A DGAI and BDA Position Paper with Specific Recom-mendations
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Guidelines and Recommendations Special Articles 329
M. Schuster1 · H. Richter1 · S. Pecher2 · S. Koch3 · M. Coburn4 Ecological Sustainability
Compiled by the DGAI/BDA Commission on Sustainability in Anaesthesiology§
in Anaesthesiology and
Intensive Care Medicine
A DGAI and BDA Position
Paper with Specific Recom-
mendations*
Citation: Schuster M, Richter H, Pecher S, Koch S, Coburn M: Ecological Sustainability in Anaesthesio
logy and Intensive Care Medicine. A DGAI and BDA Position Paper with Specific Recommendations*.
Anästh Intensivmed 2020;61:329–338. DOI: 10.19224/ai2020.329
1 Klinik für Anästhesiologie, Intensiv
Summary be avoided in both the operating theatre
medizin, Notfallmedizin und Schmerz
and intensive care unit without upsetting
therapie, Kliniken Landkreis Karlsruhe, This position paper with specific recom
Fürst-Stirum-Klinik Bruchsal, Rechberg existing processes.
mendations was commissioned by the
klinik Bretten, Akademische Lehrkran
kenhäuser der Universität Heidelberg DGAI and BDA executive committees in In addition to these measures directly
2 Klinik für Anästhesie und Intensiv March 2020 and was compiled by the related to the field of anaesthesiology,
medizin, Diakonie Klinikum Stuttgart joint “Commission on Sustainability in this position paper addresses further
3 CharitéCentrum für Anästhesiologie und Anaesthesiology”. areas of concern indirectly associated
Intensivmedizin CC 7, Campus Charité with the everyday professional role
Mitte & Campus Virchow – Klinikum, With the impending climate disaster in
Charité Universitätsmedizin Berlin of the anaesthesiologist. As such, the
mind, the aim of this position paper is to
4 Klinik für Anästhesiologie, Uniklinik paper alludes to the significance of
delineate with which specific measures
RWTH Aachen sustainable mobility with regard to every-
anaesthesiologists can contribute to a
day commutes, patient transfers, and
§ Members of the Commission on consistent and sustained reduction in
Sustainability in Anaesthesiology
conferences. Improved energy manage
CO2 emissions and minimise the nega
(in alphabetical order): ment may commence in the operating
tive ecological implications associated
Prof. Dr. Thomas Bein, Prof. Dr. Mark theatre and intensive care unit but must
Coburn1, Prof. Dr. Herwig Gerlach, with the fields of anaesthesiology and
ultimately encompass the whole hospital
Priv.-Doz. Dr. Susanne Koch2, Dr. Ana intensive care medicine. The paper is as a significant source of CO2 emissions.
Kowark, Dr. Ferdinand Lehmann, divided into six sections and, on the
Dr. Sabine Pecher, Dr. Hannah Richter, Numerous measures can already be im
Prof. Dr. Rolf Rossaint, Dr. Charlotte basis of published literature, presents plemented today, and appropriate steps
Samwer, Priv.-Doz. Dr. Christian Schulz, the currently available evidence on should be taken at a local level. Last but
Prof. Dr. Martin Schuster3 how anaesthesiologists can incorporate
(1: Chair DGAI, 2: Instigator, 3: Chair
not least, the importance of research and
sustainability aspects in their professional teaching is emphasized as a key factor in
BDA)
sphere of influence. Special attention successfully facing the challenge of eco
is directed towards the environmental logical sustainability in anaesthesiology
effects of drugs used in anaesthesiology and intensive care medicine.
and intensive care and their impact on
climate change. In that regard, the direct
and potent greenhouse gas effects of
Preface
* Resolution of the Execuitve Commitee of volatile anaesthetics are emphasized. In In March 2020 the Professional Asso
the DGAI, dated 16.03.2020/of the BDA, consequence, specific recommendations ciation of German Anaesthesiologists
dated 24.04.2020.
