Hospitals want to strongly reduce anesthetic gases, but not all doctors are participating

taketonews

“Pete, shall I relax a little?”

“Is good.”

In the corner of the operating room of St. Antonius in Nieuwegein, Larah Verhees, a nurse anesthetist, pulls open a chest of drawers. There are dozens of jars with blue lids. Verhees takes one and pulls up a white substance with a plastic syringe. It is propofol, a medicine to put and keep people under anesthesia.

A surgeon and three other doctors bend over an open abdomen with scalpels. Verhees’ field of work is not there, but above the patient’s head. Above the gray hair of a seventy-something whose aorta is being replaced, it is full of devices, there is a tangle of wires, at least eight IV bags and several monitors. On one of them, Verhees looks at a white line that is constantly moving, with the value added: 39, 40, 41, 40.

It’s the man’s brain activity. It is the responsibility of Verhees and Piet de Witte, anesthesiologist, to keep the man under anesthesia.

NRC asked the seventy Dutch hospitals about their use of anesthetic gases. More than fifty responded. Anesthetic gases are harmful greenhouse gases for the environment, while putting patients under anesthesia can also be done with virtually no harmful emissions, with the drug propofol. It took a long time for this realization to penetrate hospitals, but in recent years many hospitals have caught up and are increasingly banning the gases. But not all doctors and hospitals want to change their way of working, or are convinced.

All hospitals appear to use (to a greater or lesser extent) anesthetic gas sevoflurane, which according to researchers is 508 times as strong as the gas CO2 regarding global warming. At least two hospitals sporadically use another gas, desflurane, which is nearly 7,000 times stronger than CO2. Legislation is being prepared in the EU to ban this gas altogether. At least eighteen hospitals also use laughing gas as an anesthetic, which is 250 times as strong as CO2.

Unlike CO2 anesthetic gases and nitrous oxide remain in the atmosphere for a much shorter time. According to studies, sevoflurane leaves the atmosphere within a few years and desflurane after around fifteen years, laughing gas remains in the air for more than a hundred years. CO2 is, all in all, much more harmful to the planet than anesthetic gases, because so much more is emitted.

A bottle of propofol.

Photo Dieuwertje Bravenboer

Almost anesthetic gas free

A small group of hospitals, including those of St. Antonius in the province of Utrecht, try not to use anesthetic gases at all. The only group for which it makes an exception in principle are children. For them, an operation is already very exciting, even injecting an IV (to administer propofol) is considered too drastic by doctors.

Switching to propofol requires a new approach. In the operating room, anesthesiologist De Witte shows how easily he can administer anesthetic gas. “It’s a cap on, turn this button open, and then it sleeps. We can measure how much anesthetic gas someone exhales and then we know for sure that someone is deeply under anesthesia. You see how easy it is.”

There is more to watch out for with propofol (not a greenhouse gas, but a substance that is administered via an IV). Is the infusion set properly, what about brain activity, is the patient sweating, what about blood pressure and heart rate? More complex, but during operations there is always a nurse anesthetist or anesthetist present who can monitor this. And there are also benefits to the drug. For example, studies show that patients wake up less nauseated from an operation with propofol.

Since 2019, the hospital in Nieuwegein has been more aware of anesthetic gases (often referred to as ‘vapour’ by doctors). “We went from almost 100 percent vapor to almost 100 percent propofol,” says De Witte.

Most anesthesiologists were positive, but not everyone was immediately convinced. “I have driven colleagues completely crazy in recent years,” says De Witte. “Then I share photos of green Austrian mountains with a pathetic trail of snow from the snow machine through them in our app group. ‘Keep using a lot of vapour, eh’, I would add.”

De Witte himself always used anesthetic gases, including the highly polluting desflurane. “It is scandalous stuff. According to the manufacturer, it works better with obese patients, in practice I noticed little of that. During my training ten years ago I tried to raise the problem of gases in the hospital where I worked at the time. Then it was laughed off. Everyone used vapor.”

Read also: 27 kilograms of waste from one operation. Healthcare has a huge sustainability problem

Also at the North and South Poles

Nationally, Niek Sperna Weiland, anesthesiologist at the Amsterdam UMC and chairman of the sustainability working group of the Dutch Association for Anaesthesiology, is a major driver of the use of propofol instead of anesthetic vapour. “In 2012, there were the first sounds within anesthesia in the Netherlands about the impact of those resources. We now have more and more insight into how they behave in the atmosphere. In 2015, Swiss researchers found rising concentrations of anesthetic gases at the North and South Poles.”

Still, it took a long time for the anesthesiologists to really wake up. For example, several hospitals indicate that they only stopped using desflurane in recent years. Two hospitals still use isoflurane (1,800 times as strong as CO2), one of which says he will stop next year.

However, the vast majority of hospitals now say they use more propofol than before. A small group of hospitals has managed to completely reduce the use of anesthetic gases to only children and possibly even seriously ill patients.

