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1 November 2022

Why anaesthesia needs to cut its carbon footprint

Dr Helgi Johannsson, sustainability lead at the Royal College of Anaesthetists, on reducing emissions in pain relief and surgery.

By Sarah Dawood

In 1846, the removal of a tumour from a patient’s neck in a Boston, Massachusetts hospital heralded a new era in modern medicine. When a dentist named William Morton gave ether vapour to one Gilbert Abbott, the surgeon Dr John Warren was able to operate without causing Abbott any apparent distress.

Such use of anaesthesia enabled doctors to leave behind medicine’s more grisly past. There are relatively few drawbacks to the option of pain-free procedures. But one problem now overshadows this mainstay of modern medicine: its carbon footprint. The emissions produced from being anaesthetised can be equivalent to those produced by a car journey from London to Leeds.

Environmental impact is not something we tend to associate with the healthcare sector, but the NHS is responsible for roughly 20 million tonnes of carbon dioxide emissions annually – 4 per cent of England’s total carbon footprint, according to the NHS’s 2020 net zero plan.

Anaesthetic and analgesic (pain relief) gases comprise 2 per cent of the NHS total. This might sound small but it is significant given the size of the NHS’s building and transport estate, which will encompass a large proportion of its footprint. The commonly used general anaesthetic gas desflurane is particularly harmful; it has 2,500 times more global warming potential than carbon dioxide. Using a single bottle is equivalent to burning 440 kilograms of coal.

Dr Helgi Johannsson, an NHS consultant anaesthetist at the Imperial College Healthcare NHS Trust, is the sustainability lead and vice-president at the Royal College of Anaesthetists. He has campaigned for the elimination of desflurane, and believes the NHS has an obligation to become more eco-friendly.

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“Healthcare has an absolutely enormous carbon footprint,” he tells Spotlight. “Just because others are worse, it doesn’t mean we shouldn’t improve. Just because our neighbour drives an SUV, it doesn’t give us the right to use a private jet.”

There are alternative anaesthetics available; the gas sevoflurane, for example, has a warming effect that is nearly 38 times lower than desflurane. Intravenous anaesthetics such as propofol, injected as liquids, carry an even smaller footprint (though it has other drawbacks, such as harming aquatic life if not properly disposed). There are clinical implications for phasing out desflurane – it is often used when operating on patients with obesity, for instance. But the NHS’s goal to reduce its anaesthetics carbon footprint by 40 per cent means that its use is dwindling.

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“I think we’ve almost won this one now,” says Johannsson. “I suspect we won’t get rid of anaesthetic gases completely, but I think we’ll get rid of desflurane. There’s no evidence for it being better, it’s just a case of adjusting your practice a little bit.”

However, the use of nitrous oxide – more commonly known as “gas and air” – for managing labour pain is a more complex moral conundrum. An hour’s use of the analgesic gas warms the atmosphere by an equivalent of roughly 16kg of carbon dioxide, the same as driving 106 kilometres. The process through which it is stored and delivered in hospitals – via pipes from a large central repository – also means that a lot of it is wasted. The Nitrous Oxide Project run by NHS Lothian in Scotland found that “wastage… is a far more significant problem than that of persistent clinical usage”. But unlike anaesthetics, there is no directly equivalent replacement.

Johannsson believes that nitrous oxide should remain available but major adjustments to labour care are needed. Rethinking the hospital’s infrastructure, such as replacing the wasteful central pipeline system and installing technology that could capture and recycle exhaled nitrous oxide, would be a good start.

He is also calling for a national improvement plan on NHS labour wards for access to pain relief. Equipment such as transcutaneous electrical nerve stimulation (TENS) machines are currently not available on the NHS, while staffing shortages mean that anaesthetists are often delayed in delivering spinal epidurals.

“Labour is a very, very painful thing,” Johannsson says. “We need good access to anaesthesia services, rather than the patient having to wait in absolute agony for an hour because the only available anaesthetist is in the operating theatre.” Additionally, more holistic changes, such as training for midwives in aromatherapy and hypnotherapy treatment, as well as better patient preparation in pain management, would help to create a less stressful environment. “We need to consider labour pain in a much more forward-thinking way,” he says.

Earlier intervention and a focus on prevention could result in carbon savings across the board, Johannsson believes. “Efficient and equitable medicine is actually more eco-friendly medicine,” he says. “Most of the things we can do to protect the environment would also save us money and provide better patient care.” Surgical backlogs, for instance, are causing millions of people to wait many months for routine operations, during which time, their condition deteriorates. This means they require longer operations that are more complicated, often with general anaesthetic rather than local, all increasing the surgery’s carbon footprint.

This applies to primary care as well; inhaler emissions account for 3 per cent of the NHS carbon footprint, with propellant-based – or “puffer” – inhalers being the worst offenders. As well as steering patients towards alternatives such as dry powder inhalers, a more robust GP asthma service would empower patients to better manage their condition, resulting in less use of inhalers. “Patients protect the environment by having the disease well controlled,” explains Johannsson.

Cutting red tape around fastidious NHS protocols would also help to reduce waste. Johannsson believes there is an over-zealousness surrounding disposable plastic products, cleanliness and waste disposal that has worsened since the pandemic. One example is the requirement to incinerate rather than recycle drapes used in surgery if there is a single drop of blood on them.

“We need to keep patient safety at the absolute centre of what we’re doing,” he says. “But we also need to think about the likelihood of harm to the individual, which in many cases is so small compared to the greater harm to the planet and humanity.”

The government has a responsibility to ensure all NHS guidelines consider environmental impact alongside cost and patient safety, he adds.

“The NHS will always procure the cheapest thing, and that’s sometimes disposable rather than reusable,” he says. “But all NHS procurement needs to be done in an ecologically beneficial way. Every purchase a hospital makes should take into account the environment.”

[See also: “This is just not safe for anyone”: the NHS doctors at breaking point]