream. A range of dosage forms and hence materials were identified, which could present challenges for future waste treatment approaches. Hazardous drugs were identified including cytotoxic compounds, which should go into a separate waste stream for incineration. There is a need for similar data to be collected from multiple sites to fully appreciate the magnitude and composition of pharmaceutical waste. This will allow for the suitability of current practices for managing this hazardous waste stream to be evaluated.
Reynier T, Berahou M, Albaladejo P, Beloeil H. Moving towards green anaesthesia: Are patient safety and environmentally friendly practices compatible? A focus on single-use devices. Anaesth Crit Care Pain Med. 2021;40(4):100907. Keywords: Anaesthesia; Disposable equipment; Durable medical equipment; Environment; Life cycle; Nosocomial infection
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Objective: Discuss if the use of disposable or reusable medical devices leads to a difference in terms of hospital-acquired infection or bacterial contamination. Determine which solution is less expensive and has less environmental impact in terms of carbon footprint, energy and water consumption and amount of waste.

Methods: We carried out a narrative review. Articles published in English and French from January 2000 to April 2020 were identified from PubMed.

Results: We retrieved 81 articles, including 12 randomised controlled trial, 21 literature reviews, 13 descriptive studies, 6 experimental studies, 9 life-cycle studies, 6 cohort studies, 2 meta-analysis, 4 case reports and 8 other studies. It appears that pathogen transmission in the anaesthesia work area is mainly due to the lack of hand hygiene among the anaesthesia team. The benefit of single-use devices on infectious risk is based on weak scientific arguments, while reusable devices have benefits in terms of costs, water consumption, energy consumption, waste, and reducing greenhouse gas emissions.

Conclusion: Disposable medical devices and attire in the operating theatre do not mitigate the infectious risk to the patients but have a greater environmental, financial and social impact than the reusable ones. This study is the first step towards recommendations for more environmental-friendly practices in the operating theatre.
McGain F, Sheridan N, Wickramarachchi K, Yates S, Chan B, McAlister S. Carbon Footprint of General, Regional, and Combined Anesthesia for Total Knee Replacements. Anesthesiology. 2021;135(6):976-991.
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Abstract
Background: Health care itself contributes to climate change. Anesthesia is a "carbon hotspot," yet few data exist to compare anesthetic choices. The authors examined the carbon dioxide equivalent emissions associated with general anesthesia, spinal anesthesia, and combined (general and spinal anesthesia) during a total knee replacement.

Methods: A prospective life cycle assessment of 10 patients in each of three groups undergoing knee replacements was conducted in Melbourne, Australia. The authors collected input data for anesthetic items, gases, and drugs, and electricity for patient warming and anesthetic machine. Sevoflurane or propofol was used for general anesthesia. Life cycle assessment software was used to convert inputs to their carbon footprint (in kilogram carbon dioxide equivalent emissions), with modeled international comparisons.

Results: Twenty-nine patients were studied. The carbon dioxide equivalent emissions for general anesthesia were an average 14.9 (95% CI, 9.7 to 22.5) kg carbon dioxide equivalent emissions; spinal anesthesia, 16.9 (95% CI, 13.2 to 20.5) kg carbon dioxide equivalent; and for combined anesthesia, 18.5 (95% CI, 12.5 to 27.3) kg carbon dioxide equivalent. Major sources of carbon dioxide equivalent emissions across all approaches were as follows: electricity for the patient air warmer (average at least 2.5 kg carbon dioxide equivalent [20% total]), single-use items, 3.6 (general anesthesia), 3.4 (spinal), and 4.3 (combined) kg carbon dioxide equivalent emissions, respectively (approximately 25% total). For the general anesthesia and combined groups, sevoflurane contributed an average 4.7 kg carbon dioxide equivalent (35% total) and 3.1 kg carbon dioxide equivalent (19%), respectively. For spinal and combined, washing and sterilizing reusable items contributed 4.5 kg carbon dioxide equivalent (29% total) and 4.1 kg carbon dioxide equivalent (24%) emissions, respectively. Oxygen use was important to the spinal anesthetic carbon footprint (2.8 kg carbon dioxide equivalent, 18%). Modeling showed that intercountry carbon dioxide equivalent emission variability was less than intragroup variability (minimum/maximum).

