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.
The Anesthesia Patient Safety Podcast delivers the best of the APSF Newsletter and website directly to you, so you can listen on the go! This includes some of the most important COVID-19 information on airway management, ventilators, personal protective equipment (PPE), drug information, and elective surgery recommendations.
Don't forget to check out APSF.org for the show notes that accompany each episode, and email us at podcast@APSF.org with your suggestions for future episodes. Visit us at APSF.org/podcast and at @APSForg on Twitter, Facebook, and Instagram.
Anesthesia Patient Safety Podcast
#247 Nudge Your Way to Greener Pediatric Anesthesia
Climate change has arrived in the operating room, and pediatric anesthesiologists are taking action. Dr. Eva Lu-Boettcher, pediatric anesthesiologist and Director of Anesthesia Quality and Safety at the University of Wisconsin Children's Hospital, shares her journey toward sustainable anesthesia after witnessing firsthand the effects of climate change—including her Wisconsin community experiencing the world's worst air quality from wildfires.
The healthcare sector contributes a staggering 8% of total U.S. greenhouse gas emissions, with anesthesia practices like high fresh gas flow during pediatric mask inductions representing significant contributors. Dr. Lu-Boettcher reveals how simple adjustments to match fresh gas flow with a patient's minute ventilation can dramatically reduce carbon emissions without compromising safety or induction effectiveness.
What makes Dr. Lu-Boettcher's approach particularly fascinating is her application of behavioral science and "nudge theory" to achieve lasting change. By implementing default ventilator settings, providing comparative feedback to providers, and creating electronic reminders, her team achieved a remarkable 41% increase in compliance with sustainable practices.
Ready to make your anesthesia practice more sustainable? Listen now to learn practical techniques for greener pediatric anesthesia care that maintains the highest safety standards while protecting our planet. The future of anesthesia must balance excellent patient care with environmental stewardship—and the time to start is now.
For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/247-nudge-your-way-to-greener-pediatric-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 are continuing our interview series on safe and sustainable pediatric anesthesia care with experts in the field. We talk about the scope of the problem and what anesthesia professionals can do to make sustainable 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 Eva Lou Betker. Stay tuned for our conversation about this important topic. Before we dive further into the episode today, we'd like to recognize Eagle, a major corporate supporter of APSF. Eagle has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, eagle. We wouldn't be able to do all that we do without you. And now my conversation with Dr Eva Lou Betker To get started today. Can you please introduce yourself and tell us about your anesthesia training career and your current role?
Speaker 1:My name is Eva Lou Betker. I'm a pediatric anesthesiologist at the University of Wisconsin in the United States. I completed my residency and fellowship at the University of Michigan and have been practicing in the field of pediatric anesthesia since I'm currently the director of anesthesia quality and safety at the Children's Hospital. At our institution, I've been focusing our QI efforts on initiatives to help reduce carbon emissions, which has led to a significant shift in our practice.
Speaker 2:Today we're going to be talking about pediatric anesthesia and sustainability. What got you interested in this area?
Speaker 1:Yeah, great question. My personal interest in pediatric anesthesia sustainability started years ago, initially due to conversations with our co-workers who, like me, were starting to notice the impact of climate change on our daily lives. We lived in the northern part of the central US and ice cover over our Great Lakes is at a record low, affecting our severity of our winter. Snowstorms In their summer and spring, floods and wildfires have significantly impacted our friends' and families' lives, and in the summer of 2023 alone, pollution from wildfires were so severe that it limited my young children's ability to play outside.
Speaker 1:At one point, we had the worst air quality in the world, right here in Wisconsin. As a parent looking to protect our children's future, I wanted to dive much deeper into what we can do to limit our contribution to climate change, even at work. In the US, the health care sector contributes to around 80 percent of the total US greenhouse gas emissions, higher than most other developed nations. In pediatric anesthesia, high fresh gas flow used during mass inductions, volatile waste during mass-only anesthetics and the frequent use of nitrous oxide are really great potential areas to reduce our carbon footprint.
Speaker 2:Now we're going to be talking about how to make changes in anesthetic practice to a more sustainable anesthetic, so can you tell us more about behavioral sciences and nudges in anesthesia? How does this work and how can anesthesia professionals use this method for making changes in their department?
Speaker 1:Yes, of course. Nudge theory is based on the idea that our choices are influenced by how these choices are really presented to us. The concept is coined by Thaler and Sunstein and encourages us to understand how people think and make choices, incorporating behavioral economic insights to nudge people towards particular decisions or outcomes. Nudges are actually all around us In the operating room. For example, by setting lower default tidal volumes in our anesthesia ventilators, we can help increase compliance with lung protective ventilation to our anesthetics. This is an example of a default nudge. In other operating room examples, real-time reminders via electronic anesthesia records to redose antibiotics can lead to a significant increase in correctly re-administered second doses of antibiotics, and this is an example of a prompting nudge. So these are just a few examples of how nudges can be utilized in anesthesia to guide our behaviors towards safer and higher quality of care within our practice.
Speaker 2:All right now, if we put the two together. Can you tell us about your work with sustainability and nudges? How can anesthesia professionals practice more sustainable anesthesia, especially with pediatric anesthesia?
