Let’s now blame the Anesthesiologists for contributing to Climate change!

[deleted1156722]

“Emissions of anesthetic gases in the United States alone are estimated to equal the annual emissions of one coal-fired plant, or nearly 1 million automobiles per year”.
Really compelling medical indication to convert General Anesthesia-> Regional Anesthesia!

Anesthesiologists Tackle Climate Change in the OR

Anesthesia gases are a critical tool in health care, but they also play a significant role in making the global health care industry the world’s fifth largest emitter of greenhouse gases.

www.cuimc.columbia.edu

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[anbuitachi]

“Emissions of anesthetic gases in the United States alone are estimated to equal the annual emissions of one coal-fired plant, or nearly 1 million automobiles per year”.
Really compelling medical indication to convert General Anesthesia-> Regional Anesthesia!

Anesthesiologists Tackle Climate Change in the OR

Anesthesia gases are a critical tool in health care, but they also play a significant role in making the global health care industry the world’s fifth largest emitter of greenhouse gases.

www.cuimc.columbia.edu

there is a HUGE movement here to move away from volatiles/nitrous and move to TIVA

however i am not aware of any good data showing the climate effects of TIVA? All those bottles of propofol and plastic im sure costs CO2 to produce, and then dispose. and many people here use BIS monitor when doing TIVA.

 

[deleted1156722]

We can safely predict that in the next few decades, the use of volatiles will be viewed the same way as we currently view chloroform...an interesting historical technique but with no place in modern practice.
However, with this extreme focus on carbon footprints, the environmental impacts of TIVA such as drug manufacturing, single plastics, Propofol and metabolites polluting waterways, etc is conveniently ignored… much the same way as the aggressive proponents of Solar energy/ panels conveniently ignore the environmental pollution caused by the heavy metals in the manufacturing process.

Sadly, the agenda shapes the narrative.

 

[drmwvr]

about the only elements of anesthesia practice that is not single use is the machine and the anesthesia cart...and in most places, scrubs. It'd take less than a month to fill some ORs from floor to ceiling with the waste generated from the cases done in them. talk about rearranging deck chairs....more solid gold coming from the US university system mission creep...one coal fired plant equivalent for what is provided in this country in terms of anesthesia care? That's not a better than even trade off how?

 

[Maz777]

Give me back my reusable laryngoscopes, Glidescope handles, NIBP cuffs, pulse ox probes, EKG cables, etc. All are single-use pieces of crap now. Then we can have a chat about how my anesthetic is destroying the environment.

These movements are designed for ivory tower types to give themselves made-up titles and feel good about themselves.

 

[Ronin786]

Really don't get the TIVA push. So much effort for slower wake-ups and not much better PONV.

 

[Gas you down]

This is all laughable. This is a tiny fraction of all health care pollution. I feel like it’s being used to push getting rid of Des

 

[Drwine]

Really don't get the TIVA push. So much effort for slower wake-ups and not much better PONV.

If we had target controlled TIVA in the US it would make more sense. Think if we still had copper kettles and Vernitrols to do inhalation anesthesia?

 

[deleted1156722]

Wouldn’t be surprised if at some point, there will be new standards and additional “carbon tax” for hospitals from the Climate Activist Lobby, both from Federal Govt and other regulatory bodies. These could potentially impose huge penalties for hospitals and putting hospitals and their viability at risk.

“Besides the federal government, the Joint Commission, which accredits 80% of hospitals, is expected to offer new accreditation standards for addressing climate impacts within a few months, and to start a review of existing standards to be sure they don’t encourage waste or unnecessary consumption.”

‘If I were a hospital, I’d be reading the tea leaves’: Pressures grow on the health care industry to reduce its climate pollution

Some hospitals have begun to tout their efforts to combat climate change, with scattershot examples of progress. Yet hospitals have long been laggards in even tracking and reporting their emissions and waste.

www.statnews.com

 

[abolt18]

Wouldn’t be surprised if at some point, there will be new standards and additional “carbon tax” for hospitals from the Climate Activist Lobby, both from Federal Govt and other regulatory bodies. These could potentially impose huge penalties for hospitals and putting hospitals and their viability at risk.

“Besides the federal government, the Joint Commission, which accredits 80% of hospitals, is expected to offer new accreditation standards for addressing climate impacts within a few months, and to start a review of existing standards to be sure they don’t encourage waste or unnecessary consumption.”

‘If I were a hospital, I’d be reading the tea leaves’: Pressures grow on the health care industry to reduce its climate pollution

Some hospitals have begun to tout their efforts to combat climate change, with scattershot examples of progress. Yet hospitals have long been laggards in even tracking and reporting their emissions and waste.

www.statnews.com

This is hilarious considering some of the most wasteful things we do are 100% driven by JC rules.