are made on reducing the damaging (BDA) and the German Society of Anaes
Interest to disclose effects of volatile anaesthetics on the cli thesiology and Intensive Care Medicine
The authors have no financial or other com
peting interest to disclose. This recommen mate. With regard to consumables, the (DGAI) executive committees assigned
dation was unfunded. increasing use of disposable single-use the joint “Commission on Sustaina-
items is the subject of critical analysis, bility in Anaesthesiology” the task of
Keywords and the need to incorporate the carbon compiling a position paper with specific
Guidelines – Anesthesio footprint in the selection of products is recommendations. Both executive com
logy – Sustainability – Climate stressed. As waste has significant direct mittees approved the publication of this
change – CO2 emission and indirect ecological effects, the 5R position paper in its current form during
concept is used to show how waste can their sessions on the 16th March 2020330 Special Articles Guidelines and Recommendations
(DGAI) and 24th April 2020 (BDA). With plemented immediately at a local level the grave”, including the following po
the publication of this position paper, by anaesthesiologists. However, a good sitions: 1) extraction of raw materials, 2)
both BDA and DGAI expressly commit number of measures, including many processing and manufacturing, 3) trans
themselves to the goal of carbon neutral, with significant leverage, are arduous to port and packaging, 4) use, reutilisation
sustainable health care and will there implement at a local level alone. As and maintenance, 5) recycling and 6)
fore, together with other actors in the such, achieving carbon neutrality in
disposal. Water use and release of toxins
health care sector, use their influence on anaesthesiology and intensive care
are additional important factors besides
politics and on the industry to actively medicine over the next three decades
will require wide-ranging technological CO2 release [15].
further the necessary transformational
process. innovation and significant investment in
energy efficient refurbishment and in the A. Drugs
Introduction infrastructure of individual hospitals.
Major issues such as assuring generation R1: G
eneral anaesthesia using volatile
The 2018 Intergovernmental Panel on of energy from renewable sources or re anaesthetics and/or nitrous
Climate Change report was climate alising sustainable transport are tasks for oxide should be maintained in
scientist’s warning not to exceed the society as a whole and require political such a fashion that the smallest
1.5 °C limit of global warming. Only a implementation. As a professional and a quantity of anaesthetic possible is
rapid and substantial worldwide reduc scientific body, we will use our influence discharged into the environment.
tion in CO2 emissions over the next few to demand these changes. This requires consistent use of
years can avert runaway effects such In the past, close coordination between minimal-flow anaesthesia.
as the melting of Antarctic ice masses practising physicians and the industry – R2: Use of desflurane should be
or thawing of permafrost soils, which especially in the fields of anaesthesio reserved for cases in which it
threaten to make the effects of climate logy and intensive care medicine – have appears mandated on medical
change uncontrollable [1]. led to a variety of technical innovations grounds. Of those volatile
As physicians we are under a special ob which have made patient care safer and anaesthetics commonly used,
ligation. Over the next decades, climate opened new horizons of clinical possibi sevoflurane is the least potent
change will lead to a change for the lity for the good of patients. Seen in the greenhouse gas.
worse in health care for a great number light of the climate crisis, this close coor R3: U se of nitrous oxide should be
of people across the planet and pose dination should be further strengthened, avoided unless its use appears
grave challenges to health care systems aiming to promote the transformation to mandated on medical grounds.
in almost every country [2]. At the same ecologically sustainable patient care.
R4: The development, trialling and
time, the health care system is itself
use of scavenging and recycling
responsible for significant emissions of Glossary systems for volatile anaesthetics
greenhouse gases, owning 4.4% of glo
should be expedited.
bal greenhouse gas emissions in 2014 CO2e: CO2 equivalents
[3]. In response, numerous professional Emissions of greenhouse gases other R5: In contrast to inhalational
medical bodies have issued their own than CO2 can be converted to CO 2 anaesthesia techniques, total
statements alluding to the urgent need to equivalents. This entails calculating the intravenous and regional anaes
reduce CO2 emissions across the health quantity of CO2 which would exhibit thesia do not intrinsically cause
care sector [4–8]. Physicians are called the same effect in the atmosphere as the direct greenhouse gas emissions.
upon to adjust their consumer behaviour emission in question by using the mass Use of these techniques to avoid
and – in the spirit of divestment cam of that emission and its Global Warming greenhouse gas emissions is judi
paigns – their investment decisions to Potential [13]. cious when they are appropriate
prioritise climate protection [9]. from a medical standpoint.
