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For an Australian hospital with six operating rooms, converting from single-use to reusable anaesthetic equipment saved more than AUD$30 000 (£18 000) per annum, but increased the CO 2 emissions by almost 10%. The CO 2 offset is highly dependent on the power source mix, while water consumption is greater for reusable equipment.

Inclusive of labor, the reusable central venous catheter insertion kits were less expensive than were the single-use kits. For our hospital, which uses brown coal-sourced electricity, the environmental costs of the reusable kit were considerably greater than those of the single-use kit. Efforts to reduce the environmental footprint of reusable items should be directed towards decreasing the water and energy consumed in cleaning and sterilization. The source of hospital electricity significantly alters the relative environmental effects of reusable items.

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

Objectives:To estimate the carbon footprint of five common hospital pathology tests: full blood examination; urea and electrolyte levels; coagulation profile; C-reactive protein concentration; and arterial blood gases.Design, setting: Prospective life cycle assessment of five pathology tests in two university-affiliated health services in Melbourne. We included all consumables and associated waste for venepuncture and laboratory analyses, and electricity and water use for laboratory analyses.Main outcome measure: Greenhouse gas footprint, measured in carbon dioxide equivalent (CO 2 e) emissions.Results: CO 2 e emissions for haematology tests were 82 g/test (95% CI, 73-91 g/test) for coagulation profile and 116 g/test (95% CI, 101-135 g/test) for full blood examination. CO 2 e emissions for biochemical tests were 0.5 g/test CO 2 e (95% CI, 0.4-0.6 g/test) for C-reactive protein (low because typically ordered with urea and electrolyte assessment), 49 g/test (95% CI, 45-53 g/test) for arterial blood gas assessment, and 99 g/test (95% CI, 84-113 g/test) for urea and electrolyte assessment. Most CO 2 e emissions were associated with sample collection (range, 60% for full blood examination to 95% for coagulation profile); emissions attributable to laboratory reagents and power use were much smaller. Conclusion:The carbon footprint of common pathology tests was dominated by those of sample collection and phlebotomy. Although the carbon footprints were small, millions of tests are performed each year in Australia, and reducing unnecessary testing will be the most effective approach to reducing the carbon footprint of pathology. Together with the detrimental health and economic effects of unnecessary testing, our environmental findings should further motivate clinicians to test wisely.The known: Health care ultimately generates 7% of national carbon emissions in Australia. A considerable proportion of the cost of health care in Australia is associated with pathology services (12% of Medicare spending). The new:The overall carbon footprints of five common hospital pathology tests, measured as carbon dioxide equivalent (CO 2 e) emissions, ranged between 0.5 and 116 g CO 2 e, equivalent to driving a car between 3 m and 0.8 km. The implications:Opportunities to reduce the carbon footprint of pathology testing are limited. The greatest environmental benefit can be achieved by reducing unnecessary testing. Environmental impact, together with cost-effectiveness and health outcomes, should be considered when ordering tests. 25 Bell KJL, Doust J, Glasziou P, et al. Recognizing the potential for overdiagnosis: are high-sensitivity cardiac troponin assays an example? Ann Intern Med 2019; 170: 259. 26 Bjørn Morten H. Too much technology. BMJ 2015; 350: h705. 27 Spelman D. Inappropriate pathology ordering and pathology stewardship. Med J Aust 2015; 202: 13-15. https://www.mja. com.au/journ al/2015/202/1/inapp ropri atepatho logy-order ing-and-patho logy-stewa rd ship 28 Pathirana T, Clark J, Moynihan R. Mapping the drivers of overdiag...

We modelled the financial and environmental costs of two commonly used anaesthetic plastic drug trays. We proposed that, compared with single-use trays, reusable trays are less expensive, consume less water and produce less carbon dioxide, and that routinely adding cotton and paper increases financial and environmental costs. We used life cycle assessment to model the financial and environmental costs of reusable and single-use trays. From our life cycle assessment modelling, the reusable tray cost (Australian dollars

ObjectiveTo examine the environmental life cycle from poppy farming through to production of 100 mg in 100 mL of intravenous morphine (standard infusion bag).Design‘Cradle-to-grave’ process-based life cycle assessment (observational).SettingsAustralian opium poppy farms, and facilities for pelletising, manufacturing morphine, and sterilising and packaging bags of morphine.Main outcome measuresThe environmental effects (eg, CO2 equivalent (‘CO2 e’) emissions and water use) of producing 100 mg of morphine. All aspects of morphine production from poppy farming, pelletising, bulk morphine manufacture through to final formulation. Industry-sourced and inventory-sourced databases were used for most inputs.ResultsMorphine sulfate (100 mg in 100 mL) had a climate change effect of 204 g CO2 e (95% CI 189 to 280 g CO2 e), approximating the CO2 e emissions of driving an average car 1 km. Water use was 7.8 L (95% CI 6.7– to 9.0 L), primarily stemming from farming (6.7 L). All other environmental effects were minor and several orders of magnitude less than CO2 e emissions and water use. Almost 90% of CO2 e emissions occurred during the final stages of 100 mg of morphine manufacture. Morphine's packaging contributed 95 g CO2 e, which accounted for 46% of the total CO2 e (95% CI 82 to 155 g CO2 e). Mixing, filling and sterilisation of 100 mg morphine bags added a further 86 g CO2 e, which accounted for 42% (95% CI 80 to 92 g CO2 e). Poppy farming (6 g CO2 e, 3%), pelletising and manufacturing (18 g CO2 e, 9%) made smaller contributions to CO2 emissions.ConclusionsThe environmental effects of growing opium poppies and manufacturing bulk morphine were small. The final stages of morphine production, particularly sterilisation and packaging, contributed to almost 90% of morphine's carbon footprint. Focused measures to improve the energy efficiency and sources for drug sterilisation and packaging could be explored as these are relevant to all drugs. Comparisons of the environmental effects of the production of other drugs and between oral and intravenous preparations are required.

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