In the United States, the health care sector is responsible for 10% of the nation’s carbon emissions.1 Anesthesia-related care is responsible for 5% of total health care carbon emissions.2 Within hospitals themselves, as much as 33% of waste is produced by perioperative services.3 Medical waste is a significant source of pollution, with the health care industry acting as a major contributor to the nation’s greenhouse gas (GHG) emissions.4 Given the acceleration of climate change in recent years, it is critical to reduce waste and identify opportunities for using fewer products. While extensive research has delved into how health care impacts climate change, as well as the effects of climate change furthering health disparities, the specific intersection of perioperative medicine, its environmental impact, and institutional racism within this scope remains underexplored.
A vicious cycle of climate change exacerbating institutional racism exists, with Black, Indigenous, and people of color (BIPOC) communities facing increased health care burdens associated with climate change.5 These vulnerable groups face heightened environmental risks contributing to increased health care utilization. For instance, Black Americans experience a higher rate of asthma.6 They are also 75% more likely to reside near areas with high-emissions or harmful industrial activities, facing air pollution levels that are at least 56% greater than equitable standards.5 This disparate care can further intensify climate change through increased waste generation associated with increased health care service delivery (Figure).

Anesthesiologists and other clinicians involved in perioperative medicine must be conscious of how climate change and institutional racism negatively affect the health outcomes of BIPOC populations. These include numerous environmental impacts that are associated with increased hospital length of stay (LOS) and choice of medications administered.7 Thus, in our quest to improve patient safety and increase efficiency, we examine the impact of institutional racism on climate change through the lens of anesthesiology and perioperative medicine.
THE IMPACT OF CLIMATE CHANGE ON HEALTH CARE UTILIZATION
Increasing temperatures cause heat waves, leading to increased morbidity and mortality, particularly among the elderly and those with preexisting health conditions.4 These changes can increase demand for hospital resources such as emergency and perioperative services.8 Furthermore, individuals of BIPOC communities are at a higher risk of climate change–related complications in comparison to their White counterparts.4 The exacerbation of air pollution by climate change can lead to respiratory diseases such as asthma and chronic obstructive pulmonary disease as well as cardiovascular problems. This may present challenges for anesthesiologists, including difficulty in managing ventilation and physiological responses during the administration of anesthetic care. Extreme weather events, such as hurricanes and floods, can disrupt health care services, including prehospital care, emergency department operations, operating room schedules, and access to anesthesia supplies.9 Anesthesiologists may need to adapt and provide care in less-than-optimal conditions during these times. As climate change continues to evolve, these effects will likely become more pronounced, calling for urgent action and adaptation in the field of anesthesiology.
PERIOPERATIVE WASTE
As research on climate change advances, the health care sector’s significant role in global GHG emissions is becoming increasingly evident. Among the various contributors, perioperative waste is a significant player, stemming from the sheer volume of procedures performed annually and the associated waste generation, producing up to 33% of all hospital waste.3 Perioperative waste encompasses the materials used before, during, and after operative procedures, including single-use plastic items, medical equipment, gowns, gloves, and anesthetic volatile gases. The coronavirus disease 2019 (COVID-19) pandemic increased requirements for single-use plastic packaging and disposable medical devices, with 1 study examining hospital waste reporting a 48% increase in waste produced from January 2018 to August 2021 across 20 public and private hospitals.10 When extrapolated to the millions of procedures performed across the United States annually, this results in billions of pounds of waste, much of which ends up in landfills or incinerated, contributing to substantial GHG emissions.
