American Society of Regional Anesthesia and Pain Medicine May 2018 - 30

Figure 1: CO2 equivalency per hour of the three commonly used

Figure 2: Various advantages of regional anesthesia, including lower
environmental burden.

Because inhalational anesthetics do not fall under mandatory
lists of agents reported by the pollution-monitoring agencies and
are also the only agents left out of the Montreal Protocols list of
halogenated fluorocarbons to be phased out by 2030, market
research expects an increase in the consumption of inhalational
anesthetics in the range of 10-15% per year. Our own practice
habits, including the choice of inhalational anesthetic and the fresh
gas flows we run, largely determine what impact our anesthetics
make on the environment.

REGIONAL ANESTHESIA AND THE ENVIRONMENT
Regional anesthesia is an elegant modality to reduce or to avoid
general anesthesia and can potentially play a leading role in green
anesthesia. It has repeatedly proven benefits, including improved
pain control and functional outcomes. Potential reductions in cancer
recurrence or chronic pain require more compelling evidence
(Figure 2) before they can be widely accepted as fact. Logic
suggests that regional anesthesia is currently the anesthetic with
the lowest environmental burden. Hence this presents us with a
great opportunity to generate evidence and determine the favorable
environmental impact of regional anesthesia either as a sole
anesthetic or in combination with general anesthesia. One of the
SIG's main goals is to launch projects exploring the environmental
impact of various anesthetic techniques including regional
anesthesia.

volatile anesthetics at 1 MAC concentration and 0.5 L/min fresh gas flow.
Calculations are based on the International Government Panel on Climate
Change's Fifth Assessment Report. MAC (minimal alveolar concentration).

General anesthesia via intravenous agents is undoubtedly far better
for the atmosphere, but it comes with its own set of problems. Our
pharmaceuticals will reach soil and water either through excretion
of the unchanged product or its metabolites or as waste occurring in
the OR. We need to further our understanding of the life cycle of our
medications and how they impact our ecology and population health.
With all this in mind, one of the SIG's goals is to bring components of
environmental sustainability into the practice of all anesthesiologists
through educational initiatives. Some of the SIG's educational
objectives are to advocate for improved and financially beneficial
technology. Xenon, for example, has no known environmental impact
and should likely receive additional attention and research.
Various metrics exist or are being developed to assist in our
understanding of GHGs' impact on the atmosphere and their role
in climate change. However, our understanding remains far from
complete. Global warming potential-or the more appropriately
termed relative cumulative forcing index-is an index of the total
energy added to the climate system by our inhalation anesthetics
relative to that added by CO2, which was most recently updated
in the fifth Assessment Report by the Intergovernmental Panel on
Climate Change. Furthering all our understanding of the metrics, as
well as their values and shortcomings, is an important SIG goal to
advance research and communication in this area.

30

WASTE IN THE OR
Planetary resources are finite, and it is important to be responsible
in their use. Media marketing increasingly promotes disposable
OR equipment. However, the environmental impact of such an
approach is not entirely clear. It will be important to generate
independent life-cycle analyses for various equipment and to
determine where reusable options might be more environmentally
responsible.
Medication waste is another major issue that causes not only the
aforementioned problems with soil and groundwater pollution, but
also financial losses in the range of hundreds of millions of dollars
per year. The downstream effects of such waste require significant
research, which is in its infancy.
These examples are mere starting points for the field of green
anesthesia. Progress will likely include rethinking tendencies and
practices that have become prevalent in anesthesia in particular and

American Society of Regional Anesthesia and Pain Medicine
2018



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