Original Title: Diminuer l’empreinte carbone des agents anesthésiques inhalés au bloc opératoire lors d’une anesthésie générale : stratégies et enjeux à considérer

Authors' objectives: In recent years, the use of certain anesthetic agents inhaled in the operating room during general anesthesia, particularly desflurane and nitrous oxide, has come under increasing criticism for their high carbon footprint. Following a request from the Association des anesthésiologistes du Québec, the Direction des affaires pharmaceutiques et du médicament of the Ministère de la Santé et des Services sociaux (MSSS) commissioned the Institut national d'excellence en santé et en services sociaux (INESSS) to formulate recommendations on clinical practices to reduce the carbon footprint of inhaled anesthetic agents in the operating room, without compromising the delivery and safety of care. The mandate also included anticipating the issues associated with these changes, and the mitigating actions to be planned where appropriate. This clinically relevant work is consistent with the Greening Operating Room Practices of the MSSS 2023-2028 Sustainable Development Action Plan.

Authors' results and conclusions: RESULTS (#1 ANESTHETIC GASES: A TARGET FOR REDUCING THE CARBON FOOTPRINT OF GENERAL ANESTHESIA): In Quebec, the healthcare sector generates 3.6 % of greenhouse gas (GHG) emissions. Anesthetic gases, including halogenated agents (desflurane, isoflurane, sevoflurane), nitrous oxide and metered-dose inhalers, account for 3 % of the healthcare sector, or 0.1 % of Quebec's GHGs. • Inhaled anesthetic agents all have a carbon footprint, albeit of various sizes. According to current scientific data: – the carbon footprint of desflurane anesthesia is around 40 times greater than that of sevoflurane; – the carbon footprint of isoflurane anesthesia is around 1.8 times greater than that of sevoflurane. (#2 ACTIVE ANESTHESIOLOGISTS FACE THE CHALLENGE OF GLOBAL WARMING): With the aim of reducing the carbon footprint of anesthesia, these documents and positions advocate reducing the carbon footprint of anesthetic gases, notably by withdrawing desflurane and reducing the use of nitrous oxide. • Many Quebec institutions, supported by committed Anesthesiologists, have taken steps to reduce or eliminate the use of desflurane and nitrous oxide for general inhalation anesthesia. • The move to reduce the use of desflurane is already underway in all regions of Quebec and has been for at least 5 years. Of the pharmacies that shared their data, 27 % supplied no desflurane cylinders to the operating room in 2023. (#3 NCREASING LEGISLATION TO REGULATE THE WITHDRAWAL OF DESFLURANE): In April 2024, England's National Health Service (NHS) withdrew desflurane from its hospitals, with the exception of those performing long-term neurosurgeries (e.g., long cranial neurosurgical procedures lasting more than 10 hours and requiring the patient to be awake immediately after surgery), for which exceptional clinical reasons could be cited to justify the use of this agent. As of 2026, the European Union will ban the use of desflurane unless, for exceptional medical reasons, no other anesthetic can be used. (#4 Clinical Advantage of Desflurane over Sevoflurane: Inconclusive Scientific Data): According to the information available, the safety profile of various halogenated agents is similar. However, desflurane is contraindicated for use with a mask during the induction phase, due to its pungency. (#5 ELIMINATING DESFLURANE: A COST-EFFECTIVE INITIATIVE): Gradual replacement of desflurane by sevoflurane could result in savings of $204,400 over 3 years, the magnitude of the expected savings being influenced by the speed of desflurane elimination. • However, depending on the organizational arrangements in place (contracts for the rental of evaporators and the purchase of agents), losses and/or penalties could reduce the expected savings. (#6 NITROUS OXIDE: FACILITIES AND PRACTICES TO BE OPTIMIZED): According to the consultations held and as observed in several jurisdictions around the world, N2O leaks from centralized systems have been observed in some Quebec hospitals. For example, in Scotland, the National Health Service in Lothian, which includes 21 hospitals, reported that around 80 % of nitrous oxide distributed through pipelines does not reach patients because of leaks, gas expiry dates, or theft for recreational use. • The data obtained did not provide a picture of nitrous oxide consumption as a carrier gas in the operating theatre. Nevertheless, according to the consultations held, several Quebec institutions have stopped using the centralized nitrous oxide distribution system and replaced it with portable type E cylinders, without this having significantly affected the delivery and organization of care. (#7 SUPPORTING SUSTAINABLE DEVELOPMENT THROUGH TARGETED ORGANIZATIONAL STRATEGIES): Restricting access to gases and equipment, notably by controlling orders, discontinuing vaporizer rental contracts and removing this option from institutional forms are also strategies suggested by the various stakeholders consulted. • The carbon footprint of inhaled anaesthetic gases can also be reduced through the use of more modern anaesthesia equipment low fresh gas flows, targetcontrolled inhalational anesthesia).

