Anesthesia Equipment and Supplies: Greening the Operating Room and Perioperative Arena

Plastic pollution is a growing concern. Without change in current practice, the volume of all the plastic in the world’s oceans is expected to exceed that of the fish by 2050.⁴⁴ Microplastics and nanoplastics are ubiquitous in rain and tap water,⁴⁵ and in table salt,⁴⁶ and are found in human placenta and meconium,⁴⁷ blood,⁴⁸ and wild animal stool⁴⁹. Chemical additives (e.g., phthalates) that impart desirable characteristics to plastics, such as pliability, are known endocrine disrupters and are found in human urine, blood, and sweat.⁵⁰ Carcinogens and neurotoxins are also released through production and incineration of plastics.⁵¹ Plastics are derived from fossil fuels and their production and combustion contribute significantly to air pollution and greenhouse gas emissions.⁵¹

Supply chains are responsible for between 60-80% of health care system greenhouse gas emissions.^37-43 While emissions embedded in the supply chain are outside the direct control of health care organizations, there are two important ways to influence these emissions. First, through addressing drivers of wasteful and low-value resource consumption, anesthesiologists can work to eliminate unnecessary pollution and increase supply chain resilience by becoming better resource stewards. Second, through procurement decision-making, health care organizations can leverage their purchasing power (individually and collectively through group purchasing organizations) to influence manufacturers and distributors to improve the environmental performance of the products and services they provide. An important example is the Greener NHS program, which has a net-zero road map for suppliers. All vendors are required to report organizational emissions (e.g., using the Carbon Disclosure Project) ⁵² and demonstrate carbon mitigation progress according to science-based targets and timelines.⁵³ Beyond ensuring corporate responsibility, there are several management strategies health care organizations can employ to incentivize environmentally preferable performance of supplies.⁵⁴

Single-use Disposable Versus Reusable Equipment

In addition to traditional criteria for equipment selection such as cost, efficacy, and ease of use, environmental considerations now play an important role in equipment choices. Both due to convenience and perceptions around infection prevention, in recent decades a trend has developed toward more single-use disposable devices¹³⁶. Greater awareness of environmental and public health harms stemming from supply chain pollution, as well as the need for improved resilience, are driving a renewed appreciation for reusable devices. Both disposable and reusable equipment cause some harm to the environment; however, it is not immediately obvious which is least harmful. For example, single-use disposable devices do not require energy and water for decontamination whereas reusable alternatives require substantially fewer materials and less energy for manufacturing and waste disposal. Several LCAs in the biomedical literature have systematically examined the total life cycle impacts and demonstrated environmental and cost benefits of reusable devices.^{13,15,32,54,55} For example, single-use disposable rigid laryngoscope handles and blades result in 16-25 and 6-8 times more greenhouse gas emissions, respectively, using standard U.S. energy mix when compared to alternative reusable devices under different approved cleaning scenarios.¹⁵ Life cycle costs of procurement, labor, and materials for cleaning, refurbishing, repackaging, and waste disposal management at one hospital in the northeastern U.S. in 2018 found that, when extrapolated over one year (60,000 intubations), estimated costs increased between $495,000 and $604,000 for single-use disposable handles and between $180,000 and $265,000 for single-use disposable blades when compared to reusables.¹⁵ Costs will vary between institutions; however, this study exemplifies the virtue of life cycle costing across an organization as opposed to misleading results from focusing on siloed cost assessments from either procurement or the central sterilization and supply departments.

Whereas the energy mix (fractions from petroleum, natural gas, coal, nuclear, and renewable sources) in the study above assumed average U.S. fractions, if conducted in Europe, the results would favor reusables even more substantially owing to Europe’s greater average reliance on clean energy. However, the same study conducted in Australia or China would tend to slightly favor single-use disposable alternatives, owing to their heavy reliance on dirty energy (especially brown coal).^{10,15,17,54,56} This supports the importance of transitioning to clean energy sources. This also exemplifies the need to question study context when interpreting literature.

Reprocessed Equipment

Because a device is labeled as single-use disposable does not mean it cannot be re-used. Rather, it means an entity that reuses it must ensure it is safely decontaminated and functions as the original manufacturer intended. Reprocessing of single-use devices has largely been outsourced to a third-party industry that is regulated by the FDA.^14,54,57,58 The Medical Device User Fee and Modernization Act (MDUFMA) of 2002 requires that all reprocessed single-use disposable devices be labeled as such with the identification of the reprocessing company. All adverse events associated with their use are required to be reported to the FDA. In January 2008, the U.S. Government Accountability Office (GAO) released a report indicating reprocessed single-use disposable devices do not present an increased health risk to patients.⁵⁸ Of the 434 adverse events reported to the FDA between 2003 and 2006 in which reprocessed single-use disposables were identified, only 65 actually involved a reprocessed device, and all adverse events were similar to those reported for new devices.

Examples of disposable perioperative equipment commonly reprocessed include simple devices such as pulse oximeter probes, blood pressure cuffs, and compression sleeves, as well as complex devices such as laparoscopic surgical trocars and harmonic scalpels. Many individual hospitals and health systems have recorded significant cost savings by selling used single-use disposable devices to reprocessing vendors and buying reprocessed medical equipment at a substantial discount.^59,60 Peer-reviewed research is beginning to demonstrate reprocessed single-use devices are environmentally preferable to reusable equipment, e.g. invasive angiography catheters61, however more research is required on various complex devices.^14,54

Kit Reformulation

Procedure supplies are frequently packaged as kits to ease case preparation. Prefabricated kits are designed to appeal to a large variety of providers and therefore contain supplies that are not routinely used during each procedure and are consequently re-cleaned (reusables), or thrown away (disposables), despite being unused. Unused consumable components in kits may not be used on subsequent patients, as they have already been “bought.” One strategy to prevent waste and save costs is to reformulate and streamline kits. This should be done for kits assembled internally, as well as prefabricated kits assembled by third-party vendors. A challenge includes gaining agreement by providers on the items deemed essential components.⁶²

The Environmental Impact of Manufacturing and Disposing of Capital Anesthesia Equipment

Care must be taken to avoid premature equipment upgrades that are both costly to organizations and environmentally harmful. Capital equipment, such as anesthesia machines and monitors, are composed of metals, molded plastics, and rare earth metals contained in computer components. Manufacturing and finishing of both metals and plastics often involves the release of environmental toxins. For example, the computer industry uses more than 1,000 hazardous substances in the manufacturing of computer chips. Chip factories in Silicon Valley have left a legacy of pollution, creating 29 superfund sites in Santa Clara County, California, alone. In 2008, the U.S. Environmental Protection Agency (EPA) amended the Clean Air Act adding National Emission Standards for Hazardous Air Pollutants (NESHAP).⁶³ The legislation targets air pollution from nine metals, including cadmium, chromium, lead, manganese, and nickel, which are often emitted into the air from various operations at metal and electronic fabrication and finishing plants.

The disposal of capital medical equipment also poses problems for the environment. Older anesthesia machines and monitors often can be refurbished and resold or donated. Some component materials are potentially recyclable, such as stainless steel, aluminum, brass, zinc, nickel, and copper. The challenge is to separate the reusable and recyclable materials from the non-reusable ones. Purchasing agreements can be negotiated to require returning old equipment for refurbishing and donation, repurposing of parts, or recycling by a third-party verified green vendor.

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