Speaker 1:My work in sustainability leverages nudge interventions to help guide anesthesia professionals towards greener OR practices. Lately we've been focusing on mass conductions. During mass conduction, excessively high fresh gas flows lead to volatile waste. However, reducing fresh gas flows should take account of maintaining safe and effective concentrations of volatiles. For a timely induction, the key really is to use fresh gas flows that do not exceed a patient's minute ventilation. In general, when using induction fresh gas flows that approximate a patient's minute ventilation, we can prevent rebreathing, which can potentially slow down induction speed and reduce efficacy of our induction. As fresh gas flow is increased above minute ventilation and rebreathing is eliminated, there's really no increase in induction speed and just increased volatile waste. And for the purposes of mass conduction in pediatric population, the minute ventilation can be estimated to be around 150 mLs per kilogram. So this is approximately 3 liters per minute of fresh gas flow in patients under 20 kilograms and up to 6 liters per minute for patients above 40 kilograms. To put this into perspective, for an uncomplicated 10-kilogram pediatric patient, when the stevofluorine vaporizer is set to a maximum value of around 8% for a three-minute mask induction, the carbon emissions difference between using minute ventilation-based fresh gas flow and just 10 liters per minute of fresh gas flow is really equivalent to driving 6.5 miles in a car. So if you think about how many three-minute inductions we're doing via mask and how many we perform in a year, this is a significant contribution to our carbon footprint.
Speaker 1:So at our children's hospital we instituted minute ventilation-based mask induction strategies using several nudge interventions in conjunction with provider education.
Speaker 1:First of all, we set our default fresh gas flow during induction to three liters per minute on our ventilators, with a quick button option to increase fresh gas flow based on patient's weight.
Speaker 1:So this has resulted in a great 41% increase in compliance with minute ventilation based fresh gas flow during induction. Second, we utilized monthly provider email feedback indicating their individual compliance with minute ventilation based induction fresh gas flow compared to their colleagues. This is a form of social norm nudge and this has resulted in an 11% increase in compliance as well. Third, we instituted reminders in our intra-op electronic records at the beginning of the case to display the appropriate induction fresh gas flow based on patient's minute ventilation weight, and this has resulted in an additional 10% increase in compliance. So, interestingly, changing defaults at our institutions seem to have affected provider behaviors pretty evenly across the board amongst our faculty trainees, crnas and anesthesia assistants. However, provider feedback and reminders seem to have affected trainee behaviors a little bit more than the other groups. All of these behavior changes have been relatively sustained since we started our initiatives about two and a half years ago.
Speaker 2:Oh, that is so interesting about the trainees being more susceptible to changes after getting provider feedback and reminders. It probably says a lot about where they are in their career and how they are kind of in this process of getting feedback and making changes, and that's how they're able to incorporate it very easily.
Speaker 1:Yeah, absolutely, and it's interesting that defaults have pretty evenly affected provider behaviors, despite their background, training and years and experience, and that indicates to me that that mode of nudge seems to be a lot more effective in the operating room, at least for sustainability initiatives, especially when we're under time pressure to make some of the decisions quickly in the beginning of the case.
Speaker 2:Now the other thing we really want to combine is sustainability and safety. So is sustainable anesthesia compatible with safe anesthesia? How can anesthesia professionals provide safe and effective sustainable anesthesia, especially during induction?
Speaker 1:Absolutely Sustainable anesthesia can be very much part of safe and effective anesthesia. Our goal with any mask induction is to ensure that we provide safe and effective concentrations of volatile agent to induce patients smoothly. We had talked briefly about how re-breathing can impact this process and we can discuss a bit more about priming here as well. So during a mask induction without priming, much of the anesthetic initially supplied by the fresh gas flow is diluted by the exiting gas into the breathing system. As mass conduction proceeds. Fresh gas flow fills the inspiratory limb during inspiration and then the internal components, such as the absorbent canister and the reservoir bag during exhalation.
Speaker 1:The inspired anesthetic concentration rises with each breath. However, priming will increase this concentration of anesthetic in the internal components of the breathing system even before induction, which will help reduce the dilution of the anesthetic and the fresh gas flow once induction begins to speed up the induction process. So when done correctly, priming does not necessarily contribute to a significant volatile waste. The priming method we practice at our institution that balances patient comfort and the goal of a rapid induction is to empty the reservoir bag at the same time the vaporizer is turned on, then applying the mask of the patient as soon as the reservoir bag is full. This approach can ensure that some anesthetic in the gas is taken from the internal components during the inspiration to help reduce the dilution of the desired dialed-in anesthetic concentration.
Speaker 2:Now, what do you hope to see going forward when it comes to sustainable and safe pediatric anesthesia care?
Speaker 1:Yeah, great question. Well, I hope to see that pediatric anesthesiologists engage in more quality improvement initiatives involving sustainability and take advantage of local resources to help with these initiatives, May that be sustainability interest groups, technological aids, default changes and nudges or any other measures to help bring attention to this important area.
Speaker 2:So what's next for your research or projects?
Speaker 1:Our next area of focus is to incorporate other aspects of sustainability decision support into our EHR or electronic health records, and our anesthesia workstation. In addition, we're also working on incorporating sustainability education into anesthesia training in order to educate the next generation on our initiatives.
Speaker 2:Is there anything else that you want to talk about today that we haven't already talked about?
Speaker 1:Well, no, I think we covered all the bases that I wanted to address, so thank you for having me on this podcast.
Speaker 2:Thank you for joining us. Thank you so much to Dr Eva Lou Becker and Dr Liz Hansen for joining me on the show for the past two weeks. We hope that you enjoyed these conversations and can use some of the considerations and resources that we talked about to help make your anesthesia practice safer and more sustainable. If you have any questions or comments from today's show, please email us at podcast at apsforg. 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 apsforg for detailed information and check out the show notes for links to all the topics we discussed today.
Speaker 2:There is still time to apply for the APSF Board of Directors, patient safety priority groups and other associated committees, work groups and task forces. This position is open for medical students, anesthesia residents, student registered nurse anesthetists or student anesthesiologist assistants who are in training at the time of the application. It is for a two-year term. There is still time to apply. The application deadline is March 31st 2025. So what are you waiting for? We hope that you will consider applying or supporting an anesthesia learner in their application. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.