GWP: Global Warming Potential R6: P harmaceutical waste should be
As high-tech, resource hungry fields,
The Global Warming Potential describes avoided on both economic and
anaesthesiology and intensive care me-
the substance-specific greenhouse effect ecological grounds.
dicine are involved in a significant por-
compared to CO2 over a specified length R7: Pharmaceutical waste must be
tion of CO2 emissions across the health
of time. In general, the interval chosen is disposed of in an appropriate fa
care sector [10–12]. In the past few years,
100 years (GWP100) [14]. shion and must not be introduced
numerous professional anaesthesiologic
bodies have published recommenda LCA: Life-Cycle Assessment into the sewage system. As a rule,
tions for anaesthetists on how they can it is appropriate to dispose of
A life-cycle assessment can be used to
contribute to reducing CO2 emissions such waste resulting from anaes-
determine the actual carbon footprint
[5–8]. thesia and intensive care by
of consumables, drugs and medical
incineration together with other
The following recommendations focus procedures. This involves analysing the
residual waste.
on those measures which can be im ecological footprint from “the cradle toGuidelines and Recommendations Special Articles 331
Volatile anaesthetics (VA) and nitrous flurane significantly worsens the carbon anaesthesia cases per annum, the annual
oxide exhibit potent greenhouse effects footprint of the volatile agent [21,25]. carbon footprint is equivalent to that of
when released into the atmosphere. Both During the maintenance of general up to 200 average citizens in Germany.
sevoflurane and desflurane are hydro anaesthesia, doubling the flow rate will Avoiding desflurane could obviate 67%
fluorocarbons (HFCs), whilst isoflurane, double the emissions from VA [19,21, of emissions attributable to an anaesthe
enflurane and halothane are chlorofluo 24–26]. As such, utilising minimal flow sia department [28].
rocarbons (CFCs) and exhibit additional for maintenance of anaesthesia is to be Various technical solutions for capturing
ozone-depleting effects. The same is recommended in any case. A higher fresh rather than emitting VAs and nitrous
true for nitrous oxide (N2O) [11,16–19]. gas flow should be reserved for situations oxide are currently in development or
VAs show a significantly larger negative in which the depth of anaesthesia needs almost ready for market. Using such
impact on the climate than CO2. That to be changed rapidly. Also when initia technologies, VAs can be destroyed by
impact is recorded as the comparative ting emergence, high flows should only thermal, catalytic or photochemical
greenhouse effect in relation to CO2 be used once the vapor has been shut off means, or processed for reuse [24,25,
(Global Warming Potential, GWP). To [25]. 29–31]. Today, systems which capture
ensure the total atmospheric lifetime of
Volatile agents used for general anaes nitrous oxide used in obstetrics, destro
CO2 is taken into account [22], an obser
thesia are currently discharged into the ying it by means of a thermal catalytic
vation period of 100 years (GWP100) is
environment in their entirety, causing process, are already in practical use [24,
typically selected [17,19–21].
a significant greenhouse effect. World 30]. The technical means for reacquiring
VAs exhibit their principal greenhouse wide emissions from VA totalled 3 m tons sevoflurane from specially designed ac
effect during their atmospheric lifetime, CO2 equivalent in 2014, not including tivated carbon filters, making it available
instead of uniformly throughout the the effect ascribable to nitrous oxide. for reuse on patients after distillation and
100-year timeframe. Applying GWP100 80% of these emissions were attributable sterilisation, already exist. As such, at
will lead to the negative impact of VAs to desflurane alone [11]. In an average some point in the future, VAs could re
on the climate being underestimated for anaesthesia department, use of VAs will present a test case for licensing recycled
the next 10 – 30 years. As such, a GWP be responsible for between 3.5 and drugs. The process of capturing VAs in
observation period of 20 years can be 118.3 kg CO2 equivalent per anaes carbon filters – as is commonly practised
helpful in demonstrating the greenhouse thesia case [27,28]. Assuming 10,000 on intensive care units in Germany – is
effect which will set in within the rele
vant social and political time remaining
to battle global warming (Tab. 1) [19]. Table 1
Global Warming Potentials and atmospheric lifetimes of inhaled anaesthetics
In addition to the greenhouse effect per
(Sulbaek Anderson et al. 2012 [17]).