 

[nimbus]

This is hilarious considering some of the most wasteful things we do are 100% driven by JC rules.

Then we’ll need to hire more managers to navigate competing and incompatible mandates from different agencies.

That said, I wouldn’t mind getting the reusable Heine blades back. They were replaced years ago with disposable single use junk.

Recently we were told by our infection control people that we need to sterile process our ultrasound probes between each use. That created a tremendous amount of work for our anesthesia techs. At the same time, we were told by a systemwide supply chain committee that we will be using reusable pulse oximeter sensors throughout the perioperative period. They just need to be wiped with CaviWipes between each use 🤔. And I do wonder where the thousands of CaviWipes we use every day end up.

 

[Anestheezee]

I think we certainly could be doing and teaching more low flow/ metabolic flow anesthesia than 2 LPM. That goes a long way at reducing wasteful emissions.

 

[T-burglar]

None of this matters. we are headed for 3 degrees C of warming faster than has ever occurred in the history of the planet and the temperatures will be like they were jn the Eocene era and humanity will be extinct.

There’s nothing anyone can do, just stop worrying about it and be happy you got to live at the peak of civilization

 

[sanityonleave]

Then we’ll need to hire more managers to navigate competing and incompatible mandates from different agencies.

That said, I wouldn’t mind getting the reusable Heine blades back. They were replaced years ago with disposable single use junk.

Recently we were told by our infection control people that we need to sterile process our ultrasound probes between each use. That created a tremendous amount of work for our anesthesia techs. At the same time, we were told by a systemwide supply chain committee that we will be using reusable pulse oximeter sensors throughout the perioperative period. They just need to be wiped with a CaviWipes between each use 🤔. And I do wonder where the thousands of CaviWipes we use every day end up.

This is one of my biggest frustrations with the medicine behemoth.

Why is it that if I want to change clinical practice, I need 3 RCTs and a signed letter from Jesus Christ himself -- but if some committee decides on an arbitrary recommendation they don't have to prove anything or collect any data after the fact? It would be nice if infection control at least did some bull**** study where they swabbed all the ultrasound probes and found they grew MRSA or VRE or whatever -- at least then maybe it would be plausible as a route of infection.

It's not just the hospital, either. I love the reams of data ASRA produced when they arbitrarily decided preop couldn't give the 5,000 of subcu heparin before my epidural (notwithstanding that the pharmacokinetics of SQH make that absolute nonsense). Now I get pages every morning from preop asking if they can give the SQH that's ordered. Then again, the only people I've known who ended up on those committees did so because they were too much of a 007 to actually provide anesthetic care, so I guess that's the answer to all of this.

 

[Guillemot]

Just run low flow sevo and call it a day 🤷‍♂️

 

[anaesthetic]

Then again, the only people I've known who ended up on those committees did so because they were too much of a 007 to actually provide anesthetic care, so I guess that's the answer to all of this.

I know so many ASA “diplomats” and board members who could not solo an ASA 1 lap appy to save their lives. It’s embarrassing, but I guess that’s how it is in most fields. The higher “up” you go, the further away you get from the actual work.

 

[jwk]

If we had target controlled TIVA in the US it would make more sense. Think if we still had copper kettles and Vernitrols to do inhalation anesthesia?

I used them both. They work great!

 

[Dr. Rude]

I used them both. They work great!

They do. So do 1970s cars. Just lacking significant safety features.

 

[GassYous]

I think we certainly could be doing and teaching more low flow/ metabolic flow anesthesia than 2 LPM. That goes a long way at reducing wasteful emissions.

Apparently 2L or more is good for when you're running tiva because you use up the co2 canister more slowly. Drives me nuts when I see people run 2 or more with gas or wake up on 15 liters of flow. Just dumb.

 

[Urzuz]

So much effort for slower wake-ups and not much better PONV.

While I agree running TIVAs on every patient is unnecessary, it goes without saying that on certain patients it really is game changing in terms of their PONV and their overall periop recovery.

Like everything in medicine, coming up with an individualized plan for a patient requires nuance and a tiny bit of brain power, rather than the one-size-fits-all checklist BS that every administrator, clipboard RN, and academician gets off on.

 

[Ronin786]

While I agree running TIVAs on every patient is unnecessary, it goes without saying that on certain patients it really is game changing in terms of their PONV and their overall periop recovery.

Like everything in medicine, coming up with an individualized plan for a patient requires nuance and a tiny bit of brain power, rather than the one-size-fits-all checklist BS that every administrator, clipboard RN, and academician gets off on.

