Identifying barriers to the use of total intravenous anaesthesia: a pan-London multi-centre survey for the assessment of clinician rationale

Background: The impending climate crisis represents one of the greatest threats to global health over the coming century. Anaesthetic gases represented 2% of the NHS’ total carbon footprint,1 and with the NHS committing to becoming carbon neutral by 2045, reduction of waste greenhouse gases will need to play a vital role in this. We therefore sought to understand the clinician rationale for the use of inhalation gases over TIVA through means of a questionnaire, with particular focus on agents with the greatest environmental impact: desflurane and nitrous oxide (N2O). Methods: Anaesthetists across London were invited to complete a questionnaire, comprising questions on grade, place of work, use of TIVA, change in practice over preceding 5 yr, reasoning for continuing to use volatiles over TIVA, and focused questions on desflurane and N2O use. Results: A total of 141 clinicians responded across over 18 hospitals; a majority of these (77.5%) were consultant grade. N2O is still used by 55% of respondents in their current practice. Desflurane is used by only 19% of clinicians overall. Reasons include cardiac stability, analgesic properties, and obstetrics. Forty-one percent clinicians stated that they rarely (<25% of cases) use TIVA, although 44% overall stated that their use of TIVA had increased from 5 yr ago. Use of TIVA was different between district general (DGH) and tertiary centres with 57% of DGH clinicians rarely using TIVA, compared with 30% in tertiary centres. A significant difference was not observed across training grades. Stated barriers to TIVA were risk of awareness (46%), licensing in children (18%), unfamiliarity (17%) lack of equipment (13%), and case length (8%). Conclusions: As healthcare services strive to reduce environmental impact, understanding of potential barriers is of paramount importance. This survey provides a snapshot of current anaesthetic practice and highlights areas which can be targeted as part of environmental action plans moving forward. Representativeness of our findings should be assessed in larger sample sizes. 1.National Health System Sustainable Development Unit. Carbon footprint update for NHS in England 2012 2013. Available from: https://www.sduhealth.org.uk/policy-strategy/reporting/nhs-carbon-footprint.aspx.