quantity of substance used, the actual
quantity of the VA required to reach GWP100 GWP20 Atmospheric lifetime (in years)
an adequate minimal alveolar con CO2 1 1 30 – 95 (23)
centration (MAC) needs to be factored N2 O 298 289 114
into the equation. During steady state Sevoflurane 130 440 1.1
and assuming identical flow rates, use Desflurane 2,540 6,810 14
of desflurane for general anaesthesia Isoflurane 510 1,800 3.2
emits approx. 50 times as much CO2 Halothane 50 190 1.0
equivalent as when sevoflurane is used. Enflurane 680 2,370 4.3
This difference becomes all the more
apparent when the emissions caused
by inhalational agents for maintenance Table 2
of anaesthesia during steady state are Emissions from 6 hours of inhalational anaesthesia during steady state, converted to kilometres
converted and expressed as kilometres travelled by car (based on Sherman and Feldman 2017 [24]).
travelled by car [17,21,24]. Emissions
Minimal-Flow Low-Flow High-Flow- High-Flow-
from 6 hours of inhalational anaesthe Anaesthesia Anaesthesia Anaesthesia Anaesthesia
sia – the equivalent of one working day 0.5 l/min 1 l/min 2 l/min 5 l/min
– are set out in this fashion in Table 2, Sevoflurane 2,2% 19.3 km 38.6 km 77.2 km 183.5 km
based on GWP100s. The results assume Desflurane 6,7% 898.0 km 1,825.0 km 3,650.0 km 9,067.0 km
general anaesthesia during steady state, Isoflurane 1,2% 38.6 km 67.6 km 144.8 km 366.9 km
and so do not include the induction and
Nitrous oxide (N2O) 280.0 km 550.4 km 1,081.5 km 2,723.0 km
emergence phases. Using nitrous oxide 60%
as a carrier gas for sevoflurane or iso332 Special Articles Guidelines and Recommendations
insufficient on its own, however, as (based on the earlier Persistence, Bioac-
those VAs are released from the filter into cumulation and Toxicity (PBT) Index) R2: Use of reusable fabrics such as
surgical gowns, caps and drapes
the atmosphere after the filter has been was designed to grade the risk phar
should be considered.
disposed of [24,25]. maceuticals pose to the environment.
The score should be consulted whenever R3: Single-use items made of metal
With regard to CO2 emissions attribu
possible when selecting drugs, so as to have a particularly poor carbon
table to production, distribution and
ensure the smallest possible impact on footprint and replacing them
disposal of almost all other drugs com
the environment. Unfortunately, a signi with reusable products should be
monly used in anaesthetics, precise data
ficant portion of anaesthesiologic drugs assessed.
are lacking such that it is impossible to
make detailed statements with regard to have yet to be graded [38]. R4: Manufacturers should be called
specific drugs. Waste drugs can be introduced into the upon to provide full life-cycle
environment when they are discarded assessments of the carbon
As methods such as TIVA or regional
improperly via the sewage system – footprints of medical devices.
anaesthesia do not generate direct emi-
ssions of greenhouse gases, the emissi propofol remnants have been found in
hospital wastewater [39]. Propofol has a Single-use items are ubiquitous in
ons associated with those methods are
Hazard Score of 4 (on a scale of 0 to anaesthesia and intensive care and are
significantly lower than from inhalatio
the maximum of 9) and is neither biode increasingly displacing reusable pro
nal anaesthesia [24,25,32–34].
gradable in water nor under anaerobic ducts. The main influencing factors in
When considerable drug quantities are the decision process between single-use
conditions [25,33,36,40].
discarded, it is expedient to consider and reusable products are quoted as
using smaller vials [25]; up to 20% of All departments must establish pro
concern for hygiene, convenience, and
propofol waste, for example, is conside cedures for correct disposal of pharma
cost. Environmental factors have traditi
red to be avoidable [35]. In some situa ceutical waste and train staff in the
onally played a lesser role [15].
tions, switching from 50 or 100 ml vials implementation.
