Anesthesia Patient Safety Podcast
The official podcast of the Anesthesia Patient Safety Foundation (APSF) is hosted by Alli Bechtel, MD, featuring the latest information and news in perioperative and anesthesia patient safety. The APSF podcast is intended for anesthesiologists, anesthetists, clinicians and other professionals with an interest in anesthesiology, and patient safety advocates around the world.
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Anesthesia Patient Safety Podcast
#246 Ditching Nitrous Oxide: The Bike Commuter's Guide to Safe and Sustainable Anesthesia
Dr. Liz Hansen takes us behind the scenes of a remarkable transformation at Seattle Children's Hospital, where pediatric anesthesiologists have reduced their greenhouse gas emissions by over 90% without compromising patient safety. A lifelong environmentalist and bike commuter, Dr. Hansen was shocked to discover that anesthesia gases contributed to 7% of her hospital's total emissions. This revelation sparked a personal and professional journey to align her clinical practice with her environmental values.
The conversation reveals practical strategies for reducing anesthesia's carbon footprint, from eliminating nitrous oxide to implementing low-flow techniques. Dr. Hansen shares how her team gradually won over colleagues by demonstrating that sustainable practices could maintain or even improve patient outcomes. She offers detailed insights into working with child life specialists, adapting mask induction techniques, and using data tracking to drive continuous improvement.
What makes this story particularly powerful is the ripple effect beyond a single institution. Dr. Hansen co-founded Project SPRUCE (Saving Our Planet by Reducing Carbon Emissions), an international consortium of anesthesia groups collaborating to reduce their environmental impact. Member organizations have already achieved their first-year goal of 50% emissions reduction, with more ambitious targets on the horizon.
For anesthesia professionals concerned about climate change but unsure how to make a difference, this episode offers hope and concrete action steps. Remember, "the antidote to despair is action." Download the Yale Gassing Greener app, try a nitrous-free induction on your next cooperative patient, or advocate for addressing gas leaks in your facility's central supply system. Your individual choices matter, especially when they inspire others to follow your lead.
For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/246-ditching-nitrous-oxide-the-bike-commuters-guide-to-safe-and-sustainable-anesthesia/
© 2025, The Anesthesia Patient Safety Foundation
You're listening to the Anesthesia Patient Safety Podcast, the official podcast of the Anesthesia Patient Safety Foundation. We're bringing you the very best from the APSF newsletter and website, as well as the latest information in perioperative patient safety. Thanks for joining us.
Speaker 2:Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel and I'm your host. Thank you for joining us for another show. We have an exciting interview series that we are kicking off today, all about safe and sustainable pediatric anesthesia care. We talk about the scope of the problem and what anesthesia professionals can do to make sustainable and safe anesthesia care part of their practice for all patients. Our guest on the show today is Dr Liz Hansen, so stay tuned for our conversation about this important topic. Before we dive further into the episode today, we'd like to recognize Draeger Medical, a major corporate supporter of APSF. Draeger Medical has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care, that no one shall be harmed by anesthesia care. Thank you, draeger Medical. We wouldn't be able to do all that we do without you. And now my conversation with Dr Liz Hansen. Welcome to the show. Can you introduce yourself and tell us a little bit about your anesthesia training career and your current role?
Speaker 3:Hi, well, thanks for having me here. I'm Liz Hanson. I'm a pediatric anesthesiologist at Seattle Children's Hospital and an associate professor of anesthesiology and pain medicine at the University of Washington. I graduated from the medical scientist training program at Washington University in St Louis and then I did my residency training at UW and stayed on at Seattle Children's for my pediatric anesthesia fellowship.
Speaker 2:So can you tell us what got you interested in pediatric anesthesia and sustainability?
Speaker 3:Starting out in medical school, I knew I wanted to work with kids. I thought I'd become a pediatric infectious disease specialist, like my undergraduate research mentor. Once I got into the clinical rotations, though, I realized I just loved the operating room, setting doing procedures and working at a faster pace. I then got the chance to do a pediatric anesthesia rotation and the decision was made. It's the best job I get to play games with my patients, help take away their pain and guide them through a stressful and scary experience, all while working with the best team of surgeons, nurses, techs and anesthesia colleagues.