No argument here. If anything the TIVA increase is directly tied to some of the administrator and checklist BS. There's a huge national push to report PONV numbers in the same vein as SSI and other SQS data. Except the metrics being captured are very poor surrogates for whether PONV occurred or not (mainly whether the patient received anti-emetics in PACU). In my experience across a number of large hospital systems, this is really pushing TIVA as a way to decrease PONV at huge cost and without any measurable improvement in PONV rates. Ditto the rampant use of all these expensive new drugs that don't do much better than scop + ondansetron (for your average patient).

 

[NumTacos]

This is all laughable. This is a tiny fraction of all health care pollution. I feel like it’s being used to push getting rid of Des

There are also good economic reasons to get rid of Des, this is probably what really gets the attention of the admin types.

 

[deleted1156722]

There are also good economic reasons to get rid of Des, this is probably what really gets the attention of the admin types.

There is evidence to support that the real issue is bottom line: finance > carbon footprint.
The anesthesia departments in all the eight Providence Health hospitals in Oregon, switched to the use of sevoflurane from desflurane. They now save about $500,000 a year.
However Providence healthcare system’s CEO Lisa Vance passionately stated that the hospital system didn't change its use of the gas because of the money. It changed because the World Health Organization assertion that climate change is the No. 1 public health issue.
Yeah right!

https://www.cnn.com/2019/05/31/health/climate-change-anesthesia-partner/index.html

 

[Simba1711]

6 liters/min for tiva

Apparently 2L or more is good for when you're running tiva because you use up the co2 canister more slowly. Drives me nuts when I see people run 2 or more with gas or wake up on 15 liters of flow. Just dumb.

 

[Ronin786]

6 liters/min for tiva

Is that the optimal flow to eliminate gas on wake-up as well?

 

[GassYous]

Is that the optimal flow to eliminate gas on wake-up as well?

I just put it on mv

 

[coffeebythelake]

Is that the optimal flow to eliminate gas on wake-up as well?

There is no optimal flow rate to wake up on gas, not after your FI sevo % is 0. At that point its all gradient between blood and alveoli. CO2 level matters most at that point, and your ability to increase MV to breathe off that brain sevo without hyperventilating to the point of eliminating respiratory drive or inducing cerebral vasoconstriction

 

[pgg]

about the only elements of anesthesia practice that is not single use is the machine and the anesthesia cart...and in most places, scrubs.

Our scrub machines dispense them in disposable plastic bags. The scrubs get laundered and repackaged into individual bags.

Just run low flow sevo and call it a day 🤷‍♂️

I was a fan of desflurane.

You can use low flows with sevo, and you should, but there's no denying that low flow kinetics are simpler and easier and more predictable with desflurane. And yeah anyone can wake up any patient at any time with any gas, but desflurane patients make the transition from awake-enough-to-extubate, to wide-****ing-awake, substantially faster. So much faster that sometimes it can be jolting to patients (especially peds), although that "emergence delirium" is easily preventable by people familiar with des who know you need to use some opioids instead of deferring pain management to a PACU RN 20 minutes after hand-off when the rest of the sevo is gone.

All I've got now is sevoflurane, and life is fine, but it's a shame that cost and greenhouse gas concerns killed des. I just add it to the list of things that get ****tier in the world as I get older.

I miss lawn darts, too, they were good for keeping the kids off my lawn.

 

[Maz777]

It's only a matter of time before we are forced to wear single-use scrubs made out of that terrible surgical gown material. Prepare yourselves for those Infection Control losers to force this upon us with zero real-world data. Some idiotic company will jump at the opportunity to mass produce it and claim that it decreases perioperative infection risk based on some garbage in vitro data.

 

[GassYous]

Our scrub machines dispense them in disposable plastic bags. The scrubs get laundered and repackaged into individual bags.



I was a fan of desflurane.

You can use low flows with sevo, and you should, but there's no denying that low flow kinetics are simpler and easier and more predictable with desflurane. And yeah anyone can wake up any patient at any time with any gas, but desflurane patients make the transition from awake-enough-to-extubate, to wide-****ing-awake, substantially faster. So much faster that sometimes it can be jolting to patients (especially peds), although that "emergence delirium" is easily preventable by people familiar with des who know you need to use some opioids instead of deferring pain management to a PACU RN 20 minutes after hand-off when the rest of the sevo is gone.

All I've got now is sevoflurane, and life is fine, but it's a shame that cost and greenhouse gas concerns killed des. I just add it to the list of things that get ****tier in the world as I get older.

I miss lawn darts, too, they were good for keeping the kids off my lawn.