Conclusions: All anesthetic approaches had similar carbon footprints (desflurane and nitrous oxide were not used for general anesthesia). Rather than spinal being a default low carbon approach, several choices determine the final carbon footprint: using low-flow anesthesia/total intravenous anesthesia, reducing single-use plastics, reducing oxygen flows, and collaborating with engineers to augment energy efficiency/renewable electricity.
Seglenieks R, Wong A, Pearson F, McGain F. Discrepancy between procurement and clinical use of nitrous oxide: waste not, want not. Br J Anaesth. 2022;128(1):e32-e34. [REQUEST ARTICLE VIA LIBRARY] Keywords: environmental impact; nitrous oxide; procurement; sustainability; waste.
Allen C, Smith AF, Nathanson MH. What can anaesthetists do to help combat the global climate emergency?. Anaesthesia. 2022;77(4):367-371. Keywords: sustainability; climate change
Baerg T, Klapman S, Cloyd B, et al. Identifying patterns of utilization of single-use video laryngoscopy and supraglottic airway devices to reduce waste. Journal of head & neck anesthesia. 2021;5(1):35. Keywords: Single-use airway equipment; waste reduction
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Introduction:
Lean management, a systematic method of reducing waste in manufacturing, is an approach that has led to quality improvement and cost reduction in health systems. Utilization of single-use airway equipment, such as videolaryngoscope (VL) blades and supraglottic airways (SGAs) has helped reduce the risk of cross-contamination and the time and cost associated with reprocessing and sterilization.
Methods:
We examined the efficiency of single-use VL blades and SGAs within our tertiary care health system. Purchasing data were reviewed and compared with device utilization within the electronic medical record to determine the amount of waste of disposable airway equipment. Direct observations (Gemba walks) were made in the operating rooms to assess device utilization. For SGAs, a diagnostic questionnaire was sent to providers regarding approaches to use.
Results:
We found the total cost of opened but unused VL blades equaled $29,267. For SGAs, we found that devices were often opened before use and that there is a 16.67% first-time failure rate for placement of SGAs.
Conclusions:
Through education and organizing device setup, and streamlining communication, there is a possibility to reduce future waste.
Pearson F, Sheridan N, Pierce JMT. Estimate of the total carbon footprint and component carbon sources of different modes of labour analgesia [epub ahead of print, 2022 Feb 9]. Anaesthesia. Keywords: Carbon footprint; Epidural; Labour analgesia; Sustainability
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The UKNational Health Service’s Sustainable Development Unit calculated that 30% of greenhouse gas emissions from anaesthetic services in 2017 were attributable to nitrous oxide used in maternity services [1]. We set out to compare the carbon dioxide equivalence (CO2e) of pharmaceutical options for labour analgesia to help inform UK healthcare staff andpatients.
Griffiths J, Hill A, Spiby J, Gill M, Stott R. Ten practical actions for doctors to combat climate change. BMJ. 2008;336(7659):1507-1507.
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The effects of climate change on health are already here, from increasing food prices to floods. Doctors led the charge on tobacco—we must do the same for climate change.
White SM, Shelton CL, Gelb AW et al. Principles of environmentally-sustainable anaesthesia: a global consensus statement from the World Federation of Societies of Anaesthesiologists [epub ahead of print, 2021 Nov 1]. Anaesthesia. Keywords: anaesthesia; carbon; climate change; consensus; environment; sustainability
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The Earth's mean surface temperature is already approximately 1.1°C higher than pre-industrial levels. Exceeding a mean 1.5°C rise by 2050 will make global adaptation to the consequences of climate change less possible. To protect public health, anaesthesia providers need to reduce the contribution their practice makes to global warming. We convened a Working Group of 45 anaesthesia providers with a recognised interest in sustainability, and used a three-stage modified Delphi consensus process to agree on principles of environmentally sustainable anaesthesia that are achievable worldwide. The Working Group agreed on the following three important underlying statements: patient safety should not be compromised by sustainable anaesthetic practices; high-, middle- and low-income countries should support each other appropriately in delivering sustainable healthcare (including anaesthesia); and healthcare systems should be mandated to reduce their contribution to global warming. We set out seven fundamental principles to guide anaesthesia providers in the move to environmentally sustainable practice, including: choice of medications and equipment; minimising waste and overuse of resources; and addressing environmental sustainability in anaesthetists' education, research, quality improvement and local healthcare leadership activities. These changes are achievable with minimal material resource and financial investment, and should undergo re-evaluation and updates as better evidence is published. This paper discusses each principle individually, and directs readers towards further important references.