Speaker 3:My interest in sustainability has been pretty lifelong. I've always been a recycling champion, a bike commuter, an environmentalist. The connection to anesthesiology began when I started as an attending, nearly eight years ago now. Anesthesiology began when I started as an attending. Nearly eight years ago now, I had the chance to meet with our sustainability manager at Seattle Children's Hospital, colleen Grohl, to discuss the hospital's greenhouse gas inventory. She actually performed this inventory as part of the hospital's commitment to sustainability and, as you know, delivery of healthcare causes unnecessary pollution and contributes to the problems of global warming and a less healthy planet for our patients. This poses an existential threat to the health and lives of people all over the world.
Speaker 3:In June 2022, seattle Children's Commitment to Sustainability strengthened with signing on to the HHS Healthcare Sector Pledge. Our CEO, dr Jeff Sparing, committed to reducing the organization's emissions and achieving carbon neutrality by 2025. So this year, actually so. Colleen showed me the data for anesthesia gases, based on our annual purchasing data of these agents, and I was shocked to learn that 7% of our total hospital's emissions were from the gases that I was using every day to care for my patients. She also introduced me to some tools and resources that showed how to deliver lower emissions anesthetics to our patients without compromising safety.
Speaker 2:Can you tell us some more about your work with eliminating the use of nitrous oxide? How did you get started on this project and what have you learned along the way to help others out who might be interested in doing the same thing?
Speaker 3:Well, I've learned a lot. When I started out in training, the dogma for all of us was that any patient getting an inhalation induction, except for maybe little babies, should get 50% nitrous oxide with sevoflurane. I was also taught to use high flow nitrous oxide for teenagers during IV placement. But then I did the math using the Yale Gassing Greener app, which is a really great resource for those who might want to download it, and I found that even just five minutes of nitrous oxide at 50% at our typical fresh gas flows was equivalent to driving about 25 miles in a standard gas powered car. And that's just for a few minutes for one patient.
Speaker 3:So at this time I was biking to work, I was avoiding driving my car unnecessarily. But then when I, you know, I was biking to work, I was avoiding driving my car unnecessarily. But then when I was at work, I had this massive carbon footprint. So I phased nitrous out of my routine practice and I realized I could still provide my patients with a really smooth experience. I had to modify my technique a little bit. I did more mask preparation, coaching and distraction, but I got pretty good at it rather quickly.
Speaker 3:I'm also lucky enough to work with a team of really talented CRNAs who were really they were game to try without nitrous as well, and I could see their skills growing as we learned how to do this. Together and a few more colleagues joined our nitrous free cohort and we educated the group over the next year and now our entire anesthesia group at Seattle Children's uses nitrous oxide for fewer than 1% of our patients and our outcomes remain really excellent. We have very high family satisfaction scores and all of our other balancing measures have remained the same or improved throughout other QI work.
Speaker 2:Really interesting how you are able to start from just a small cohort and then branch out over your entire department. Well done, and don't worry to our listeners, I will include the information about any apps and resources that we talk about on the show today in the show notes as well. Now can you tell us a little bit more about mask acceptance and the use of child life?
Speaker 3:I cannot sing the praises of child life specialists enough. They are amazing. They're caring individuals who make such a difference for our patients. I work really closely with our child life team and I actually I began talking with them about our efforts to reduce emissions, including our transition away from nitrous oxide, and they were really interested. They invited me to give a presentation about sustainability and anesthesia to their entire child life group and they were completely interested. They invited me to give a presentation about sustainability and anesthesia to their entire child life group and they were completely on board to support our efforts in emissions reduction.
Speaker 3:So now when I have a patient who might be nervous about anesthesia and especially mask induction, I try to involve our child life specialists early on. They help with introducing the mask to the child. They offer scents to paint inside the mask. They offer stickers for decoration. They'll also help the child practice breathing through the mask even before we arrive at the operating room. They partner with families to meet the child where they are and help with providing appropriate distraction as well.
Speaker 3:Another technique we've learned as we do nitrous-free mask induction is coupled with another low emissions tactic low fresh gas flows.