Authors' recommendations: At the end of the discussions and deliberations, members of the Standing Deliberative Committee formulated the general guidelines for the various recommendations. In particular, they stressed that environmental, socio-cultural, clinical, organizational, and economic indicators all support the withdrawal of desflurane in favour of sevoflurane. In their view, no clinical benefit justifying the exclusive use of desflurane for inhalation anesthesia could be identified in the course of the work. In light of the overall assessment of value and the deliberations held with the Standing Deliberative Committee - Health Intervention Methods (CDP-MIS), the INESSS recommends that guidelines and measures be implemented by the MSSS and healthcare institutions, to achieve, in the near future, and according to a plan and schedule that take into account local organizational specificities: • eliminating the use of desflurane (except in very exceptional situations - see additional recommendation below); • closure of centralized nitrous oxide distribution systems (by ceasing to supply pipelines) and the omission of this type of system from construction plans for future hospital infrastructures. • To achieve this overall objective, the INESSS recommends that, from a clinical standpoint when an operating room procedure requires the use of general anesthesia by inhalation: • desflurane should no longer be used, and only in exceptional situations. In such cases, the medical reasons justifying the absence of an alternative to desflurane should be documented (e.g. in the patient record or anesthesia form)

Authors' methods: The evaluation questions for this work were formulated to meet the objectives of the mandate, covering the socio-cultural, clinical, organizational, and economic dimensions of the INESSS Statement of Principles and Ethical Foundations as well as the pharmacological and environmental considerations inherent in the decision-making questions. In collaboration with a scientific information consultant (librarian), a systematic search of the scientific literature was conducted in the MEDLINE, Embase and EBM Reviews (Cochrane Database of Systematic Reviews) databases. A manual search of grey literature was also conducted, consulting, among others, the websites of learned societies specializing in the field, as well as regulatory, health, or health technology evaluation agencies. The references of the selected publications were also consulted to identify other relevant documents, including systematic reviews in support of the recommendations published in the selected clinical practice guides, guidelines, or position statements. For rapid reviews, document selection and evaluation of methodological quality or scientific credibility were conducted independently by two scientific professionals. The extraction, analysis, and synthesis of the information gathered to respond to certain aspects of the clinical, sociocultural, and economic dimensions were conducted by one professional, then validated by a second. Product monographs for inhaled anesthetic agents commercially available in Canada were consulted, as was Health Canada's MedEffect registry. The websites of federal, territorial, and provincial governments, groupings, communities of practice, or learned societies specializing in the field, and of Quebec associations, federations, and professional orders involved in this work were also consulted. Quebec data on the acquisition and consumption of anesthetic agent cylinders were obtained from clinical-administrative databases and from collaborators in charge of procurement in healthcare institutions and at the government level. Efficiency and budget impact analyses were conducted on the basis of scientific and contextual data. Stakeholder perspectives were gathered through an Advisory Committee made up of healthcare professionals with various specialties and expertise in anesthesiology, practicing in facilities located in metropolitan or urban areas and offering several types of surgical services, for both adults and children. Ad hoc consultations with head pharmacists, directors, and professionals from the facilities' quality, evaluation, performance and ethics departments, biomedical engineers, and finally directors of the Government Procurement Centre also enabled us to gather various data relating to volume, inventory management, anesthetic equipment and the specifics of current contracts, as well as organizational issues specific to their work environment. Deliberations on the recommendations, based on an overall assessment of the evidence regarding the four dimensions relevant to the work, were conducted with the members of the Standing Deliberative Committee - Healthcare Intervention Methods. Finally, the overall quality of the work, its acceptability, and applicability were assessed by external readers specialized or involved in the field of interest.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/diminuer-lempreinte-carbone-des-agents-anesthesiques-inhales-au-bloc-operatoire-lors-dune-anesthesie-generale-strategies-et-enjeux-a-considerer.html

Year Published: 2024

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/diminuer-lempreinte-carbone-des-agents-anesthesiques-inhales-au-bloc-operatoire-lors-dune-anesthesie-generale-strategies-et-enjeux-a-considerer.html

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)