GHG AND GENERAL ANESTHESIA
Just 7 days into July 2023, we witnessed “the hottest day in modern history,” with scorching temperatures across the globe, and ocean surface temperatures surpassing 90ºF on Miami’s coast.11 A significant portion of this warming is attributed to GHGs, such as methane, N2O, and hydrofluorocarbons.2 GHGs contribute to heating the planet in a variety of ways. They absorb solar radiation and reflect this energy emitted as infrared radiation or heat back to earth. Additionally, GHGs can absorb infrared radiation from each other, effectively trapping heat emitted from other GHGs that would otherwise leave the planet. After absorbing infrared radiation, energy is reemitted in all directions, causing widespread warming. Not only have we accelerated GHG production through carbon-releasing activities such as burning hydrocarbon fuels and deforestation, but we also continue to contribute GHGs through the use of general anesthetics. Halogenated compounds, such as volatile anesthetic agents, account for 11% of global GHGs, and contribute to global warming by increasing planet temperature over 2000 times that of CO2.12
UNEQUAL DISTRIBUTION OF ANESTHETICS IN MINORITY POPULATIONS
Despite advancements in medicine, disparities persist in health care for BIPOC populations, resulting in adverse health outcomes.13 One underexplored area of this disparity lies in the administration of anesthetics––general and regional. The unequal distribution of anesthetics in BIPOC patients can lead to higher readmission rates, prolonged hospital stays, increased health care waste, and subsequent environmental harm.7 The choice between general and regional anesthesia often depends on patient-specific factors and the nature of the procedure. However, research has suggested that BIPOC patients may be more likely to receive general anesthesia, even when regional anesthesia may be a suitable alternative with less risk. For example, Black patients are 2.76 times more likely to receive general anesthesia than epidural anesthesia for inguinal hernia repairs.14 This trend carries through in other procedures as well, such as cesarean delivery.15 Similar disparate care has been documented in pediatric patients with Black children more likely to be given inhalational versus intravenous anesthetics compared to White children.16 These discrepancies may be due to provider biases, lack of patient education, or institutional factors such as limited access to high-quality care.
The unequal utilization of anesthetics has significant clinical consequences. General anesthesia has higher associated risks, including longer recovery times, which could lead to premature discharges due to perceived recovery.17 Consequently, these patients have a higher risk of postoperative complications, leading to readmissions.7 Rehospitalization not only negatively impacts patient outcomes, burdens the health care system, and puts more stress on the medical care team, but also leads to increased health care waste. Each patient admission utilizes resources that include medical supplies, pharmaceuticals, energy for diagnostics and treatment, and anesthetic gases.18 Anesthetic gases, including sevoflurane, isoflurane, desflurane, and N2O, are all potent GHGs.19 Increased use of these gases among BIPOC populations due to the bias towards general anesthesia exacerbates their environmental impact on heating the planet further. Readmissions compound this issue by repeating the resource-intensive admission process and increasing the overall waste generated per patient encounter. Addressing the root causes of readmissions due to unequal anesthetic use could significantly reduce health care waste.
It is imperative that we encourage larger, more robust studies that examine the contributions of different anesthetics on GHG emissions and climate change to make better decisions around their clinical use. For instance, McGain et al20 found that all anesthetic approaches in their study (general anesthesia, spinal anesthesia, and combined general and spinal) had similar carbon footprints. However, this study was underpowered; desflurane was not used, while N2O was used on only 1 patient.
As advocates for a cleaner, healthier, and more sustainable world, it is incumbent on us to rigorously evaluate and significantly modify our practices to minimize contributions to global warming. Health care sustainability research has started exploring how anesthesiologists can adapt their practices to be more sustainable. One notable study examined the concept of reducing fresh gas flow while still maintaining safe and effective care.21 The investigation also demonstrated that using balanced or minimal fresh gas flow during induction and anesthesia maintenance could potentially halve CO2 emissions. This modification in practice not only maintains patient safety with sufficient fresh gas flow but also significantly decreases the carbon footprint of volatile anesthetic use. Additionally, the same study explored the utilization of total intravenous anesthesia (TIVA) and local or regional anesthesia as alternatives to general anesthesia.14 Sherman et al19 investigated anesthetic choice and hospital sustainability and found that propofol impacted GHG production almost 4 times less than desflurane or N2O.