Speaker 3:So what I do? I typically start oxygen only at about three liters per minute and help the child get used to the feeling of breathing through the mask even before introducing any gas. The flow is low enough that it's not a blast of air up their nose and they can take a moment to get used to it without you worrying that if they move away, everyone else in the room is breathing their SIVO fluorine. So then, once they're used to the mask with oxygen alone, we turn the SIVO vaporizer on while using our handy distraction methods, and I often coach at this point some older kids. They can breathe through their mouth at this point, so the smell is less noticeable. For kids that can cooperate with a vital capacity breath, I offer the option of a faster induction with a primed circuit. So there we would practice the deep breaths with the mask only and then, when they're ready, connect the hose to the mask, and some of the older kids do really well with this method and they're asleep within two to three breaths.
Speaker 2:That's really great to be able to have different options for children who are at different ages and developmental stages too, which is one of the hallmarks of pediatric anesthetics. So how can anesthesia professionals get started for making these changes in their department, and what have you learned along the way?
Speaker 3:For many of my peers and patients, the issue of climate change is daunting, never mind confronting the fact that, while working to care for our community on a daily basis, we're now finding out. You know we're contributing significantly to global warming. But, as one of my really inspirational colleagues likes to say, the antidote to despair is action and there are reasons to be optimistic. Anesthesiologists in particular have the potential to have a major impact on the environmental footprint of a hospital. So I would say, if you're interested in this and you're still using nitrous oxide, I encourage you to try a nitrous-free induction on your next patient. You can start with a cooperative patient who is likely to accept the mask well and then move into more challenging cases after that. Try out some of the apps on your phone or a tablet for distraction and spend an extra minute with your patient ahead of time to prepare them for the mask. Other simple but impactful practice changes include turning off fresh gas flow rather than turning off the vaporizer. When performing airway management like intubation, you can use low fresh gas flows even with sevofluorine, as modern CO2 absorbers do not cause compound ape creation. The ASA now even has a statement in favor of low flow use with sevofluorine. If you want to learn more about low flow, I highly recommend the APSF course on low flow, and we'll link to that as well. Other tips avoid desfluorine along with avoiding nitrous oxide, as they are both very potent greenhouse gases and nitrous oxide also depletes the ozone layer.
Speaker 3:At a departmental level, folks can identify a sustainability champion to lead their group. Maybe that's you. We have found that education and socialization, along with practice constraints and data feedback, have allowed us to reduce the environmental footprint of our inhaled anesthetics by over 90%. This requires support from leadership, ongoing educational efforts for new hires and rotating trainees and some method for data collection and feedback. We use a software solution developed by my colleague, dr Dan Lowe, called Adaptix. Using this software, we can easily track our emissions, identify folks with the lowest emissions to serve as role models and educators and pinpoint the areas to focus on next, along with monitoring our balancing measures.
Speaker 2:That is really interesting. How often do you get a report on your own usage and emissions?
Speaker 3:So with Adaptix you can look at the data all the way up to the day before.
Speaker 3:So I can go and right now pull up a report and see what my emissions were for the patients that I took care of yesterday.
Speaker 3:And so, as the champion in my department, I was creating reports for our entire group on a monthly basis when we first started this project and now that we are really in kind of a new steady state, I don't send out reports every month but rather about every quarter. But anytime people want they can log into the software and query their data and look to see what their emissions are for their own cases. We also use it to look at different surgery types. So we were able to identify that ENT was one of our more challenging areas because those are short cases. So the impact of the inhalation induction is really hard to overcome and you know cases like ear tubes, where we may be holding a mask for the entire case, tend to have higher average emissions, average per minute emissions. And again, you know, with various approaches and strategies we were able to reduce those emissions, but the software allowed us to really identify where we needed to do that work.
Speaker 2:That is awesome. Can you tell us more about your work with sustainability? How can anesthesia professionals practice more sustainable anesthesia, especially with pediatric anesthesia, and why are you so passionate about sustainability?
