Sustainable anaesthesia practices in EUROPE

A cross-sectional observational study (SUSTAIN-EUROPE) 

Climate change poses an escalating threat to global health.^1,2 In response to the climate crises, anaesthesiology societies worldwide are calling for urgent action to reduce the carbon footprint of clinical care.^3-6 They recommend using regional and total intravenous anaesthesia where possible and sevoflurane with minimal fresh gas flow (FGF) settings for inhalational anaesthesia cases. However, the actual use of different anaesthesia techniques and ventilation settings in routine clinical care remains largely unknown. 

Considering an estimated 234 million major surgeries are performed globally each year, the limited data on real-world anaesthesia practices is surprising.⁷ Available data on sustainable anaesthesia practices suggests room for improvement.^8-12 For example, in a European survey, only 49% of 1285 anaesthetists reported using FGF <1.0L/min in inhalational anaesthesia cases, and only 15% reported FGF <0.5L/min.⁸ Additionally, 64% of respondents preferred volatile anaesthetics, with sevoflurane used by 83% and desflurane by 10%.⁸  

SUSTAIN-EUROPE is designed to close the knowledge gap on contemporary anaesthesia practices. This multicentre, cross-sectional observational study captures a broad picture of routine clinical care across diverse European hospital settings in both adult and paediatric populations. The primary outcome is the type of anaesthesia. Secondary endpoints include sustainability-relevant parameters such as volatile anaesthetic or FGF type and additional ventilation variables. 

The study is centred around simplicity and inclusivity: a pragmatic approach, a short case report form, and a brief data collection period will allow participation from hospitals across all clinical levels, with or without dedicated research teams. For the first time in the history of the ESAIC Clinical Trials Network, data collection is planned via a dedicated app to minimise local workload and make participation easily accessible. 

SUSTAIN-EUROPE marks a foundational step towards more sustainable anaesthesia practices in Europe. By shedding light on current daily practices and evaluating the implementation of professional guidelines, this study will provide evidence for future initiatives to improve anaesthesia care—for our patients and our planet. 

Interested in joining a major European clinical study on real-world anaesthesia practices and sustainability? For any questions, please contact: sustain-europe@esaic.org  

Authors

• Linda Grüßer, University Hospital RWTH Aachen, Germany
• Patricio Gonzalez-Pizarro, La Paz Children’s Hospital, Madrid, Spain  

For the Steering Committee:  

Karin Becke-Jakob (Universitäts-Kinderspital beider Basel (UKBB) Switzerland); Anna Camporesi (“V. Buzzi” Children’s Hospital, Milan, Italy); Mark Coburn (University Hospital Bonn, Bonn, Germany); Nicola Disma (IRCCS Istituto Giannina Gaslini, Genoa, Italy); Alexander Fuchs (Inselspital, University Hospital Bern, Bern, Switzerland); Sabrine N.T. Hemmes (The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands); András Keszei (Medical Faculty RWTH Aachen, Aachen, Germany); Ana Kowark (University Hospital Bonn, Bonn, Germany); Jan Larmann (University Hospital RWTH Aachen, Germany); David van Meenen (Amsterdam UMC, Amsterdam, Netherlands); Nicolaas H. Sperna Weiland (Amsterdam UMC, Amsterdam, Netherlands) 

References

1. Romanello M, Walawender M, Hsu S-C, et al. The 2024 report of the Lancet Countdown on health and climate change: facing record-breaking threats from delayed action. The Lancet 2024; 404: 1847-96 
2. A Global Health Strategy for 2025-2028 – advancing equity and resilience in a turbulent world: fourteenth General Programme of Work. Geneva: World Health Organization; 2025. Licence: CC BY-NC-SA 3.0 IGO.   
3. Gonzalez-Pizarro P, Brazzi L, Koch S, et al. European Society of Anaesthesiology and Intensive Care consensus document on sustainability: 4 scopes to achieve a more sustainable practice. Eur J Anaesthesiol 2024; 41: 260-77 
4. Schuster M, Richter H, Pecher S, et al. Positionspapier mit konkreten Handlungsempfehlungen der DGAI und des BDA: Ökologische Nachhaltigkeit in der Anästhesiologie und Intensivmedizin – Aktualisierung 2024. Anästh Intensivmed 2024; 65: 541–57 
5. White SM, Shelton CL, Gelb AW, et al. Principles of environmentally-sustainable anaesthesia: a global consensus statement from the World Federation of Societies of Anaesthesiologists. Anaesthesia 2022; 77: 201-12 
6. The Australian and New Zealand College of Anaesthetists & the Faculty of Pain Medicine. PS64(G) Position statement on environmental sustainability in anaesthesia and pain medicine practice 2019.    
7. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008; 372: 139-44 
8. Gonzalez-Pizarro P, Koch S, Muret J, et al. Environmental sustainability in the operating room: A worldwide survey among anaesthesiologists. European Journal of Anaesthesiology and Intensive Care 2023; 2: e0025-1-10 
9. MacNeill AJ, Lillywhite R, Brown CJ. The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems. Lancet Planet Health 2017; 1: e381-e8 
10. Dölker T, Schuler J, Wallqvist J, et al. Easy-to-implement educational interventions to bring climate-smart actions to daily anesthesiologic practice: a cross-sectional before and after study. Minerva Anestesiol 2024; 90: 126-34 
11. Zuegge KL, Bunsen SK, Volz LM, et al. Provider Education and Vaporizer Labeling Lead to Reduced Anesthetic Agent Purchasing With Cost Savings and Reduced Greenhouse Gas Emissions. Anesth Analg 2019; 128: e97-e9 
12. Dexter F, Maguire D, Epstein RH. Observational study of anaesthetists’ fresh gas flow rates during anaesthesia with desflurane, isoflurane and sevoflurane. Anaesth Intensive Care 2011; 39: 460-4