Life-cycle assessments are available for
of propofol to 20 ml vials can reduce Disposal of left-over pharmaceuticals
an ever-increasing number of medical
the quantity of drug wasted by more “down the drain”, that is via the sewage
than 90% [36]. This can, in addition, products. A review of 6 LCAs comparing
system, is unacceptable from an eco
be economically viable; wasted drugs washable, reusable surgical textiles (sur
logical point of view. As a rule, drugs
make up for approximately one quarter gical gowns and drapes) with single-use
must be disposed of by incineration.
of the total cost of drugs [35]. This calls items showed that the reusable textiles
The requisite temperatures vary [25].
for a comprehensive review taking other featured a 30–50% smaller carbon foot-
Propofol remnants aren’t destroyed until
waste (see below) into account. Drugs print. Single-use items require 200–
heated to over 1000 °C for at least 2
kept drawn up ready for use not only 300% more energy, 250–330% more
seconds [36], whilst most other drugs
cause significant costs when they ulti- water and produce 750% more waste
used in anaesthesia can be incinerated
mately remain unused but also bear a than reusable items, even when both
at lower temperatures [25]. The disposal
relevant negative ecological impact the water and energy requirements for
of pharmaceuticals should be organised
[36]. 50% of emergency drugs drawn washing and sterilising reusable items
in a pragmatic, error-resistant way: it is
up end up being discarded unused [37]. are taken into account [41].
recommended that left-over drugs should
This applies to drugs which have to be be emptied into paper towels and placed A comparison between single-use and
available for use immediately and with together with resiudal waste for incine reusable plastic anaesthetic drug trays
out delay (such as those for anaesthesia ration. Balanced electrolyte solutions showed the reusable item to be not only
for emergency caesarean section) and to without the addition of any drugs can be more ecological but also more economi
those which require dilution, which may emptied down the drain. cal [42]. For reusable laryngeal masks, a
lead to delay and dosing errors (such as significantly smaller negative ecological
bolus injections of catecholamines). It impact was shown across all examined
is appropriate to consider having these B. Consumables categories of ecological sustainability
drugs prefilled into syringes under clean [43]. Utilising single-use laryngoscopes
and sanitary conditions by the pharmacy R1: T
he increasing use of single-use increases the CO2 emissions by 16 to
or to purchase prefilled syringes, which disposable consumables in place 25 times when compared with reusable
typically have a longer shelf life and can of reusable items should be the stainless-steel devices, especially when
therefore reduce waste [15]. subject of critical analysis. An both the laryngoscope blade and the
assessment should be undertaken handle are single-use items [44,45].
The Swedish Stockholm County Council
to determine in which cases
Drug Therapeutic Committee has deve Extracting metals from ore is extremely
reusable items could present an
loped an environmental classification energy intensive and leads to a very
alternative.
for pharmaceuticals. The Hazard Score large carbon footprint [27,46]. The Ger-Guidelines and Recommendations Special Articles 333
man Society of Hospital Hygiene (DGKH) patient blood management is at
notes that use of single-use metal inst waste – which could be dispo
the same time a sound ecological
ruments (laryngoscopes, scissors, needle sed of as standard waste or even
approach.
holders, forceps etc.) is of particular recycled – must not through
concern as, in addition to the associated thoughtlessness or laziness be Recycle:
significant use of resources, erroneous disposed of as dangerous waste. Approximately 60% of waste generated
introduction of such products into the in operating theatres can potentially be
Approximately 20–30% of waste ac-
sterilisation process poses a significant recycled. A lack of containers and inf
crued in hospitals is generated in the
risk of causing corrosion of other ins rastructure, lack of knowledge, laziness
operating theatre; 25% of this waste is
truments. They go on to point out that and lack of support have been listed
generated by anaesthesia, much of it is
a good number of single-use products as barriers to effective recycling in the
packaging [51,52]. Each theatre case
are manufactured under ethically pro theatre environment [61].
generates between 7.62 and 16.39 kg
blematic conditions in underdeveloped As the largest proportion of packaging
of waste [27]. The 5R concept (reduce,
countries [47]. As such, single-use metal waste is accrued when opening equip-
reuse, recycle, rethink and research)
items should be replaced by reusable
was coined to reduce the ever-increasing ment before the patient is brought to
products whenever possible. When this
quantity of waste produced [50]. theatre, contamination of that waste is
appears impossible, at the very least
practically inconceivable. One option to
effective recycling should be implemen
Reduce: ensure recycling waste remains uncon
ted. 1 m ton of recycled steel reduces
“Doing more with less” is the most ef- taminated is to seal the recycling bags as
CO2 emissions by approx. 80% when
fective method of sparing resources and soon as the patient is brought into the
compared to manufacturing with metal
producing less waste and is both an operating theatre [15]. Clearly structured
extracted from raw materials [48,49].