Xiao MZX et al. A Roadmap for Environmental Sustainability of Plastic Use in Anesthesia and the Perioperative Arena. Anesthesiology. 2021;135(4):729-737. Keywords: Anesthesia; Environmental exposure; Perioperative care; Plastics; Recycling
Varughese S, Ahmed R. Environmental and occupational considerations of anesthesia: A narrative review and update. Anesth Analg. 2021 Oct;133(4):826-835. Keywords:
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With an estimated worldwide volume of 266 million surgeries in 2015, the call for general inhalation anesthesia is considerable. However, widely used volatile anesthetics such as N2O and the highly fluorinated gases sevoflurane, desflurane, and isoflurane are greenhouse gases, ozone-depleting agents, or both. Because these agents undergo minimal metabolism in the body during clinical use and are primarily (≥95%) eliminated unchanged via exhalation, waste anesthetic gases (WAGs) in operating rooms and postanesthesia care units can pose a challenge for overall elimination and occupational exposure. The chemical properties and global warming impacts of these gases vary, with atmospheric lifetimes of 1-5 years for sevoflurane, 3-6 years for isoflurane, 9-21 years for desflurane, and 114 years for N2O. Additionally, the use of N2O as a carrier gas for the inhalation anesthetics and as a supplement to intravenous (IV) anesthetics further contributes to these impacts. At the same time, unscavenged WAGs can result in chronic occupational exposure of health care workers to potential associated adverse health effects. Few adverse effects associated with WAGs have been documented, however, when workplace exposure limits are implemented. Specific measures that can help reduce occupational exposure and the environmental impact of inhaled anesthetics include efficient ventilation and scavenging systems, regular monitoring of airborne concentrations of waste gases to remain below recommended limits, ensuring that anesthesia equipment is well maintained, avoiding desflurane and N2O if possible, and minimizing fresh gas flow rates (eg, use of low-flow anesthesia). One alternative to volatile anesthetics may be total intravenous anesthesia (TIVA). While TIVA is not associated with the risks of occupational exposure or atmospheric pollution that are inherent to volatile anesthetic gases, clinical considerations should be weighed in the choice of agent. Appropriate procedures for the disposal of IV anesthetics must be followed to minimize any potential for negative environmental effects. Overall, although their contributions are relatively low compared with those of other human-produced substances, inhaled anesthetics are intrinsically potent greenhouse gases and pose a risk to operating-room personnel if not properly managed and scavenged. Factors to reduce waste and minimize the future impact of these substances should be considered.
Rizan C, Bhutta MF. Strategy for net-zero carbon surgery [epub ahead of print, 2021 May 8]. Br J Surg. 2021;znab130. Keywords: carbonsurgical procedures, operative
Barbariol F, et al. Evaluation of drug wastage in the operating rooms and intensive care units of a regional health service. [epub ahead of print, 2021 Mar 5]. Anesth Analg. Keywords: Environmental sustainability; Waste
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Abstract
Background: Pharmacological treatments for critical processes in patients need to be initiated as rapidly as possible; for this reason, it is a standard of care to prepare the main anesthesia and emergency drugs in advance. As a result, 20%-50% of the prepared drugs remain unused and are then discarded. Decreasing waste by optimizing drug use is an attractive strategy for meeting both cost containment and environmental sustainability. The primary end point of this study was to measure the actual amount of drug wastage in the operating rooms (ORs) and intensive care units (ICUs) of a Regional Health Service (RHS). The secondary end point was to analyze and estimate the economic implications of this waste for the Health Service and to suggest possible measures to reduce it.

