Operating in a Climate Crisis: A State-of-the-Science Review of Life Cycle Assessment within Surgical and Anesthetic Care

Abstract

BACKGROUND: Both human health and the health systems we depend on are increasingly threatened by a range of environmental crises, including climate change. Paradoxically, health care provision is a significant driver of environmental pollution, with surgical and anesthetic services among the most resource-intensive components of the health system. OBJECTIVES: This analysis aimed to summarize the state of life cycle assessment (LCA) practice as applied to surgical and anesthetic care via review of extant literature assessing environmental impacts of related services, procedures, equipment, and pharmaceuticals. METHODS: A state-of-the-science review was undertaken following a registered protocol and a standardized, LCA-specific reporting framework. Three bibliographic databases (Scopus ® , PubMed, and Embase ® ) and the gray literature were searched. Inclusion criteria were applied, eligible entries critically appraised, and key methodological data and results extracted. RESULTS: From 1,316 identified records, 44 studies were eligible for inclusion. The annual climate impact of operating surgical suites ranged between 3,200,000 and 5,200,000 kg CO 2 e. The climate impact of individual surgical procedures varied considerably, with estimates ranging from 6 to 1,007 kg CO 2 e. Anesthetic gases; single-use equipment; and heating, ventilation, and air conditioning system operation were the main emissions hot spots identified among operating room-and procedure-specific analyses. Single-use equipment used in surgical settings was generally more harmful than equivalent reusable items across a range of environmental parameters. Life cycle inventories have been assembled and associated climate impacts calculated for three anesthetic gases (2-85 kg CO 2 e=MAC-h) and 20 injectable anesthetic drugs (0:01-3:0 kg CO 2 e=gAPI). DISCUSSION: Despite the recent proliferation of surgical and anesthesiology-related LCAs, extant studies address a miniscule fraction of the numerous services, procedures, and products available today. Methodological heterogeneity, external validity, and a lack of background life cycle inventory data related to many essential surgical and anesthetic inputs are key limitations of the current evidence base. This review provides an indication of the spectrum of environmental impacts associated with surgical and anesthetic care at various scales.

How can we address the ever-pressing need to ‘green up’ surgical practice in the National Health Service?

“…Currently, there are noticeable heterogeneity and significant gaps in reporting life cycle assessments and carbon footprint in surgical and anaesthetic practice, as shown in a recent systematic review. 27 As previously shown, strong interest in research leads to easier recruitment and reduced research cost and time. The comparison of CRASH-1 and CRASH-2 studies is an excellent example of ways to reduce research carbon footprint and obtain results faster, thus being of double significance.…”

A Transparency Checklist for Carbon Footprint Calculations Applied within a Systematic Review of Virtual Care Interventions

“…Hence, our first aim was to develop a transparency catalogue. During this period of development, two systematic reviews were published, each developing a tool for assessing quality/transparency [ 13 , 14 ]. Although Rizan et al [ 13 ] refer to the same three guidelines, their catalogue appears to be based primarily on the GHG protocol [ 11 ] rather than on a transparent synthesis of the different guidelines.…”

“…Although Rizan et al [ 13 ] refer to the same three guidelines, their catalogue appears to be based primarily on the GHG protocol [ 11 ] rather than on a transparent synthesis of the different guidelines. The catalogue of Drew et al [ 14 ] is not based on specific CF guidelines but rather on guidelines for critically reviewing LCA [ 15 ].…”

Invited Perspective: Life Cycle Analysis: A Potentially Transformative Tool for Lowering Health Care’s Carbon Footprint

“…Medicine is energy and resource intensive, and surgical and anesthetic services particularly so. In this issue, Drew et al (2021) provide new insight into the footprint of one of the most carbon-intensive areas of medical care, providing a useful new summation of evidence that has several implications for how medicine might make rapid progress in its ongoing effort to rein in iatrogenic harms.…”

“…The medical field needs to broaden its quality initiatives to include GHG mitigation activities (Ossebaard and Lachman 2021), and its chief quality officers need to develop or acquire environmental accounting expertise. Drew et al (2021) provide indicators that could be included in sustainability dashboards (e.g., the volume of desflurane and propofol used in anesthetic practices), and they recognize the importance of clinically relevant metrics that align with providers' perspectives [e.g., using maintenance of minimum alveolar concentrations for 1 h, originally developed by Sherman et al (2012)].…”