Environmental and patient safety outcomes of a health- system Green Anesthesia Initiative (GAIA): a retrospective observational cohort study

Background Inhaled anaesthetics are greenhouse gases. However, changes in the delivery of inhaled anaesthetics can mitigate environmental impact. We hypothesised that system-wide changes to the delivery of anaesthesia care would reduce environmental harm without compromising patient outcomes. Methods We launched the Green Anesthesia Initiative (GAIA) in March, 2022, with the aims of reducing the use of nitrous oxide, using less environmentally harmful inhaled fluorinated ethers, and increasing intravenous anaesthetic use. In this retrospective cohort study, we used electronic health record data from general anaesthetics performed on all patients older than 1 year between March 1, 2021, and Feb 28, 2023, at a single US academic medical centre across multiple sites, collecting data from before and after the introduction of GAIA. Patients with missing or invalid data recorded by the anaesthesia machine, patients given general anaesthetics for electroconvulsive therapy, and patients who met American Society of Anesthesiologists Physical Status Classification 6 were excluded. Using multivariable modelling, we compared estimated CO2 equivalents and, secondarily, anaesthetic dose, postoperative nausea and vomiting, pain scores on a 0-10 scale, and reports of intraoperative awareness with explicit recall. Findings We recorded 45 692 patients pre-intervention (23 193 [50<middle dot>8%] female, 22 494 [49<middle dot>2%] male, five [<0<middle dot>1%] unknown) and 47 199 post-intervention (23 981 [50<middle dot>8%] female, 23 209 [49<middle dot>2%] male, nine [<0<middle dot>1%] unknown). After the implementation of GAIA, CO2 equivalents were reduced by 14<middle dot>38 kg per patient (95% CI -14<middle dot>68 to -14<middle dot>07; p<0<middle dot>0001). There was no clinically meaningful difference in median anaesthetic delivered (minimum alveolar concentration -0<middle dot>02 [95% CI -0<middle dot>02 to -0<middle dot>01]; p<0 center dot 0001) nor pain scores (-0<middle dot>34 [-0<middle dot>39 to -0<middle dot>29]; p<0 center dot 0001). Postoperative nausea and vomiting was unchanged (odds ratio 0<middle dot>98 [95% CI 0<middle dot>94-1<middle dot>02]; p=0<middle dot>26). A small number of definite intraoperative awareness events were reported in both periods (one pre-intervention and two post- intervention). Interpretation A health-system wide intervention reduces greenhouse gas emissions attributable to anaesthesia care without detriment to patient outcomes.