Methods: This prospective observational multicenter study was conducted across 12 hospitals, all of which belong to the same RHS in the north-east of Italy. Data collection took place in March 2018 and included patients admitted to ICUs, emergency areas, and ORs of the participating hospitals. Data concerning drug preparation and administration were collected for all consecutive patients, independent of case types and of whether operations were scheduled or unscheduled. Drug wastage was defined as follows: drugs prepared in ready-to-use syringes but not administered at all and discarded untouched. We then estimated the costs of wasted drugs for a 1-year period using the data from this study and the yearly regional pharmacy orders of drugs provided to the ORs and ICUs. We also performed a sensitivity analysis to validate the robustness of our assumptions and qualitative conclusions.

Results: We collected data for a total of 13,078 prepared drug syringes. Drug wastage varied from 7.8% (Urapidil, an alpha-1 antagonist antihypertensive) to 85.7% (epinephrine) of prepared syringes, with an overall mean wastage rate of 38%. The estimated yearly waste was 139,531 syringes, for a total estimated financial cost of €78,060 ($92,569), and an additional quantity of medical waste amounting to 4968 kg per year. The total provider time dedicated to the preparation of unused drugs was predicted to be 1512 working hours per year.

Conclusions: The overall extent of drug wastage in ORs and ICUs is concerning. Interventions aimed at minimizing waste-related costs and improving the environmental sustainability of our practice are paramount. Effort should be put into designing a more efficient workflow that reduces this waste while providing for the emergency availability of these medications in the OR and ICU.
Kostrubiak MR, et al. Environmental externalities of switching from inhalational to total intravenous anesthesia. [epub ahead of print, 2021 Mar 4]. Anesth Analg. Keywords: Climate change; Environmental sustainability; Anaesthesia; Inhalational anaesthesia; Intravenous anaesthesia
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Health care systems are responsible for an estimated 10% of total greenhouse gas (GHG) emissions and contribute to a variety of other environmental concerns, from particulate air pollution to being the second-largest producer of landfill waste in the United States. With the growing awareness of the impact health care has on the environment, the calls to acknowledge and mitigate these issues have increased. National and international organizations, including Practice Greenhealth and Health Care Without Harm, now provide tools, resources, and incentives to local and regional health care systems and facilities to analyze and reduce their environmen-tal footprints. Reductions in energy use and waste, moving away from reliance on heavy metals such as mercury, and more sustainable food systems in hospi-tals offer success stories for reenvisioning the role that health care can play in moving society toward a more sustainable future. Similarly, the use of inhalational anesthetics has received special attention because of the environmental externalities to the atmosphere and the impact on global climate change.
Philipsborn RP, et al. Climate change and the practice of medicine: essentials for resident education. [epub ahead of print, 2020 Sep 8]. Acad Med. Keywords: Climate change; Medical education
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Abstract
Despite calls for including content on climate change and its effect on health in curricula across the spectrum of medical education, no widely used resource exists to guide residency training programs in this effort. This lack of resources poses challenges for training program leaders seeking to incorporate evidence-based climate and health content into their curricula. Climate change increases risks of heat-related illness, infections, asthma, mental health disorders, poor perinatal outcomes, adverse experiences from trauma and displacement, and other harms. More numerous and increasingly dangerous natural disasters caused by climate change impair delivery of care by disrupting supply chains and compromising power supplies. Graduating trainees face a knowledge gap in understanding, managing, and mitigating these many-faceted consequences of climate change, which-expected to intensify in coming decades-will influence both the health of their patients and the health care they deliver. In this article, the authors propose a framework of climate change and health educational content for residents, including how climate change (1) harms health, (2) necessitates adaptation in clinical practice, and (3) undermines health care delivery. The authors propose not only learning objectives linked to the Accreditation Council for Graduate Medical Education core competencies for resident education, but also learning formats and assessment strategies in each content area. They also present opportunities for implementation of climate and health education in residency training programs. Including this content in residency education will better prepare doctors to deliver anticipatory guidance to at-risk patients, manage those experiencing climate-related health effects, and reduce care disruptions during climate-driven extreme weather events.
Goshua A, et al. Addressing climate change and its effects on human health: a call to action for medical schools. [epub ahead of print, 2020 Nov 24]. Acad Med. Keywords: Climate change; Public health; Medical education
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Abstract
Human health is increasingly threatened by rapid and widespread changes in the environment and climate, including rising temperatures, air and water pollution, disease vector migration, floods, and droughts. In the United States, many medical schools, the American Medical Association, and the National Academy of Sciences have published calls for physicians and physicians-in-training to develop a basic knowledge of the science of climate change and an awareness of the associated health risks. The authors--all medical students and educators--argue for the expeditious redesign of medical school curricula to teach students to recognize, diagnose, and treat the many health conditions exacerbated by climate change as well as understanding public health issues. In this Invited Commentary, the authors briefly review the health impacts of climate change, examine current climate change course offerings and proposals, and describe the rationale for promptly and comprehensively including climate science education in medical school curricula. Efforts in training physicians now will benefit those physicians' communities, whose health will be impacted by a period of remarkable climate change. The bottom line is that the health effects of climate reality cannot be ignored, and people everywhere must adapt as quickly as possible.
Manger S, Sleeman N. Let’s get practical: how we can heal the planet and our patients. InSight. Published 2021 Feb 15. Keywords: Sustainability; Public health; Climate change
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Manger and Sleeman present six practical measures doctors can take, and can encourage their patients to take, which will have a positive impact on emissions and climate change while also improving health outcomes.
Dasandi N, et al. Intergovernmental engagement on health impacts of climate change. Bull World Health Organ 2021;99:102–111B. Keywords: Climate change; Public health.
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Objective To examine countries’ engagement with the health impacts of climate change in their formal statements to intergovernmental organizations, and the factors driving engagement.

