Guidelines and Recommendations Special Articles 329 M. Schuster1 · H. Richter1 · S. Pecher2 · S. Koch3 · M. Coburn4 Ecological Sustainability § Compiled by the DGAI/BDA Commission on Sustainability in Anaesthesiology in Anaesthesiology and Intensive Care Medicine A DGAI and BDA Position Paper with Specific Recom- mendations* Citation: Schuster M, Richter H, Pecher S, Koch S, Coburn M: Ecological Sustainability in Anaesthesio­ logy and Intensive Care Medicine. A DGAI and BDA Position Paper with Specific Recommendations*. Anästh Intensivmed 2020;61:329–338. DOI: 10.19224/ai2020.329 1 Klinik für Anästhesiologie, Intensiv­ Summary be avoided in both the operating theatre medizin, Notfallmedizin und Schmerz­ and intensive care unit without upsetting therapie, Kliniken Landkreis Karlsruhe, This position paper with specific recom­ existing processes. Fürst­Stirum­Klinik Bruchsal, Rechberg­ mendations was commissioned by the klinik Bretten, Akademische Lehrkran­ kenhäuser der Universität Heidelberg DGAI and BDA executive committees in In addition to these measures directly 2 Klinik für Anästhesie und Intensiv­ March 2020 and was compiled by the related to the field of anaesthesiology, medizin, Diakonie Klinikum Stuttgart joint “Commission on Sustainability in this position paper addresses further 3 CharitéCentrum für Anästhesiologie und Anaesthesiology”. areas of concern indirectly associated Intensivmedizin CC 7, Campus Charité with the everyday professional role Mitte & Campus Virchow – Klinikum, With the impending climate disaster in of the anaesthesiologist. As such, the Charité Universitätsmedizin Berlin mind, the aim of this position paper is to paper alludes to the significance of 4 Klinik für Anästhesiologie, Uniklinik delineate with which specific measures RWTH Aachen sustainable mobility with regard to every­- anaesthesiologists can contribute to a day commutes, patient transfers, and consistent and sustained reduction in § Members of the Commission on conferences. Improved energy manage­ Sustainability in Anaesthesiology CO2 emissions and minimise the nega­ (in alphabetical order): ment may commence in the operating tive ecological implications associated Prof. Dr. Thomas Bein, Prof. Dr. Mark theatre and intensive care unit but must 1 with the fields of anaesthesiology and Coburn , Prof. Dr. Herwig Gerlach, ultimately encompass the whole hospital Priv.­Doz. Dr. Susanne Koch2, Dr. Ana intensive care medicine. The paper is as a significant source of CO2 emissions. Kowark, Dr. Ferdinand Lehmann, divided into six sections and, on the Dr. Sabine Pecher, Dr. Hannah Richter, Numerous measures can already be im­ Prof. Dr. Rolf Rossaint, Dr. Charlotte basis of published literature, presents plemented today, and appropriate steps Samwer, Priv.­Doz. Dr. Christian Schulz, the currently available evidence on should be taken at a local level. Last but Prof. Dr. Martin Schuster3 how anaesthesiologists can incorporate not least, the importance of research and (1: Chair DGAI, 2: Instigator, 3: Chair sustainability aspects in their professional BDA) teaching is emphasized as a key factor in sphere of influence. Special attention successfully facing the challenge of eco­ is directed towards the environmental logical sustainability in anaesthesiology effects of drugs used in anaesthesiology and intensive care medicine. and intensive care and their impact on climate change. In that regard, the direct and potent greenhouse gas effects of Preface * Resolution of the Execuitve Commitee of volatile anaesthetics are emphasized. In In March 2020 the Professional Asso­ the DGAI, dated 16.03.2020/of the BDA, consequence, specific recommendations ciation of German Anaesthesiologists dated 24.04.2020. are made on reducing the damaging (BDA) and the German Society of Anaes­ Interest to disclose effects of volatile anaesthetics on the cli­ thesiology and Intensive Care Medicine The authors have no financial or other com­ peting interest to disclose. This recommen­ mate. With regard to consumables, the (DGAI) executive committees assigned dation was unfunded. increasing use of disposable single­use the joint “Commission on Sustaina- items is the subject of critical analysis, bility in Anaesthesiology” the task of Keywords and the need to incorporate the carbon compiling a position paper with specific Guidelines – Anesthesio­ footprint in the selection of products is recommendations. Both executive com­ logy – Sustainability – Climate stressed. As waste has significant direct mittees approved the publication of this change – CO2 emission and indirect ecological effects, the 5R position paper in its current form during concept is used to show how waste can their sessions on the 16th March 2020 330 Special Articles Guidelines and Recommendations (DGAI) and 24th April 2020 (BDA). With plemented immediately at a local level the grave”, including the following po­ the publication of this position paper, by anaesthesiologists. However, a good sitions: 1) extraction of raw materials, 2) both BDA and DGAI expressly commit number of measures, including many processing and manufacturing, 3) trans­ themselves to the goal of carbon neutral, with significant leverage, are arduous to port and packaging, 4) use, reutilisation sustainable health care and will there­ implement at a local level alone. As and maintenance, 5) recycling and 6) fore, together with other actors in the such, achieving carbon neutrality in disposal. Water use and release of toxins health care sector, use their influence on anaesthesiology and intensive care are additional important factors besides politics and on the industry to actively medicine over the next three decades CO2 release [15]. further the necessary transformational will require wide­ranging technological process. innovation and significant investment in energy efficient refurbishment and in the A. Drugs Introduction infrastructure of individual hospitals. Major issues such as assuring generation R1: General anaesthesia using volatile The 2018 Intergovernmental Panel on of energy from renewable sources or re­ anaesthetics and/or nitrous Climate Change report was climate alising sustainable transport are tasks for oxide should be maintained in scientist’s warning not to exceed the society as a whole and require political such a fashion that the smallest 1.5 °C limit of global warming. Only a implementation. As a professional and a quantity of anaesthetic possible is rapid and substantial worldwide reduc­ scientific body, we will use our influence discharged into the environment. tion in CO2 emissions over the next few to demand these changes. This requires consistent use of years can avert runaway effects such In the past, close coordination between minimal­flow anaesthesia. as the melting of Antarctic ice masses practising physicians and the industry – R2: Use of desflurane should be or thawing of permafrost soils, which especially in the fields of anaesthesio­ reserved for cases in which it threaten to make the effects of climate logy and intensive care medicine – have appears mandated on medical change uncontrollable [1]. led to a variety of technical innovations grounds. Of those volatile As physicians we are under a special ob­ which have made patient care safer and anaesthetics commonly used, ligation. Over the next decades, climate opened new horizons of clinical possibi­ sevoflurane is the least potent change will lead to a change for the lity for the good of patients. Seen in the greenhouse gas. worse in health care for a great number light of the climate crisis, this close coor­ R3: Use of nitrous oxide should be of people across the planet and pose dination should be further strengthened, avoided unless its use appears grave challenges to health care systems aiming to promote the transformation to mandated on medical grounds. in almost every country [2]. At the same ecologically sustainable patient care. R4: The development, trialling and time, the health care system is itself use of scavenging and recycling responsible for significant emissions of Glossary systems for volatile anaesthetics greenhouse gases, owning 4.4% of glo­ should be expedited. bal greenhouse gas emissions in 2014 CO2e: CO2 equivalents [3]. In response, numerous professional Emissions of greenhouse gases other R5: In contrast to inhalational anaesthesia techniques, total medical bodies have issued their own than CO2 can be converted to CO2 statements alluding to the urgent need to equivalents. This entails calculating the intravenous and regional anaes­ thesia do not intrinsically cause reduce CO2 emissions across the health quantity of CO2 which would exhibit care sector [4–8]. Physicians are called the same effect in the atmosphere as the direct greenhouse gas emissions. upon to adjust their consumer behaviour emission in question by using the mass Use of these techniques to avoid and – in the spirit of divestment cam­ of that emission and its Global Warming greenhouse gas emissions is judi­ paigns – their investment decisions to Potential [13]. cious when they are appropriate prioritise climate protection [9]. from a medical standpoint. GWP: Global Warming Potential R6: Pharmaceutical waste should be As high­tech, resource hungry fields, The Global Warming Potential describes avoided on both economic and anaesthesiology and intensive care me­ the substance­specific greenhouse effect ecological grounds. dicine are involved in a significant por­ compared to CO2 over a specified length tion of CO2 emissions across the health R7: Pharmaceutical