Background Health care itself contributes to climate change. Anesthesia is a “carbon hotspot,” yet few data exist to compare anesthetic choices. The authors examined the carbon dioxide equivalent emissions associated with general anesthesia, spinal anesthesia, and combined (general and spinal anesthesia) during a total knee replacement. Methods A prospective life cycle assessment of 10 patients in each of three groups undergoing knee replacements was conducted in Melbourne, Australia. The authors collected input data for anesthetic items, gases, and drugs, and electricity for patient warming and anesthetic machine. Sevoflurane or propofol was used for general anesthesia. Life cycle assessment software was used to convert inputs to their carbon footprint (in kilogram carbon dioxide equivalent emissions), with modeled international comparisons. Results Twenty-nine patients were studied. The carbon dioxide equivalent emissions for general anesthesia were an average 14.9 (95% CI, 9.7 to 22.5) kg carbon dioxide equivalent emissions; spinal anesthesia, 16.9 (95% CI, 13.2 to 20.5) kg carbon dioxide equivalent; and for combined anesthesia, 18.5 (95% CI, 12.5 to 27.3) kg carbon dioxide equivalent. Major sources of carbon dioxide equivalent emissions across all approaches were as follows: electricity for the patient air warmer (average at least 2.5 kg carbon dioxide equivalent [20% total]), single-use items, 3.6 (general anesthesia), 3.4 (spinal), and 4.3 (combined) kg carbon dioxide equivalent emissions, respectively (approximately 25% total). For the general anesthesia and combined groups, sevoflurane contributed an average 4.7 kg carbon dioxide equivalent (35% total) and 3.1 kg carbon dioxide equivalent (19%), respectively. For spinal and combined, washing and sterilizing reusable items contributed 4.5 kg carbon dioxide equivalent (29% total) and 4.1 kg carbon dioxide equivalent (24%) emissions, respectively. Oxygen use was important to the spinal anesthetic carbon footprint (2.8 kg carbon dioxide equivalent, 18%). Modeling showed that intercountry carbon dioxide equivalent emission variability was less than intragroup variability (minimum/maximum). Conclusions All anesthetic approaches had similar carbon footprints (desflurane and nitrous oxide were not used for general anesthesia). Rather than spinal being a default low carbon approach, several choices determine the final carbon footprint: using low-flow anesthesia/total intravenous anesthesia, reducing single-use plastics, reducing oxygen flows, and collaborating with engineers to augment energy efficiency/renewable electricity. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New
Peri-operative medicine, defined as the medical care of patients from the time of contemplation of surgery through the operative period to full recovery, is being formally integrated into the care of surgical patients internationally, with large collaborative groups developing clinical and research agendas focusing on peri-operative outcomes [1, 2]. This integration follows recognition by the Lancet Commission on Global Surgery that five billion people globally do not have access to safe anaesthesia and surgery, which are essential to reducing the global burden of disease [3-5]. An acknowledgement of this problem, which was neglected in health systems for over 50 years, was made in 2015 when the World Health Organization's Sixty-Eighth World Health Assembly passed a resolution to make safe surgery and anaesthesia an essential requirement of universal health coverage. This means that emergency and essential surgical care and anaesthesia are now embedded into the post-2015 global agenda and the sustainable development goals (SDG) [6]. Recognising the multidisciplinary, collaborative approach of peri-operative medicine and matching this with global agendas and goals will assist in enabling access to safe surgery to all. Caesarean section surgery is an essential surgical operation This procedure makes up approximately 30% of all operations in low middle-income countries each year [7-9]. Despite this, the 131 million pregnant women who might require this major abdominal surgery each year are rarely specifically highlighted in discourse on peri-operative medicine [7]. This is of concern as caesarean section surgery often occurs in an emergency setting, always involves bleeding and often a high risk of significant haemorrhage (> 500 ml), and is associated with the well-recognised postoperative complications of bleeding, infection, deep vein thrombosis and pulmonary embolism. These perioperative problems often occur on the background of comorbid conditions of hypertension (10% of pregnant women), obesity, diabetes and anaemia. Caesarean section surgery has been identified as a Bellwether procedure by Global Surgery 2030 [4] meaning that it is an essential surgical procedure and one that should be able to be offered in all hospitals. Raising the profile of caesarean section surgery in pregnant women is necessary to enable the provision of safe peri-operative care to this often-forgotten group of surgical patients. Pregnant women are an integral peri-operative medicine population The antenatal and postnatal period is also the peri-operative period for 23 million young women globally who have caesarean section surgery each year (18.6% of pregnant women globally) [9]. The global maternal mortality ratio (MMR) in 2015 was 385 deaths per 100,000 women giving birth [10]. Given the number of women who undergo caesarean section surgery, the global problem of maternal mortality is intimately linked with a solution offered by the framework of peri-operative medicine. In the African 1504
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