Methods We obtained the texts of countries’ annual statements in United Nations (UN) general debates from 2000 to 2019 and their nationally determined contributions at the Paris Agreement in 2016. To measure countries’ engagement, we used a keyword-in-context text search with relevant search terms to count the total number of references to the relationship of health to climate change. We used a machine
learning model (random forest predictions) to identify the most important country-level predictors of engagement. The predictors included political and economic factors, health outcomes, climate change-related variables and membership of political negotiating groups in the UN.

Findings For both UN general debate statements and nationally determined contributions, low- and middle-income countries discussed the health impacts of climate change much more than did high-income countries. The most important predictors of engagement were health outcomes (infant mortality, maternal deaths, life expectancy), countries’ income levels (gross domestic product per capita), and
fossil fuel consumption. Membership of political negotiating groups (such as the Group of 77 and Small Island Developing States) was a less important predictor.

Conclusion Our analysis indicated a higher engagement in countries that carry the heaviest climate-related health burdens, but lack necessary resources to address the impacts of climate change. These countries are shouldering responsibility for reminding the global community of the implications of climate change for people’s health.
Humphreys G, Cousins S. The seeding of climate smart health care. Bull World Health Organ 2021;99:81–82. Keywords: Climate change; Public health.
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After a slow start, climate-smart health initiatives are gaining momentum. Gary Humphreys and Sophie Cousins report.

Oderberg I.Air grievances: silence swirls around the toll of bushfire smoke during pregnancy. The Guardian. Published 2021 Jan 11.

Webster P. Canada's municipalities push for health-based climate action. Lancet. 2021 Jan 2;397(10268):14-15. doi: 10.1016/S0140-6736(20)32753-7.

Wanderer JP, Nathan N. Reduce, reuse… reprocess? Strategies for extended use of N95 masks. Anesthesia and Analgesia. 2021 Jan;132(1):1. doi: 10.1213/ANE.0000000000005300.

McMichael C, Kelman I, Dasgupta S, Ayeb-Karlsson S.Climate change is resulting in profound, immediate and worsening health impacts, over 120 researchers say. Published 2020 Dec 3.

Davey M.Australia's bushfire season saw spikes in emergency respiratory visits and inhaler sales, report finds. The Guardian. Published 2020 Nov 25.

Evitaputri D. Prime Minister must tackle climate change with same urgency as COVID-19: open letter from health groups. [Internet]. Climate and Health Alliance. Published 2020 Nov 16.

CSIRO. State of the climate 2020. [Internet]. CSIRO; 2020.

Shelton CL, Sutton R, White SM. Desflurane in modern anaesthetic practice: walking on thin ice(caps)? British Journal of Anaesthesia. 2020 Oct 7:S0007-0912(20)30766-2.

Meyer MJ. Desflurane should des-appear: global and financial rationale [published online ahead of print, 2020 Aug 20]. Anesthesia and Analgesia. 2020;10.

Zhong G, Abbas A, Jones J, Kong S, McCulloch T. Environmental and economic impact of using increased fresh gas flow to reduce carbon dioxide absorbent consumption in the absence of inhalational anaesthetics[article in press, 2020 Aug 25]. British Journal of Anaesthesia. 2020. doi: 10.1016/j.bja.2020.07.043

McGain F, Muret J, Lawson C, Sherman JD. Environmental sustainability within anaesthesia and critical care [published online ahead of print, 2020 Aug 11].British Journal of Anaesthesia. 2020;S0007-0912(20)30547-X.

Zavaleta-Cortijo C, Ford JD, Arotoma-Rojas I, et al. Climate change and COVID-19: reinforcing Indigenous food systems [published online ahead of print, 2020 Aug 7]. Lancet Planetary Health. 2020;S2542-5196(20)30173-X.

