A comprehensive review published in the British Journal of Anaesthesia outlines practical approaches to reduce the environmental impact of anaesthesia and surgery throughout the entire perioperative journey, with benefits for both patient care and planetary health.
Perioperative services are among the most resource-intensive healthcare activities, contributing significantly to healthcare’s substantial environmental footprint. A new narrative review published in the British Journal of Anaesthesia provides a roadmap for reducing pollution and waste across the entire continuum of surgical care, from preoperative assessment through to postoperative recovery.
The review, authored by experts from the University of British Columbia, the National University of Singapore, and Yale School of Medicine, emphasises that healthcare providers have both the responsibility and opportunity to mitigate healthcare’s environmental impact while simultaneously improving quality of care.
The paradox of healthcare pollution
Healthcare is responsible for 4.6% of global greenhouse gas emissions and a similar proportion of air pollutants, creating what the authors describe as a paradox: an industry dedicated to healing that simultaneously contributes to environmental degradation and associated health harms. Perioperative services are particularly resource-intensive, with operating theatres being among the most energy-demanding hospital areas.
Whilst acknowledging this challenge, the review offers hope: “Opportunities exist to mitigate pollution throughout the entire continuum of perioperative care,” the authors write, “including those that occur upstream of the operating room in the process of patient selection and optimisation, delivery of anaesthesia and surgery, and the postoperative recovery period.”
Preventing surgical illness
The authors emphasise that the most effective environmental strategy is preventing the need for surgery altogether. They highlight the role healthcare providers can play in both primary prevention and advocacy for systemic changes that address the root causes of surgical conditions.
“Many surgical conditions are avoidable through primary or secondary prevention strategies or good chronic disease management,” the review states. Examples include healthcare professionals advocating for legislation and policies that minimise surgical illness, such as seatbelt laws, gun control measures, cycling infrastructure, and screening for intimate partner violence.
Appropriate care and shared decision-making
The review emphasises that high-quality surgical decision-making encompasses selecting the right operation, for the right patient, by the right provider, in the right place. This approach not only improves outcomes but also reduces unnecessary resource utilisation.
Shared decision-making is highlighted as particularly important. When patients are fully informed and engaged in decisions about their care, studies show that approximately 20% of elective procedures would be unwanted under circumstances of optimised decision-making. The authors note that decision support tools not only help avoid unwanted procedures and their associated pollution but also “increase knowledge scores, lead to more realistic perceptions of the benefits and harms of surgical treatment, reduce decisional conflict, reduce uncertainty, and generate greater agreement between patient values and decisional outcomes.”
Environmentally conscious anaesthesia choices
The review provides detailed guidance on reducing the environmental impact of anaesthetic practices, noting that inhaled anaesthetic gases are potent greenhouse gases with global warming potentials ranging from 144 to 2540 times that of carbon dioxide.
Desflurane and nitrous oxide are identified as having climate impacts “one to two orders of magnitude greater than that of isoflurane and sevoflurane in clinically relevant doses, suggesting that the former should be avoided when clinically safe.” Some health systems have already eliminated desflurane from pharmacy formularies given its outsized environmental footprint and the availability of alternatives.
The authors also advocate for low-flow anaesthesia techniques, which can significantly reduce anaesthetic gas waste, and suggest prioritising intravenous and regional anaesthesia approaches when clinically appropriate. They note that comprehensive environmental impact assessments demonstrate that inhaled anaesthesia emissions are significantly greater than those associated with intravenous and local anaesthesia.
Circular economy principles for perioperative supplies
Medical devices, particularly single-use consumables, represent another significant source of perioperative emissions. The review advocates for applying circular economy principles to address this issue, including reduction, reuse, repair, reprocessing, and recycling.
“The suite of strategies for maximising material resource value in a circular economy is arranged in a hierarchy, with reduction being the kingpin sustainability strategy,” the authors explain. They recommend opening only immediately required items during procedures and keeping “just in case” materials unopened but accessible.
The review cites evidence that reusable products are generally environmentally preferable to disposables. A systematic review of perioperative product life cycle assessments found that reusable products were environmentally preferable across 28 studies encompassing rigid laryngoscopes, laparotomy pads, laryngeal mask airways, surgical linens, and surgical scissors.
The authors also advocate for modular, repairable medical devices and note the potential of hybrid instruments that combine reusable handles with disposable components, which can reduce emissions by approximately 75% compared with fully single-use equivalents.
Operating theatre facility emissions
The review addresses facility-level environmental impacts, noting that the majority (90-99%) of operating theatre energy consumption relates to heating, ventilation, and air conditioning. The authors suggest that while individual clinicians may have limited influence on dayto-day energy consumption, teams can advocate for design modifications, renewable energy sources, and improved efficiency at institutional levels.
They also highlight the issue of nitrous oxide leakage through central piping systems. Studies from hospitals on three continents discovered that “the vast majority of nitrous oxide (75-95%) leaks out through central piping at the point of tank manifold connections before use, and through tank remnant discharge (~10%) before return to vendor.” The authors recommend capping outlets of existing piped systems and avoiding new installations.
Postoperative strategies for reduced environmental impact
After surgery, opportunities exist to mitigate environmental impacts by shifting care to less resource-intensive settings, adopting a stewardship approach to inpatient care, and strengthening coordination across the healthcare system.
The authors note the trend toward same-day discharge for procedures previously requiring inpatient stays, including laparoscopic appendectomies, robotic prostatectomies, mastectomies with reconstruction, and joint arthroplasties. They emphasise the role of Enhanced Recovery After Surgery (ERAS) programmes in facilitating early discharge and the potential of home hospital services as “the next evolution of ERAS in delivering patient-centred, value-based, and environmentally sustainable care.”
The review also addresses opportunities to reduce unnecessary waste of medical supplies on postoperative wards and in ICUs, and to minimise unnecessary laboratory investigations and diagnostic imaging. A study of acute care general surgery inpatients revealed that 76% underwent unnecessary blood tests during their hospital stay.
Mobile applications and virtual care platforms can also reduce the environmental impact of postoperative follow-up by decreasing in-person visits, emergency department presentations, and readmissions, the authors note.
A holistic approach to sustainable perioperative care
The review concludes by emphasising the need for a holistic approach that considers the entire continuum of care rather than focusing exclusively on operating theatre practices.
“Surgical and anaesthesia teams are positioned to modify considerable swaths of healthcare emissions,” the authors write.
“Within this holistic approach, clinicians can engage in prevention of surgical illness, ensure appropriate clinical decisions, and be stewards of healthcare resources. Innovation and collaboration are required to redesign clinical care pathways and processes, optimise logistical systems, and address facility emissions.”
Perhaps most importantly, the authors highlight that these environmental improvements also enhance care quality: “The results will extend beyond the reduction of public health damages from healthcare pollution to the provision of higher-value, higher-quality, patient-centred care.”
This comprehensive review provides a practical framework for perioperative teams seeking to reduce their environmental footprint while improving patient outcomes, demonstrating that sustainability and clinical excellence can be synergistic rather than competing priorities.
Reference:
MacNeill, A. J., Rizan, C., & Sherman, J. D. (2024). Improving sustainability and mitigating the environmental impact of anaesthesia and surgery along the perioperative journey: a narrative review. British Journal of Anaesthesia, 133(6), 1397-1409.
doi: https://doi.org/10.1016/j.bja.2024.05.042
