The inexorable rise in health care costs has brought ever-greater emphasis on cost reduction in all aspects, including anesthesia care. Intraoperative anesthesia-related expenditures comprise upward of 6% of the total hospital cost for an inpatient procedure (Curr Opin Anaesthesiol 2012;25:221-5). We describe efforts at Ohio State to reduce both direct and environmental procedural costs while maintaining environmental stewardship.

We initially focused on curbing the use of desflurane. Desflurane’s rapid action and its favorable pharmacokinetic profile make it a desirable volatile anesthetic. However, it has both direct costs (it is approximately 10 times more expensive than isoflurane and four times more expensive than sevoflurane) and environmental costs (BMJ 2022;377:o1301). The global warming potential (GWP) of desflurane is about 3,700, approximately 10 times greater than sevoflurane and twice that of isoflurane. Even more daunting is the fact that yearly emissions of inhaled anesthetic agents in CO2 equivalents are comparable to those emitted from 1 million cars or one coal-fired power plant (Br J Anaesth 2010;105:760-6).

Current recommendations to reduce the environmental burden from waste anesthesia gases highlight the importance of avoiding desflurane and nitrous oxide, lowering fresh gas flows, and considering total intravenous anesthesia (TIVA) and regional anesthesia techniques where applicable (ASA Monitor 2023;87:24).

Our efforts to reduce desflurane use were initially unsuccessful. Our departmental communications were focused on reducing pharmaceutical costs of desflurane. Despite repeated messaging from 2014 to 2017, our desflurane expenditures continued to rise, reaching their peak in 2017 (Figure 1).

Figure 1: Timeline of communication within the Department of Anesthesiology at The Ohio State University Wexner Medical Center from 2014-19, with initial emphasis on cost reduction, and later years bringing environmental awareness.

Figure 1: Timeline of communication within the Department of Anesthesiology at The Ohio State University Wexner Medical Center from 2014-19, with initial emphasis on cost reduction, and later years bringing environmental awareness.

In 2018, we started to include the environmental costs of desflurane, focusing on sustainable anesthesia practice. We first launched an informative Grand Rounds presentation, followed by a survey to assess knowledge and willingness of anesthesia professionals to change practice to reduce negative impacts on the environment (Figures 2 and 3). We found that through direct interaction, 90% of our anesthesiologists were willing to change practice. Now we had an opportunity for significant change to occur! We added visual aids to the OR, most notably on the anesthesia machine, to cue anesthesiologists to reduce desflurane usage. This included a “weeping” polar bear sticker (Figure 4) highlighting CO2 equivalents.

Figure 2: Survey results – barriers to reducing environmental impact from anesthesia gas usage.

Figure 2: Survey results – barriers to reducing environmental impact from anesthesia gas usage.

 

Figure 3: Survey results – anesthesia professionals' willingness to change practice to reduce environmental impact of anesthetic gases.

Figure 3: Survey results – anesthesia professionals’ willingness to change practice to reduce environmental impact of anesthetic gases.

Figure 4: Sticker placed on anesthesia machines to serve as a visual cue. Includes table with tropospheric lifetime and 20-year global warming potential of inhaled anesthetics (Jt Comm J Qual Patient Saf 2015;41:522-8).

Figure 4: Sticker placed on anesthesia machines to serve as a visual cue. Includes table with tropospheric lifetime and 20-year global warming potential of inhaled anesthetics (Jt Comm J Qual Patient Saf 2015;41:522-8).

In the first year after this initiative, desflurane use decreased by 31%, with an overall decrease of 46% in the CO2 equivalents per minute of OR time. This momentum continued to carry over, as there was a steady decline of 70% in the following years (Figure 5).

“Desflurane’s rapid action and its favorable pharmacokinetic profile make it a desirable volatile anesthetic. However, it has both direct costs (it is approximately 10 times more expensive than isoflurane and four times more expensive than sevoflurane) and environmental costs.”

Figure 5: Desflurane spend from 2014-23 at the Department of Anesthesiology, The Ohio State University Wexner Medical Center.

Figure 5: Desflurane spend from 2014-23 at the Department of Anesthesiology, The Ohio State University Wexner Medical Center.

An additional effort focused on reducing the use of inhaled volatile anesthetics and nitrous oxide. Recent randomized controlled trials comparing TIVA and inhaled anesthetics in obstructive sleep apnea (OSA) surgery demonstrated improved recovery times and decreased need for supplemental oxygen requirements in the TIVA cohort (Laryngoscope 2023;133:984-92). Now that remifentanil is generic, the direct costs of TIVA are comparable to inhaled anesthetics, while the environmental cost is substantially less (Anesth Analg 2019;128:13-5).

“Even more daunting is the fact that yearly emissions of inhaled anesthetic agents in CO2 equivalents are comparable to those emitted from 1 million cars or one coal-fired power plant.”

Further sustainability and cost-reduction strategies are on the way. Newer anesthesia machines with capabilities to automatically titrate end-tidal concentrations of volatile anesthetic agent and flow rates are enabling cost reductions while improving sustainability by automating green practices. Evolving technology improvements with enhanced reporting metrics and dashboards that provide information on volatile agent costs and CO2 equivalents per case and per anesthesiologist can drive accountability in the future.

In conclusion, we found that anesthesiologists were not motivated by the hospital’s requests to reduce costs. However, anesthesiologists were highly motivated by environmental sustainability. Perhaps the latter was seen as more meaningful, potentially impacting their personal lives and those of their families. Reducing direct and environmental costs while maintaining patient safety are mutually compatible goals. Our experience may help other institutions align patient care priorities with economically and environmentally responsible provision of anesthesia care.