Wyssusek K, Keys M, Laycock B, et al. The volume of recyclable polyethylene terephthalate plastic in operating rooms - A one-month prospective audit [published online ahead of print, 2020 Jun 4]. American Journal of Surgery. 2020;S0002-9610(20)30267-1. doi:10.1016/j.amjsurg.2020.05.011

Pierce T, Lawson C. A call to arms. RCOA Bulletin; 2020; 1(119); 34-35.

Groome J. Greener anaesthesia and sustainability project. RCOA Bulletin; 2020; 1(119); 32-33.

National Institute of Water and Atmospheric Research (NIWA). Climate change adaptation toolbox. [Internet]. NIWA; 2020.

PS64 Background paper select references

McGain F. Why anaesthetists should no longer use nitrous oxide. Anaesthesia and Intensive Care. 2007 Oct;35(5):808-9.

Ryan SM, Nielsen CJ. Global warming potential of inhaled anesthetics: application to clinical use. Anesthesia and Analgesia. 2010 Jul;111(1):92-8.

McGain E, Hendel SA, Story DA. An audit of potentially recyclable waste from anaesthetic practice. Anaesthesia and Intensive Care. 2009 Sep;37(5):820-3.

The Lancet Planetary Health. Our polluted world: the need for a global pollution strategy. [Editorial] The Lancet Planet Health.2017 Sep 1; 1(6):e209.

Poore KR, Hanson MA, Faustman EM, Neira M. Avoidable early life environmental exposures. Lancet Planet Health. 2017 Aug 1;1(5):e172-e173.

Andersen MPS, Nielsen OJ, Wallington TJ, Karpichev B, Sander SP. Medical intelligence article: assessing the impact on global climate from general anesthetic gases. Anesthesia and Analgesia. 2012 May;114(5):1081-5.

Sherman J, Le C, Lamers V, Eckelman M. Life cycle greenhouse gas emissions of anesthetic drugs. Anesthesia and Analgesia. 2012 May;114(5):1086-90.

Eckelman MH, Sherman J. Environmental impacts of the US health care system and effects on public health. PLoS One. 2016 Jun 9;11(6):e0157014.

Pinkney J, Rance S, Benger J, Brant H, Joel-Edgar S, Swancutt D, et al. How can frontline expertise and new models of care best contribute to safely reducing avoidable acute admissions? A mixed-methods study of four acute hospitals. 2016 Jan. Health Serv Deliv Res;4(3).

Blau E, Asrar FM, Arya N, Schabort I, Abelsohn A, Price D. Greener medical homes: Environmental responsibility in family medicine. Canadian Family Physician. 2016 May;62(5):381-4.

Sneyd JR, Montgomery H, Pencheon D. The anaesthetist and the environment. Anaesthesia. 2010 May;65(5):435-7.

The Association of Anaesthetists of Great Britain and Ireland. Safety Guideline. Infection Control in Anaesthesia. [Internet] 2008 Sep; 63(9): 1027–36.

Frischknecht R, Jungbluth N, Althaus H-J, Doka G, Dones R, Heck T, et al. The ecoinvent Database: Overview and Methodological Framework. International Journal of Life Cycle Assessment. 2005;10(1):3- 9.

Weidema B P, Bauer C, Hischier R, Mutel C, Nemecek T, Reinhard J et al. Overview and methodology. Data quality guideline for the ecoinvent database version 3. Ecoinvent Report 1(v3). St. Gallen: The ecoinvent Centre; 2013.

Overcash M. A comparison of reusable and disposable perioperative textiles: sustainability state-ofthe-art 2012. Anesthesia and Analgesia. 2012 May;114(5):1055-66.

McGain F, McAlister S, McGavin A, Story D. The financial and environmental costs of reusable and single-use plastic anaesthetic drug trays. Anaesthesia and Intensive Care. 2010 May;38(3):538-44.

Eckelman M, Mosher M, Gonzalez A, Sherman J. Comparative life cycle assessment of disposable and reusable laryngeal mask airways. Anesthesia and Analgesia. 2012 May ;114(5):1067-72.

McGain F, Story D, Lim T, McAlister S. Financial and environmental costs of reusable and singleuse anaesthetic equipment. British Journal of Anaesthesia. 2017 Jun 1;118(6):862-9.