Is this related to sux darts?

 

[nimbus]

Is this related to sux darts?

We had them when I was a kid.

Now they look like this. They’re no longer darts at all 🙁

 

[nimbus]

It's only a matter of time before we are forced to wear single-use scrubs made out of that terrible surgical gown material. Prepare yourselves for those Infection Control losers to force this upon us with zero real-world data. Some idiotic company will jump at the opportunity to mass produce it and claim that it decreases perioperative infection risk based on some garbage in vitro data.

Wait til they start swabbing our OR shoes…..

 

[pgg]

Sad. Good luck putting an eye out with that.

 

[DocVapor]

We had them when I was a kid.

View attachment 370006


Now they look like this. They’re no longer darts at all 🙁

View attachment 370007

They could still be darts if you just tried harder.

 

[psychbender]

Sad. Good luck putting an eye out with that.

Challenge accepted.

 

[drmwvr]

I miss lawn darts, too, they were good for keeping the kids off my lawn.

It's where the idea for IO access came from....

 

[Ronin786]

There is no optimal flow rate to wake up on gas, not after your FI sevo % is 0. At that point its all gradient between blood and alveoli. CO2 level matters most at that point, and your ability to increase MV to breathe off that brain sevo without hyperventilating to the point of eliminating respiratory drive or inducing cerebral vasoconstriction

Sure. This was more of a response to the comment about putting the flow up to 15L on wake-up. At some point you need some amount of flow to prevent rebreathing of exhaled gas. I imagine it's less than 15L but more than 0.5L.

 

[abolt18]

Sure. This was more of a response to the comment about putting the flow up to 15L on wake-up. At some point you need some amount of flow to prevent rebreathing of exhaled gas. I imagine it's less than 15L but more than 0.5L.

I just make my flows above the patient's minute ventilation. Boom. No rebreathing.

 

[MirrorTodd]

Sure. This was more of a response to the comment about putting the flow up to 15L on wake-up. At some point you need some amount of flow to prevent rebreathing of exhaled gas. I imagine it's less than 15L but more than 0.5L.

You can prevent rebreathing of gas by disconnecting them from the vent and letting them breath room air. Little sevo high never hurt any OR staff right?

 

[periopdoc]

There is evidence to support that the real issue is bottom line: finance > carbon footprint.
The anesthesia departments in all the eight Providence Health hospitals in Oregon, switched to the use of sevoflurane from desflurane. They now save about $500,000 a year.
However Providence healthcare system’s CEO Lisa Vance passionately stated that the hospital system didn't change its use of the gas because of the money. It changed because the World Health Organization assertion that climate change is the No. 1 public health issue.
Yeah right!

https://www.cnn.com/2019/05/31/health/climate-change-anesthesia-partner/index.html

They are saving $500,000 per year ON DESFLURANE. How much are they losing on additional time in the OR and PACU due to slower wakeups and discharges? Nobody wants to calculate that, significantly higher, cost.

 

[rowsdower88]

slower wakeups and discharges

ngl, bit of a self report here. Just get better at waking people up with sevo man. Turn the gas down earlier, mess around with your flows. Get good.

 

[anaesthetic]

ngl, bit of a self report here. Just get better at waking people up with sevo man. Turn the gas down earlier, mess around with your flows. Get good.

Seconded. I haven’t used des for a few years despite its availability in our ORs. I don’t really miss it and have had zero complaints about speed. I like sevo for its bronchodilatory properties, has less tachycardia/hypertension than des, blows off in about the same time given a long enough case. Works better for our ASA 3.5-4 population who all smoke and have CAD/PAD.

 

[T-burglar]

The first realization in your quest to get good with sevo is nobody on the planet needs a full mac of gas, and most people don’t even need a half Mac if they’re tubed and paralyzed

 

[pgg]

ngl, bit of a self report here. Just get better at waking people up with sevo man. Turn the gas down earlier, mess around with your flows. Get good.

JFC, talk about "self reporting" and missing the point ...

It's not the time until the patient's wakeup.

Anyone can wake up anyone at any time with any gas. That shouldn't be in question, even though you snidely imply periopdoc of all people[1] needs to just "get good" ...

It's the time between wakeup and the patient's discharge.

Often it doesn't matter, because PACU nurses have X amount of charting and Y amount of chatting and Z amount of [other superfluous task], so discharge is frequently not dependent on the patient's wakefulness anyway.


I will say this - if you're as "good" with desflurane as you are with sevoflurane, much of the time you'd be able to roll the gurney through PACU and straight to their car in the parking lot, if not for the paperwork. The transition from awake enough to extubate and awake enough to discharge is that fast.