ecologically and an economically sus programmes facilitate the introduction
Using LCAs, the purchasing process can tainable concept [53]. There are a good of recycling programmes and increase
incorporate sound ecological factors. number of ways to conserve materials their efficiency. Recycling bins should
They can also show ways to implement without risking patient safety or quality be easily accessible and marked with
improvements. As energy sources and clear instructions as to what belongs in
along the way.
transport show significant heterogeni them. Involving local recycling compa
city, LCAs are specific to their respective The following measures can be named
as examples: nies and providing recurring training to
geographic region. Extrapolations should staff are essential [15].
be regarded with circumspection and • When used in conjunction with
manufacturers called upon to provide individual patient filters, ventilator Paper/cardboard, plastic, glass, batteries,
national LCAs [15,50]. circuits can be used for 7 days printer cartridges, electronic waste and
(except when soiled or used for metal can all be collected in the operat
contagious patients); several studies ing suite for recycling. Recycling can
C. Waste Management have shown that the number of also be cost effective [7]. Approximately
pathogens in the circuit was not 30% of theatre waste is made up of
R1: T
he 5R concept of waste increased after 7 days vs 24 hours plastics, including items manufactured
management (reduce, reuse, [54–57], leading the DGAI and from polypropylene and PET (single-use
recycle, rethink and research) DGKH to recommend this approach textiles, blue sterilisation packaging
should be implemented. [58]. Furthermore, the use of wash for medical and surgical instruments),
R2: An efficient recycling concept able, reusable ventilator circuits polyethylene (plastic tubing, beakers
should be shown to be operating should be considered [55]. and trays), polyurethane, PVC (suction
in all areas of operating theatre • Pre-packed sets, e.g. for insertion of and oxygen tubing), copolymers and
suites and intensive care units. central venous lines or for regional other compositions. Specific details are
R3: It is to be required that anaesthesia, and surgical trays often not declared appropriately or at
plastic packaging should, when often contain unnecessary plastic, all. Some types of plastic such as PVC
possible, be manufactured from gauze or other materials which are require special processing [51]. Recy
single-type plastic, which can disposed of unused. Upon request, cled plastic requires only 25% of the
undergo high-grade recycling. manufacturers can often slim down energy used to produce plastic from new
R4: Dangerous waste and the requi sets in a cost-effective manner [59]. materials [62]. When different types of
site special modes of disposal • The decision to order diagnostic plastic are mixed and recycled together,
cause very large emissions of tests should not be taken lightly – however, the resulting products are low-
CO2. Economical and ecological consider, for example, routine blood grade. This has led to calls for packaging
considerations dictate that other tests in healthy patients prior to to be produced from single-type plastic
minor elective surgery [60]. Effective and to be appropriately declared.334 Special Articles Guidelines and Recommendations
MacNeill et al. (2017) examined the all hospitals to be readily accessible
carbon footprint of three large hospitals good use. Airborn transport of
by public transport.
in Canada, the USA and England. They patients should be critically • For rural areas, ride-sharing plat
performed a detailed waste audit and evaluated. forms or centres can be developed
calculated the CO2 emissions associated R3: W
ith regard to participation in by the hospital for its employees.
with the various types of waste. Extrac conferences and work related to • Increased provision of work-from-
tion of raw materials, material-specific professional associations, public home options and video conferen
manufacturing, transport and disposal transport should be preferred. cing can reduce commutes.
alone (so without regard for additional Inland flights should be avoided Following the introduction of a mobility
CO2 emissions from product-specific whenever possible and only concept for commuter traffic, it is likely
manufacturing and product packaging) reimbursed as travel expenses in that the improved cycling and pedestrian
caused emissions of 3,254 kg CO2e/t well-reasoned exceptional cases; infrastructure and public transport offe
for plastic, 2,708 kg CO2e/t for steel and a carbon offset for the flight rings will also be used by patients.
895 kg CO2e/t for glass [13, 27]. should then be considered.