Centers for Disease Control and Prevention (CDC). Guidelines for Preventing Health-Care-- Associated Pneumonia, 2003 - Recommendations of CDC and the Healthcare Infection ControlPractices Advisory Committee. [Internet]. CDC; 2003.

Kramer A, Kranabetter R, Rathgeber J, Züchner K, Assadian O, Daeschlein G, et al. Infection prevention during anaesthesia ventilation by the use of breathing system filters (BSF): Joint recommendation by German Society of Hospital Hygiene (DGKH) and German Society for Anaesthesiology and Intensive Care (DGAI). GMS Krankenhhyg Interdiszip. 2010 Sep 21;5(2).

Dubler S, Zimmermann S, Fischer M, Schnitzler P, Bruckner T, Weigand MA, et al. Bacterial and viral contamination of breathing circuits after extended use - an aspect of patient safety? Acta Anaesthesiol Scand. 2016 Oct;60(9):1251-60.

McGain F, Algie CM, O'Toole J, Lim TF, Mohebbi M, Story DA, et al. The microbiological and sustainability effects of washing anaesthesia breathing circuits less frequently. Anaesthesia. 2014;69(4):337-42.

The Royal Australasian College of Physicians (RACP). Climate change and health position statement. November 2016. Sydney, NSW: RACP; 2016 Nov.

Intergovernmental Panel on Climate Change (IPCC). Summary for Policymakers. In: MassonDelmotte, VP. Zhai, H-O. Pörtner, D. Roberts, J. Skea, PR. Shukla, A. et al., editors. Global Warming of 1.5°C. An IPCC Special Report on the impacts of global warming of 1.5°C above preindustrial levels and related global greenhouse gas emission pathways, in the context of strengthening the global response to the threat of climate change, sustainable development, and efforts to eradicate poverty. Geneva, Switzerland World Meteorological Organization, 2018.

McAlister S, Ou Y, Neff E, Hapgood K, Story D, Mealey P, et al. The Environmental footprint of morphine: a life cycle assessment from opium poppy farming to the packaged drug. BMJ Open. 2016 Oct 21;6(10):e013302.

RNZCGP, Randerson R, Phipps R. Greening General Practice. A toolkit for sustainable practice.Wellington: The Royal New Zealand College of General Practitioners; 2016.

Mankes RF. Propofol wastage in anesthesia. Anesthesia and Analgesia. 2012 May;114(5):1091-2.

McGain F, McAlister S, McGavin A, Story D. A life cycle assessment of reusable and single-use central venous catheter insertion kits. Anesthesia and Analgesia. 2012 May;114(5):1073-80.

The Royal Australasian College of Physicians (RACP). The Health Benefits of Mitigating Climate Change Position Statement,. November 2016. Sydney, NSW: RACP; 2016 Nov

Ryan S, Sherman J. Sustainable anesthesia. Anesthesia and Analgesia. 2012 May;114(5):921-3.

Wyssusek KH, Foong WM, Steel C, Gillespie BM. The Gold in Garbage: Implementing a Waste Segregation and Recycling Initiative. AORN Jl. 2016 Mar;103(3):316.e1-8.

Gilbert N. Drug waste harms fish. Nature. 2011 Aug 15;476(7360):265.

Special Issue: Focus on Green Anesthesia (Canadian Journal of Anesthesia)

Special Issue: Focus on Green Anesthesia (Canadian Journal of Anesthesia)
This issue represents a reflection of environmental stewardship and sustainability in perioperative medicine and critical care, featuring a collection of content on the topic of “green anesthesia.”

Special Issues: Environment (Anaesthesia News)

Special Collection: Environment (Anaesthesia News)
Anaesthesia News – March 2021
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Including articles on: The procurement gap; A personal account of eco-anxiety and declaration of a climate emergency at Newcastle Hospitals; First, do no harm – NHS supply chains and oceanic health; But what about the fish? Ecotoxicology and anaesthesia; Education for healthcare sustainability.
Anaesthesia News - February 2020
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Including articles on: Reusables vs disposables – time for a new debate?; Tyres in the water, laryngoscopes in the air; What is sustainability?; What's your Carbon Instinct?; Navigating uncertainty: from poker to anaesthesia
Anaesthesia News - February 2019
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Including articles on: Fellowship in Environmentally Sustainable Anaesthesia; Come around to recycling: make a positive change; Let’s get hooked on reducing plastic waste; ‘We are living on this planet as if we had another one to go to’; ‘.....twelve years to save the world’ – the impact of desflurane on the environment (a personal view); Association of Anaesthetists goes orange, but is still green!
Anaesthesia News - May 2018
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Including articles on: The Environmental Task Group: a trainee perspective – more than low flow anaesthesia; Domestic energy consumption; Education goes green; Environmental initiatives in a new build hospital; Metal recycling in healthcare waste management; Human health depends on nature: why doctors must become eco-warriors; The Annual Association Award for Innovation in Anaesthesia, Critical Care and Pain