In general, the exact extent to which the gases have been banned, and for which operations, depends strongly on the preference of the department or the anesthesiologist who is working.

This is how the St. Anna Care Group writes in response to questions from NRC that the anaesthesiologists are not very keen on using more propofol. “Unfortunately, because this would be the most sustainable solution.” In the Albert Schweitzer hospital in South Holland, “it varies according to the preference of the individual anaesthetist, but on balance this does not yet lead to a major shift”.

Vaporless days

In many hospitals colleagues try to convince each other in creative ways. For example, a ‘vapless Thursday’ was recently organized at the Jeroen Bosch Hospital in Brabant, during which less use is made of anesthetic gases. Zuyderland in Limburg is also talking about such a vapour-free day. In the Meander Medical Center in the province of Utrecht, the gases have been strongly reduced and ‘colleagues are held accountable for unnecessary use’.

But some doctors and hospitals still have doubts about whether propofol is more sustainable than anesthetic gas. For example, the Treant care group, with hospitals in Drenthe and Groningen, writes: “Whether propofol is better than vapor is very much the question if you take everything with you (the material needed to use propofol, plastic syringes, needles) and unused propofol that must be thrown away.”

This is a ghost image, says Sperna Weiland of the association of anaesthesiologists. “Comparative studies have been done that include waste and show that the environmental damage of propofol cannot be compared to that of anesthetic gases in an order of magnitude.”

Anesthesiologist Piet de Witte places the cap for the gas over his mouth to demonstrate how this works. Photo Dieuwertje Bravenboer

Capturing anesthetic gases

Another possible solution that at least five hospitals have already opted for, and even more hospitals are looking into, is capturing anesthetic gas with a special system. The gas is collected and used as a raw material for new anesthetic gases.

The Bravis Hospital in Brabant, for example, opted for such a capture system and points out in response NRC to a notice on the hospital’s site stating that it has “stopped emitting anesthetic gases”. The hospital even won an award in 2021 for the best sustainable care initiative for ‘stopping’ the emission of gases. Sperna Weiland is annoyed by this. It is “evidently incorrect,” he says, that gas will no longer be released into the air. “The German manufacturer Baxter makes big claims about capturing anesthetic gas,” says Sperna Weiland. „While a study shows that in practice only about 25 percent of emissions are prevented. I am very skeptical about such technical solutions.”

Anesthesiologist Roland van Wandelen from the hospital says that his own research has now also shown that eventually some gas is released into the air. “This concerns anesthetic gas that is later exhaled by the patient outside the operating room.”

Many hospitals have recently focused on a capture system, but have doubts now that the manufacturer’s claim turns out to be incorrect. Some want to continue anyway, because they don’t want to completely ban anesthetic gases and every little bit helps. So did St. Anthony. “We also wanted to purchase it, but the manufacturer said: that is only allowed if you also buy all your vapor from us,” says De Witte. “We put out a tender and they were much more expensive than competitors. Still, I would like to have the system, even if it only captures part of it. Just for the operating rooms that we still do with vapor, for children, for example.”

Read also: Health Council of the Netherlands: making healthcare more sustainable is not progressing

Not in children

A seven-year-old blonde girl sits up in bed as she is wheeled into the operating room. She has a tense smile on her face. On her lap, a leopard cuddly toy has a hairnet on, just like her. A surgeon is going to surgically remove a nasty spot on her back. She climbs onto the operating bed herself.

“What a hard bed.”

“Yes, it is more comfortable at home,” says an operating assistant.

De Witte enters and introduces herself to the girl.

“Hey, you know you’re going to sleep with a cap, right? Did you practice beforehand? Do you want to put it on your nose yourself? There is such a bad smell.”

“At home we have already drawn everything that will happen,” says her mother next to the bed to the doctor, while he keeps the cap on her nose. And to her daughter: “When you wake up, I will be there.”

“You are doing very well,” says De Witte to the girl. “The winner of the week. Sleep well.”

Anesthetist Piet de Witte at St. Antonius in Nieuwegein.

Photo Dieuwertje Bravenboer

For children it is too exciting, almost all hospitals think, to put them under anesthesia with an injection. Amsterdam UMC is the only hospital that in principle has no exception for children and also uses propofol for them. “Traditionally, we find it annoying to prick children,” says Sperna Weiland. “Studies show that it doesn’t really matter for children’s experience, both a cap and an injection can be experienced as traumatic. We first give the children a special adhesive so that the injection does not hurt. If a child has had an unpleasant experience with needles in the past, we will of course make an exception.”

Sperna Weiland is happy to see that most hospitals are serious about reducing the use of anesthetic gases. With the publication of international articles, he now focuses on foreign countries. “We are actually quite far in the Netherlands. There are countries, including in Europe, where hardly any attention is paid to this problem and they use the gases much less sparingly anyway. The biggest gains can now be made abroad.”

A version of this article also appeared in the newspaper of April 4, 2023

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