Speaker 3:Well, along with the gas-related emissions reduction work we're doing in the ORs, I chair the perioperative green team and support that team in waste reduction, recycling and other sustainability efforts. In the OR and the perioperative space. Our team participates in the annual Drawdown Eco Challenge which is coming up soon, and that encourages folks to think about sustainability in their daily lives. We can include a link about that as well. When we published our emissions reduction work, it garnered a lot of interest around the world actually, and we were able to start an international consortium of anesthesia groups interested in working together to reduce emissions, called Project SPRUCE, and that stands for Saving Our Planet by Reducing Carbon Emissions. My co-PI for this project, dr Diane Gordon, is an internationally recognized leader in sustainability and chairperson for the Society for Pediatric Anesthesia Special Interest Group. In Sustainability we're mentored by past SPA president, dr Lynn Martin. The founding members of this consortium have already achieved their first goal of reducing emissions by 50% within the first year of the project, and so now we're working on additional reductions and setting additional goals.
Speaker 2:These are some excellent resources. Now, is sustainable anesthesia compatible with safe anesthesia? How can anesthesia professionals provide safe and sustainable anesthesia for their patients?
Speaker 3:Sustainable anesthesia is absolutely safe. Our consortium has shown that outcomes are the same or better with lower emissions anesthesia. Use of low flow anesthesia is safe with modern CO2 absorbers and vigilant attention to volatile concentration and FiO2. Avoiding nitrous oxide during induction allows for higher FiO2 and better pre-oxygenation. Use of propofol-based Tevas is both lower emissions and associated with improved outcomes like reduced emergence delirium, lower rates of postoperative nausea and vomiting and fewer respiratory complications.
Speaker 2:What do you hope to see going forward when it comes to sustainable and safe pediatric anesthesia care?
Speaker 3:I hope that sustainable methods for anesthesia become the default in pediatric anesthesia practices. We should track our emissions as a quality metric while monitoring balancing measures to ensure we continue to provide safe and effective care.
Speaker 2:So what's next for your research or upcoming projects?
Speaker 3:Well Project Spruce has grown and continues to recruit new members. Folks seem to be really eager to work on sustainability in healthcare and want to maximize their impact through collaboration. We continue to work together on reducing emissions and are planning to publish our first round of results, hopefully this year. At a local level, I'm working with my hospital to reduce nitrous oxide waste in our centrally piped supply. We are moving to portable tanks that can be closed off between uses, which would allow us to reduce nitrous oxide waste by over 90%. Most hospitals and surgery centers with centrally piped supplies of nitrous oxide have enormous inefficiencies as gas leaks from manifolds, tank pressure release valves, pipe fittings and connections, and we'll link to some papers that go over this problem as they've been recently published.
Speaker 2:That seems like a very good first step that doesn't even require anesthetic practitioners to change their models, because they can just stop the waste that's happening with piped in centrally piped in nitrous.
Speaker 3:Yeah, absolutely, and that that project is something that every hospital in ASC that has centrally piped nitrous should be tackling. I will say that reducing clinical use of nitrous oxide makes it easier because you won't have to change over the portable tanks as frequently and it helps to convince the hospitals that this is an important project. If you're able to reduce your clinical use and then still show that you know there's quite a lot of nitrous oxide that's being purchased, it can make the argument that the leak problem is, you know, is significant and needs to be addressed.
Speaker 2:Now, is there anything else that you want to share that we have not talked about already today?
Speaker 3:Well, my parting words, I think, would be to lead by example. As a physician, you are already a leader. Patients and colleagues listen to you, especially if you lead with knowledge, clarity and passion. Your individual actions and choices do matter, especially when working in healthcare and you're able to influence others. Physicians and hospitals must lead the way. Anesthesiologists have always been leaders in patient safety, and now we must lead in greeting the OR to combat the climate crisis.
Speaker 2:Thank you so much for joining us on the show today. We are looking forward to seeing more about your work and what comes next. Thank you so much, seeing more about your work and what comes next. Thank you so much. Thank you so much to Dr Liz Hansen for joining us on the show today. If you have any questions or comments from today's show, please email us at podcast at APSForg.
Speaker 2:Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF dot org for detailed information and check out the show notes for links to all the topics and apps and resources that we discussed today. If you like listening to our show that we discussed today, if you like listening to our show and we hope that you do please take a minute to give us a five-star rating wherever you listen to your podcasts and share this podcast with your colleagues or anyone you know who is interested in anesthesia patient safety. This is a great way to expand our listeners and to help make anesthesia safer all around the world. Thank you for listening and sharing. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.