With regard to emergency services, a
Clear definitions of the various types R4: Streaming of conferences, video reorientation towards alternative, non-
of waste are required [63,64]. Waste conferencing and webinars fossil fuels (electromobility, hydrogen
accrued in hospitals is approx. 30% should be offered as a way to fuel cells) will be unavoidable. An
medical waste originating from medical reduce travel and its associated additional option is to critically recon
treatment and nursing, and approx. 60% carbon footprint. sider the use of systems associated with
household-like waste. About 10% of
significant fossil fuel requirements – such
waste is dangerous, with 3% infectious Reducing the carbon footprint of the
as air ambulances – when their use is not
and 7% toxic waste such as chemicals health care sector will require a focus
mandated on medical grounds.
or cytostatic drugs [65]. Infectious waste on mobility; specifically, the following
has to be destroyed in specialised inci three areas of transport require attention: The significant proportion of emergen
nerators which, amongst other things, health care employees’ commute to their cies involving emergency physicians but
requires additional transport [66,67]. At respective places of work (commuter not actually requiring intervention by the
1,833 kg CO2e/t, incineration of clinical traffic), emergency medical services and physician may suggest that telemedicine
and dangerous waste causes the most outpatient transport services (patient might reduce the need to despatch a
emissions from waste disposal [27]. If transport), and trips to conferences and physician-staffed, second vehicle to
it were appropriately sorted, stored and meetings (educational travel). Reducing emergencies. In general, implementa-
transported, the largest proportion of this the carbon footprint of those individual tion of telemedical consultations can
waste could, however, be disposed of areas requires that different approaches significantly reduce the carbon footprint:
together with municipal waste in ther be considered. when the drive to the surgery by car is
mal waste treatment plants; furthermore, just 3.5 km or more, teleconsultations
a large proportion could potentially be Commuter traffic in particular exhibits are the more climate friendly option
recycled [66,67]. As such, the various an average motor vehicle occupancy [69].
different types of waste need to be rate of 1.2. A study showed employees’
The number of large, international con-
sorted, keeping the proportion of clinical drive to the place of work to be respon
ferences with ever more participants
– dangerous waste as small as possible sible for 12–39% of the carbon footprint
travelling long distances is increasing.
[10]. of a department of anaesthesiology [28].
Conference participation causes signi-
Alternative mobility concepts, suited to
ficant CO2 emissions associated with
respective areas of residence, are requi-
D. Mobility journeying, especially over long di
red if these work-related CO2 emissions
stances as is required in some cases.
are to be curbed.
R1: A
s mobility related to commuting Participants’ journeys to a single interna
is responsible for a significant Possible targets for interventions in the tional conference were associated with
proportion of the carbon hospital include [68]: a 22,000 t carbon footprint, the equi
footprint of anaesthesiology • Furtherance of cycling infrastructure valent of the average annual carbon
departments, hospitals should together with a sufficient number of footprint of 2000 citizens in Germany
develop and promote alternative bicycle parking spaces on hospital [70]. Air travel is especially problematic
mobility concepts. grounds; calls for hospitals to be because of the associated emission of
connected to bikeways. 230 g CO2e per passenger kilometre,
R2: With regard to prehospital
• Charging infrastructure for e-mobility. by far the largest carbon footprint
emergency care and critical care
transport, electromobility and • Commuter ticket schemes can associated with travel. CO2 emissions
telemedicine should be put to help promote the switch to public per passenger kilometre for travel by
transport. Calls should be made for car and train – 147 g/km and 32 g/kmGuidelines and Recommendations Special Articles 335
respectively – are notably lower [71]. (1) In operating suites, heating, ventila by up to 50%. In addition to technical
Online streaming of conferences should tion and air conditioning are com- solutions, these concepts also integrate
be expanded. Streaming of conference monly operational throughout in approaches aimed at optimising user
lectures and interactive sessions should every operating theatre, despite the behaviour. Energy saving measures
be offered as attractive options, enabling fact that those theatres are often such as these can lead to long-term cost
conference participation without travel unoccupied at least 40% of the reductions [73,79]. Each and every hos
[70]. time. Setback operation in systems pital in Germany should identify their
in unused operating theatres (“night options for introducing such measures
setback” or “unoccupied setback”) – and implement them.
