The Nitrous Oxide Project: assessment of advocacy and national directives to deliver mitigation of anaesthetic nitrous oxide

Abstract

SummaryThe environmental emissions attributed to anaesthetic nitrous oxide across the NHS are comparable to the carbon dioxide released by 135,000 flights from Frankfurt to New York. Much of these emissions are attributable to cumbersome and inadequately managed piped systems, resulting in excessive loss and waste. Since 2020, multiple hospital sites have been engaging with the Nitrous Oxide Project, a quality improvement method supporting a ‘lean systems’ approach to the provision of nitrous oxide. This review considers the frameworks supporting medical gas management in UK healthcare systems, and the impact of professional advocacy and medical gas stewardship to drive anaesthetic nitrous oxide mitigation in the NHS. Nitrous oxide mitigation efforts by grassroots and professional advocacy networks are enhanced through national centralised emission monitoring, distribution of data, technical information and provision of quality analysis. Given the climate harms of nitrous oxide, concerted efforts should be made to rationalise its use, and resources should be committed to supporting this at local, regional and national levels.

Driving down the carbon cost of peri‐operative care: old controversies, new topics, fresh perspectives and the future

“…Yet these devices and the associated technology are areas ripe for innovation and research, with potentially enormous beneficial clinical implications. Chakera et al report their experiences of the Nitrous Oxide Project, addressing medical gas management at a local, regional and national level in the NHS [10]. The losses of agent to the atmosphere from piped systems and manifolds in hospitals are staggering, and this group has shown real change through reduced overall purchases of medicinal nitrous oxide in the UK and in supporting organisations to decommission central delivery systems [11].…”

“…Yet there is an important ethical argument regarding providing appropriate analgesia to women in labour, where nitrous oxide continues to have an important role. Thankfully, Chakera et al provide solutions [10], and cracking technologies may also play a future role to reduce emissions still further [11].…”

Sustainability is a core outcome: filling research gaps in sustainable peri‐operative care

“…undertaking the Nitrous Oxide Project in three different institutions [14]. Discussion of the challenges encountered illustrates that even when the right thing to do is obvious, there is often a gap in understanding how to encourage individuals and institutions to use drugs, technologies and techniques more responsibly [15].…”

“…Nevertheless, there is much to do in sustainable perioperative research with numerous challenges and contradictions: urgent action is needed but information is incomplete [6,7,11]; rapid progress has been made and yet operating theatres remain highly resource-intensive [8,12]; implementation is challenging even when solutions are obvious [14,16,17]; `easy´things can draw focus when sometimes `difficult´things matter much more [7,8,12]; and all of this must be achieved without harming patient care [23]. The Global Stocktake report emphasises the need for investment in research [1] and it is heartening to see that taking place; not just in terms of funds, but in terms of development of expertise and sharing of resources through formal and informal networks.…”

Misconceptions about sustainable anaesthesia

“…Moving towards a leaner supply can reduce the impacts from transportation and the volume of nitrous oxide vented from expired cylinders and those removed from manifolds. Switching off (or removing) manifolds and using portable cylinders will significantly cut out unnecessary waste by bypassing the main culprits [8].…”