The energy requirements for administering anesthetics are considerably different as well. Modern anesthesia machines require substantial power for the many differing subsystems within the machine, such as the heating element used to maintain 39ºC in the Tec6 desflurane vaporizer, which uses approximately 250 watts.19 Compared to the 15 watts required to power an IV pump, this difference in required power is significant. As electricity is cheaply produced using methods that create CO2, such as fossil fuel, biomass, and waste combustion, adding to the growing global electricity requirements can further contribute to GHG production and climate change in regions where hydroelectric power is not the main source of electricity.19 Although anesthesiologists cannot alter the carbon emissions generated by electricity, they can work with their hospitals to shift toward more sustainable energy sources.12
To alleviate the environmental burden of perioperative waste, numerous strategies can be used, encompassing both the use of surgical materials and waste management techniques. One pivotal approach involves health care providers shifting their practices to incorporate reusable surgical tools and materials. This transition can drastically reduce reliance on single-use items. Surgical procedures should be planned and executed with tools that can be sterilized and reused without compromising patient safety or surgical efficacy. Another strategy centers around the conscious utilization of anesthetic gases. Their judicious use or replacement with less environmentally harmful options can significantly lower the carbon footprint of surgical procedures.19 In certain cases, the choice of regional or local anesthesia instead of general anesthesia can also reduce the environmental impact. Finally, a shift towards more sustainable waste management practices is crucial. By pursuing tailored recycling and composting methods, substantial amounts of waste can be redirected away from landfills, as approximately 25% of waste from the operating room and 15% from critical care environments can be recycled.12 Adopting a thoughtful strategy for resource management can improve the environmental footprint of an anesthesiologist by reducing reliance on waste management and recycling, which carries its own drawbacks, such as economic cost and strategic operational challenges. The Choosing Wisely initiative champions the wise use of resources while maintaining and/or improving clinical care.12
It is worth noting that the choice of anesthetic technique should always be tailored to the individual patient’s needs and the specific surgical procedure, but there are costs associated with using TIVA as well. Propofol may carry lower power requirements to administer and is not a potent GHG such as desflurane or N2O. However, there are other considerations associated with its use, such as the high rate of unused medication ranging from 32% to 51%.19 Wasted propofol must be incinerated, along with the plastics and sharps required to administer the drug. Furthermore, plastic tubing, syringes, and other waste could still contain trace amounts of propofol.19 As propofol’s lipophilic properties cause it to be insoluble in water, this drug can linger and exert its effects over an extended period of time.
By incorporating environmentally conscious anesthetic techniques, anesthesiologists can effectively contribute to the health care sector’s efforts in combating climate change. This transformation in anesthetic practice, which emphasizes sustainability without compromising patient care, highlights the importance of continual learning and adaptation in response to our evolving understanding of environmental health.
WHY ANESTHESIOLOGISTS MUST COMBAT INSTITUTIONAL RACISM
Combating institutional racism in anesthesiology has the potential to not only reduce significant disparities in care associated with worse patient outcomes but may also reduce hospital waste and mitigate climate change. Anesthesiologists have a significant influence on hospital resource utilization. On an individual level, it is difficult to work against systems that have institutionalized racism into their daily operations. However, we ask that anesthesiologists begin to take small steps to address these inequities by being more cognizant of their use of anesthetic gases, especially desflurane and N2O, leading initiatives in their own hospital contexts to reduce surgical material waste, and using better pain management strategies to decrease hospital LOS and readmissions for BIPOC patients.3 Enhanced recovery after surgery (ERAS) protocols, which provide a multimodal evidence-based approach to perioperative care meant to improve patient postoperative outcomes, have been shown to reduce hospital LOS and readmissions.22 However, differences in protocol adherence by racial and socioeconomic groups may reflect implicit biases that contribute to health care disparities.22 By advocating for the widespread adoption of ERAS protocols regardless of race or ethnicity, anesthesiologists can contribute to waste reduction and climate change mitigation.
CONCLUSIONS
Addressing institutional racism in health care is a crucial strategy to reduce hospital waste and mitigate climate change. Anesthesiologists, through their influence over perioperative resource utilization, have a unique opportunity to lead this effort. By advocating for equity in patient care, anesthesiologists can optimize the use of health care resources, reduce waste, and lessen the environmental impact of their practice.
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