E. Energy management
with the exception of required emer The cogeneration (CHP) systems com
gency theatres – can facilitate energy monly used in hospitals in Germany
R1: Concepts aimed at reducing the
savings of up to 50 % [27,74]. exhibit a high primary energy yield by
considerable power consumption
(2) First steps with regard to heating and using the heat produced during electri
associated with heating,
air conditioning concern the tempe city generation for heating or cooling the
ventilation and air conditioning
in operating theatre suites and rature curve settings in central control building. High energy yields can, how
intensive care units should be systems. In operating theatres at high ever, only be achieved during optimum
implemented. These might, ambient temperature, every reduction operation of the CHP system. Because
for example, include setback of temperature by 1° C can reduce the they currently typically consume fossil
operation in systems in operating energy required for heating by 5–8% fuels, these systems should be viewed as
theatres unused outside of usual [73]. interim technologies [79,80]. The switch
working hours and optimising (3) When considering ventilation, it to a climate-friendly future necessitates
the temperature and ventilation can – as a first step – be viable to the use of renewable energy for electri
settings. review the system and adjust the air city and heating in hospitals. Using wind
change rate to suit the room tempe power, waterpower, photovoltaics, solar
R2: All departments should work
rature [73]. In some other European thermal energy, geothermal energy or
towards ensuring that their
countries, it is already customary to biogas allows for generation of energy
hospital evaluates its options with
completely deactivate ventilation with a reduced carbon footprint, and
regard to energy saving measures,
during unoccupied periods [75]. can be devised to be cost efficient [73,
energy efficient refurbishment
(4) In less frequented areas (storage or 79].
and use of renewable energy
sources, implementing those auxiliary rooms, toilets, etc.) it is ex
pedient to control the lighting using
options in a timely manner. F. Research and Teaching
motion detectors [76].
R3: A
switch to renewable energy (5) The halogen lamps traditionally
is essential so as to reduce the R1: The effects of climate change
used in operating suites should be
carbon footprint of hospitals in on intensive and emergency
exchanged for LEDs. This measure
Germany. care, and on hospital capacity
can reduce the energy consumed for
have not yet been adequately
Both operating theatre suites and inten lighting by 80% [73,77]. In addition,
researched. Appropriate research
sive care are resource-hungry and use LEDs radiate less heat, which redu projects should be developed
very large amounts of energy [10,72]. ces the energy required for cooling and supported.
The energy consumption in operating [10].
R2: Research pertaining to ecological
theatre suites is 3 – 6 times higher than Care for patients on intensive care units sustainability in anaesthesiology
that of the rest of the hospital. Of the caused the emission of 88–178 kg CO2e and intensive care medicine
power consumed in operating suites, per patient day, with energy consumption should include issues such
90–99% is used for heating, air condi (dominated by requirements for heating, as choice of drugs and the
tioning and ventilation [27]. ventilation and air conditioning), again optimised use of volatile anaes
These CO2 emissions can be reduced making up 76–87% of the carbon foot- thetics and medical devices.
by making savings in energy consumption print [72]. A switch to renewable energy
R3: C
onferences, seminars and voca
[27,72,73]. Energy-saving measures in is recommended together with optimi
tional education events relating
operating theatre suites can reduce sation of the energy efficiency of the
to anaesthesiology and intensive
energy consumption and with that the building to reduce the carbon footprint
care medicine should be plan
carbon footprint of the operating suite by [78]. Holistic energy management con-
ned, organised and implemented
50%, a measure which also significantly cepts can enable hospitals to reduce in an ecologically responsible
cuts costs [27]. The following practical their energy requirements by up to 30%, and carbon neutral fashion.
steps should be taken: reducing the associated CO2 emissions336 Special Articles Guidelines and Recommendations
As academic teachers we have a special 5. ASA: Environmental Sustainability.
R4: Sustainability in health care American Society of Anesthesiologists.
responsibility to pass our knowledge of
should be an integral part of https://www.asahq.org/about-asa/gover
aspects of sustainability in medical care
student, postgraduate and nance-and-committees/asa-committees/
on to the next generation of doctors. As committee-on-equipment-and-facilities/
speciality training. Each and
such it is essential that sustainability be environmental-sustainability
every department is called upon
integrated into undergraduate teaching (Accessed on: 03.03.2020)
to integrate appropriate content 6. RCoA: Environment and sustainability.
as a fundamental concept. Similar efforts
into their curricula and continu Royal College of Aneaesthetists;
are required to promote knowledge of
ing medical education. Available from: https://www.rcoa.
ecologically, socially and economically ac.uk/about-college/strategy-vision/
R5: C
limate-friendly behaviour sustainable patient care through conti environment-sustainability (Accessed on:
should be encouraged in all nuing medical education and professio 03.03.2020)
departmental staff by provision nal development. 7. ANZCA: Statement on Environmental
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lead to an additional 250,000 deaths
Anaesthesiology. http://newsletter.esahq.
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