Special Issues: Climate Change

Key journals

Energy, Sustainability and Society
Online: Vol. 1, 2011 - current
>> Alternate/direct access via Springer.
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The aim of the journal is to provide an international and interdisciplinary forum for the discourse between natural scientists, engineers, social & political scientists as well as experts from industry who drive the innovation of sustainable energy systems. It is the particular aim of this journal to publish papers extending across different disciplines and providing a substantial contribution to the holistic innovation of these energy systems.
Global Sustainability
Online: Vol. 1, 2018 - current
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Global sustainability defines the conditions under which humans and nature, societies and the biosphere, the world and the Earth can co-exist in ways that enable productive harmony, stability and resilience to support present and future generations. Global sustainability science explores interactions between social and natural systems, from local to global scales, with a particular focus on sustainability as an avenue for human development in the context of global environmental change and Earth resilience.
The Lancet Planetary Health
Online: Vol. 1, 2017 - current
>> Alternate/direct access via ScienceDirect.
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The Lancet Planetary Health is a gold open access journal that seeks to be the pre-eminent journal for enquiry into sustainable human civilisations in the Anthropocene. As such, it publishes peer reviewed Research and Reviews as well as Comment and Reportage broadly encompassing sustainable development (the SDG's) and global environmental change.
Sustainability: Science, Practice, & Policy
Online: Vol. 1, 2005 - current
>> Alternate/direct access via Taylor & Francis.
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Sustainability: Science, Practice and Policy advances understanding about sustainability transformations of societal systems and seeks to catalyze social innovations that enable these transitions. Papers published in SSPP recognize that global climate change and other socio-environmental challenges require system-scale reinvention to ensure universally sufficient availability of energy, mobility, housing, and food.
Sustainable Futures: An Applied Journal of Technology, Environment and Society
Online: Vol. 1, 2019 - current
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Sustainable Futures: an applied journal of technology, environment & society is a journal focused on the intersection of sustainability, environment and technology, and their larger implications for corporation, government, education institutions, regions and society both at present and in the future. The scope of the journal is broad, and encourages interdisciplinary research, as well as welcoming theoretical and practical research from all methodological approaches.

PS64 Select references

Watts N, Adger WN, Agnolucci P, et al. Health and climate change: policy responses to protect public health. Lancet. 2015;386(10006):1861-1914. doi:10.1016/S0140-6736(15)60854-6

Malik A, Lenzen M, McAlister S, McGain F. The carbon footprint of Australian health care. Lancet Planetary Health. 2018;2(1):e27-e35. doi:10.1016/S2542-5196(17)30180-8

Sustainable Development Unit. Carbon footprint from anaesthetic gas use. [internet]. Cambridge, UK: Sustainable Development Unit; Dec 2013.

McGain F, Story D, Kayak E, Kashima Y, McAlister S. Workplace sustainability: the "cradle to grave" view of what we do.Anesthesia and Analgesia. 2012;114(5):1134-1139. doi:10.1213/ANE.0b013e31824ddfef

Maughan D, Ansell J. Protecting resources, promoting value – A doctor’s guide to cutting waste in clinical care. London, UK: Academy of Medical Royal Colleges; 2014 Nov 6.

Ard JL Jr, Tobin K, Huncke T, Kline R, Ryan SM, Bell C. A survey of the American Society of Anesthesiologists regarding environmental attitudes, knowledge, and organization. A & A Case Reports. 2016;6(7):208-216. doi:10.1213/XAA.0000000000000184

Pungsornruk K, Forbes MP, Hellier C, Bryant M. A renewed call for environmentally responsible anaesthesia. Anaesthesia and Intensive Care. 2015;43(6):800-801.

Environmental sustainability: Journals & articles

Check full-text: Lookup any journal article by DOI or PMID