But I'm sure you knew that, because you "got good", whatever that means.


[1] easily in the top 10 of the smartest people who've ever posted on this forum

 

[abolt18]

Iso for life!

 

[deleted875186]

JFC, talk about "self reporting" and missing the point ...

It's not the time until the patient's wakeup.

Anyone can wake up anyone at any time with any gas. That shouldn't be in question, even though you snidely imply periopdoc of all people[1] needs to just "get good" ...

It's the time between wakeup and the patient's discharge.

Often it doesn't matter, because PACU nurses have X amount of charting and Y amount of chatting and Z amount of [other superfluous task], so discharge is frequently not dependent on the patient's wakefulness anyway.


I will say this - if you're as "good" with desflurane as you are with sevoflurane, much of the time you'd be able to roll the gurney through PACU and straight to their car in the parking lot, if not for the paperwork. The transition from awake enough to extubate and awake enough to discharge is that fast.

But I'm sure you knew that, because you "got good", whatever that means.


[1] easily in the top 10 of the smartest people who've ever posted on this forum

Any data to support des produces less PACU time than sevo? If I remember correctly there is a demonstrative difference with iso versus sevo.

Also, for a short case why not all TIVA Esther than des, I am sure PACU times would be similarly short.

 

[rowsdower88]

JFC, talk about "self reporting" and missing the point ...

It's not the time until the patient's wakeup.

Anyone can wake up anyone at any time with any gas. That shouldn't be in question, even though you snidely imply periopdoc of all people[1] needs to just "get good" ...

It's the time between wakeup and the patient's discharge.

Often it doesn't matter, because PACU nurses have X amount of charting and Y amount of chatting and Z amount of [other superfluous task], so discharge is frequently not dependent on the patient's wakefulness anyway.


I will say this - if you're as "good" with desflurane as you are with sevoflurane, much of the time you'd be able to roll the gurney through PACU and straight to their car in the parking lot, if not for the paperwork. The transition from awake enough to extubate and awake enough to discharge is that fast.

But I'm sure you knew that, because you "got good", whatever that means.


[1] easily in the top 10 of the smartest people who've ever posted on this forum

Oh, he's smart? Word. Just needs to time his wake ups better then I guess. He used the phrase "additional time in the OR" mate.

 

[periopdoc]

Get Good. LOF'nL. It's cool though, I don't have the same reputation here as I used to. Happens when one doesn't contribute for a while.

I'm a systems guy now, and this is a systems argument. How many anesthesiologists, CRNAs, and AAs are in the eight hospital system? OAG alone has over 250. What percent of those physicians and mid-levels are likely to "get good?" What percent are even motivated to try? Even the best 10% will have some issues with unpredictable surgeons, and morbidly obese patients.

$500k saved over that system is peanuts, and is likely more than offset by the additional OR time.

While choice of anesthesia technique does not appreciably reduce time to PACU discharge (production systems aside), I do believe that there clearly is increased PACU safety, and reduced PACU workload, when choosing Desflurane for our super morbidly obese patients.

 

[rowsdower88]

Get Good. LOF'nL. It's cool though, I don't have the same reputation here as I used to. Happens when one doesn't contribute for a while.

I'm a systems guy now, and this is a systems argument. How many anesthesiologists, CRNAs, and AAs are in the eight hospital system? OAG alone has over 250. What percent of those physicians and mid-levels are likely to "get good?" What percent are even motivated to try? Even the best 10% will have some issues with unpredictable surgeons, and morbidly obese patients.

$500k saved over that system is peanuts, and is likely more than offset by the additional OR time.

While choice of anesthesia technique does not appreciably reduce time to PACU discharge (production systems aside), I do believe that there clearly is increased PACU safety, and reduced PACU workload, when choosing Desflurane for our super morbidly obese patients.

It's not THAT hard to get a good sevo wake up even in the morbidly obese. Residents and CRNAs included. If we're just going to assume docs and providers are going to not face the incentive to "get good" with sevo to be equivalent to des... I would say that's a broader systems issue that doesn't necessarily require re-adopting des to fix.

You've changed your claim from des reducing OR time/PACU discharge time to des improving PACU safety and reducing PACU workload in super morbidly obese patients.

That's fine, I just don't think there is strong evidence for this either. I think there's some reduction in post op complications w/OLV cases associated with des if I remember right? If you've seen or done some research on des being demonstrably better that would be interesting to see.

Marginally quicker to follow commands does not mean improved PACU safety to the tune of $500k+environmental concerns, but maybe you're aware of research I'm not. -shrug-

 

[T-burglar]

I still think you need to get good