Anesthetic gas switch in Quebec: Shift is slow, some say

A little over a year ago, INESSS published a notice recommending switching to a much less polluting anesthetic gas in order to reduce the carbon footprint, particularly in operating rooms, in addition to reducing costs. As cuts are being made to the healthcare system, anesthesiologists are wondering why the uniform implementation of this recommendation is taking so long.

In its opinion, the National Institute of Excellence in Health and Social Services (INESSS) indicated that it recommended sevoflurane anesthesia and the elimination, “except in very exceptional situations,” of the use of desflurane, which has a carbon footprint 40 times higher than sevoflurane.

In 2023, the number of hours of general anesthesia with desflurane represented only three per cent of the total number of anesthesia hours associated with halogenated agents, but this gas generated 51 per cent of the tonnes of CO2 equivalent associated with these agents.

Additionally, gradually replacing desflurane with sevoflurane could save $204,400 over three years. “It’s not a huge amount, but it’s still a significant amount that could certainly be used for better things than wasting it this way,” says anesthesiologist Stephan Williams.

“What makes us clinicians sad is to see cuts sometimes in things that are important for patients or things that we cannot develop, that we would like to develop and that we are told it is for budgetary reasons. At the same time, there are expenses like this that are made without benefit to the patient while the reports from our own institute of excellence – which also cost something to do – tell us to stop doing it.”

Santé Québec assures that it is working

INESSS also recommended shutting down the pipes in healthcare facilities that distribute nitrous oxide—another polluting gas that has a lifespan of 109 years in the atmosphere. “That doesn’t mean going into the walls and ripping out all the pipes; that’s a fairly simple job. There’s a central nitrous oxide tank, where we disconnect the large nitrous oxide canisters, then we put caps where the nitrous oxide was coming out of the walls. We write to everyone, we coordinate, we say, ‘Now, if you want some, it’s going to be with canisters.’ Then it’s done,” Williams said.

He is co-medical manager of the CHUM’s Strategic Committee on Carbon Neutrality and Sustainable Development, which aims to achieve carbon neutrality by 2040. Moreover, he points out that the CHUM had already closed the central nitrous oxide pipelines even before the publication of the INESSS report.

Several institutions have stopped using desflurane, but others continue to purchase it, according to Williams. Desflurane has also not been removed from the provincial drug list, contrary to INESSS’s recommendation.

Santé Québec has announced that the INESSS recommendations will be followed and that work is underway. In an email to The Canadian Press, the government-owned corporation stated that it is “committed to reducing the environmental footprint of the healthcare network and integrating the principles of sustainable development into its clinical practices.”

“The establishments (CISSS and CIUSSS) have initiated steps to gradually reduce the use of desflurane, a particularly powerful greenhouse gas, in favour of less polluting alternatives, such as sevoflurane,” wrote Santé Québec, without specifying what steps had been taken in this regard.

“If anything is moving forward, we don’t see it. Neither on the ground nor in communications,” Williams says impatiently. He points out that a lot of good work is being done in environmental sustainability of care without compromising quality, but unfortunately, he says, he sees a failure on the part of Santé Québec to generalize the local successes of clinicians.

“I’ll believe it when I see it”

“What I understand from just informal discussions with my colleagues is that many centres stopped using it (desflurane) following the publication of the report. But this group-by-group, individual-by-individual work is not something that comes from the ministry or Santé Québec, and yet, they are the ones who commissioned this report,” says Williams, who coordinates the carbon neutrality committee of the Association of Anesthesiologists.

Indeed, the Ministry of Health and Social Services has mandated INESSS to formulate recommendations on best clinical practices to reduce the carbon footprint of general inhalation anesthesia. The ministry made this request following a request from the Association of Anesthesiologists of Quebec.

On March 24, the Deputy Minister of Health and Social Services sent a letter to Santé Québec asking it to follow up on the INESSS’s advice to review the use of gases in order to reduce the carbon footprint in the health network.

“In accordance with the proposed recommendations, the MSSS has requested that the use of desflurane be minimized or even stopped, while leaving room for its use for reasons of specific medical necessity. A gradual approach is recommended to achieve this, in order to ensure compliance with existing contracts,” the ministry stated in an email.

While Williams is encouraged that Santé Québec wants to move forward with the recommendations, he is skeptical. “I’ll believe it when I see it,” he says.

—The Canadian Press’s health content is funded through a partnership with the Canadian Medical Association. Editorial choices are solely those of The Canadian Press.

–This report by La Presse Canadienne was translated by CityNews