Sustainability in the OR – eNewsletter

Further Reduction of Oxygen and Volatile Agent Waste
Four opportunities to consider during your practice

ISSUE 4 – 2023

In our previous Sustainability e-Newsletter,
we discussed oxygen’s carbon footprint and methods to reduce unnecessary waste.

Today’s e-newsletter presents
four additional opportunities for you to
implement meaningful change in your day-to-day operations.

1.  INDUCTION: Turn down the oxygen flow  

In Issue 3, we discussed reducing from 10-15 L/M to 6-8 L/M during preoxygenation. This should be continued during induction as long as mask ventilation is unproblematic.

Minimizing the fresh gas flows during induction is especially important if adding Sevoflurane. Ideally, avoid the temptation to turn on the vaporizer during mask ventilation since you are at high flows. Consider giving more of your IV induction agent instead of using a volatile agent (unless you feel it is absolutely indicated for the situation).

Some providers begin the TIVA infusions immediately after the induction bolus in order to avoid adding a volatile agent.

2.  INTUBATION: Cease or reduce the oxygen flow

Some anesthesia machines have a function where you can cease flow during intubation. This is a nice sustainability feature; however, this is not available with all machines. Newer machines do allow quick change of total gas flow to 1 L/M, which is a reasonable compromise.

If delivering SEVO during induction, either maneuver will substantially reduce the release of volatile agent into the OR and eventually to the environment.  And, of course, be sure to turn off the vaporizer before intubation.

3.  MAINTENANCE: Accept lower FiO2 – (It’s OK!)

Issue #1 of Sustainability in the OR discussed the practice of low fresh gas flows during anesthesia maintenance. With this practice, the FiO2 tends to decrease over time. For example, if delivering 50% oxygen with 1 L/M total fresh gas flow, the FiO2 may gradually decrease into the 30-35% range. With even lower fresh gas flows, the FiO2 may trend below 30%.

However, it is important to recognize that this may be perfectly fine as long as the patient’s SaO2 is acceptable.

To state the obvious, most of our patients are living their lives breathing 21% O2 at rest and with exercise. So, we need to ask ourselves why we routinely strive to provide them with 50 -60% FiO2 while anesthetized.

Providing an FiO2 that maintains an acceptable SaO2 should be our sustainable practice goal.

4.  EMERGENCE: Turn down the oxygen flow

Emergence is another time we can reduce flows, particularly after attaining an inspired SEVO concentration of zero. Remember, as long as the fresh gas flow meets or exceeds minute ventilation, the patient will not rebreathe exhaled gases.

Gone should be the days of 12 -15 L/M flows during induction and emergence!

:: TODAY’S TAKEAWAYS ::

:: Minimize oxygen flows during all phases of anesthesia.

:: Avoid adding volatile agent during induction due to high fresh gas flow.

:: Accept an adequate FiO2 that meets your patient’s needs.

NEXT TIME in Sustainability in the OR:
”How to Make Rapid Changes in Anesthetic Concentration
Using the HAND’S ON TECHNIQUE.”
Adam

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Low flow anesthesia education:

Become a low-flow anesthesia expert and earn CME’s!
Complete this hands-on low-flow anesthesia education learning modual
(if you haven’t done so already).  Earn CMEs through APSF.org.

Low-Flow Anesthesia – Anesthesia Patient Safety Foundation

This APSF module will greatly assist you in becoming much more comfortable with the concepts of safe delivery of low flow anesthesia.
Low flow anesthesia maintenance is the single best clinical practice for us to make the most of our contribution toward protecting our planet.

Please complete this excellent activity
and gradually apply what you have learned to your practice.