Green anaesthesia: a review of sustainable perioperative practices and the potential application in Malaysia
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How to Cite

Lee, K. T. ., Ngoi, S. T. ., & Shariffuddin, I. I. (2023). Green anaesthesia: a review of sustainable perioperative practices and the potential application in Malaysia. Malaysian Journal of Anaesthesiology, 2(2), 156–172.

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This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Copyright (c) 2023 Kwan Tuck Lee, Soo Tein Ngoi, Ina Ismiarti Shariffuddin


anaesthesia; climate change; recycle; reduce; reuse


Global warming and worsening climate change threaten environmental sustainability and exacerbate disease burdens worldwide. Alarmingly, the health care sector emerged as a substantial contributor to this crisis. The operating theatre significantly contributes to hospital waste and greenhouse gas emissions. Anaesthesiologists are morally compelled to combat this crisis, aligning with our oath as physicians of “first, do no harm,” ensuring patient safety extends beyond the operating room by advocating for sustainable practices that safeguard both health and the environment. Understanding the climate change indicators reveals the alarming impact of human actions on escalating greenhouse gas emissions and their dire repercussions, such as global temperature shifts, severe weather events, and heightened natural disasters.

Greener solutions and adaptive policymaking are essential to address procurement, greenhouse gas emissions, and waste management challenges in health care settings. Anaesthesiologists should collaborate with surgeons and hospital management to navigate patient-specific issues analysing the environmental impact of hospital visits, investigations, and comorbidities. Efforts toward sustainable healthcare practices in the preoperative setting, such as telemedicine adoption, promoting eco-friendly transportation, and optimising patient health before surgery should be encouraged.

Anaesthesiologists should focus on the environmental impact of anaesthesia drugs, medical equipment, and electricity usage on the environment. We should be more responsible and able to justify our practices concerning the ecological implications of inhaled anaesthetic gases, propofol disposal, plastic-based equipment, and energy demands in operating rooms. The emphasis lies on adopting the 6Rs—rethink, refuse, reduce, reuse, recycle, and research—within anaesthesia practices to minimise environmental footprints.
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World Health Organization [Internet]. Climate change. Geneva, Switzerland: World Health Organization (WHO); [cited 2023 Nov 18]. Available from:

Weiser T, Haynes A, Molina G, et al. Estimate of the global volume of surgery in 2012: An assessment supporting improved health outcomes. Lancet. 2015;385(Suppl 2):S11. 2015.

Gordon D. Sustainability in the operating room: Reducing our impact on the planet. Anesthesiol Clin. 2020;38(3):679-692.

United Nations [Internet]. Climate Action. New York, United States of America: United Nations (UN); [cited 2023 Nov 17]. Available from:

Trewin B, Cazenave A, Howell S, et al. Headline indicators for global climate monitoring. Bull Am Meteorol Soc. 2021;102(1):E20-E37.

United Nations Statistics Division. Global set of climate change statistics and indicators implementation guidelines. New York, United States of America: United Nations (UN); 2023.

World Meteorological Organization. State of the global climate 2022. Geneva, Switzerland: World Meteorological Organization (WMO); 2022.

Parmesan C, Morecroft MD, Trisurat Y. Climate change 2022: Impacts, adaptation and vulnerability. Geneva, Switzerland: Intergovernmental Panel on Climate Change (IPCC); 2022.

Centre for Research on the Epidemiology of Disasters [Internet]. EM-DAT: The international disaster database. Brussels, Belgium: University of Louvain Centre for Research on the Epidemiology of Disasters (CRED); [cited 2023 Nov 16]. Available from:

Ebi KL, Vanos J, Baldwin JW, et al. Extreme weather and climate change: Population health and health system implications. Annu Rev Public Health. 2021;42(1):293-315.

Romanello M, McGushin A, Di Napoli C, et al. The 2021 report of the Lancet Countdown on health and climate change: Code red for a healthy future. Lancet. 2021;398(10311):1619-1662.

Ebi KL, Hess JJ. Health risks due to climate change: Inequity in causes and consequences. Health Aff (Millwood). 2020;39(12):2056-2062.

Lenzen M, Malik A, Li M, et al. The environmental footprint of health care: A global assessment. Lancet Planet Health. 2020;4(7):e271-e279.

Romanello M, Di Napoli C, Drummond P, et al. The 2022 report of the Lancet Countdown on health and climate change: Health at the mercy of fossil fuels. Lancet. 2022;400(10363):1619-1654.

Sulbaek Andersen MP, Nielsen OJ, Sherman JD. Assessing the potential climate impact of anaesthetic gases. Lancet Planet Health. 2023;7(7):e622-e629.

McGain F, Hendel SA, Story DA. An audit of potentially recyclable waste from anaesthetic practice. Anaesth Intensive Care. 2009;37(5):820-823.

Cosford P. ‘Partners in clime’: Sustainable development and climate change – what can the National Health Service do? Public Health. 2009;123(1):e1-e5.

National Health Service. Carbon update for the health and care sector in England 2015. London, England: National Health Service (NHS); 2016.

Petre MA, Bahrey L, Levine M, van Rensburg A, Crawford M, Matava C. A national survey on attitudes and barriers on recycling and environmental sustainability efforts among Canadian anesthesiologists: An opportunity for knowledge translation. Can J Anaesth. 2019;66(3):272-286.

Laustsen G. Reduce–Recycle–Reuse: Guidelines for promoting perioperative waste management. AORN J. 2007;85(4):717-728.

Ard JLJ, Tobin K, Huncke T, Kline R, Ryan SM, Bell C. A survey of the American Society of Anesthesiologists regarding environmental attitudes, knowledge, and organization. A A Case Rep. 2016;6(7):208-216.

Grocott MPW, Mythen MG. Perioperative medicine: The value proposition for anesthesia? A UK perspective on delivering value from anesthesiology. Anesthesiol Clin. 2015;33(4):617-628.

Rebitzer G, Ekvall T, Frischknecht R, et al. Life cycle assessment: Part 1: Framework, goal and scope definition, inventory analysis, and applications. Environ Int. 2004;30(5):701-720.

Wernet G, Conradt S, Isenring HP, Jiménez-González C, Hungerbühler K. Life cycle assessment of fine chemical production: A case study of pharmaceutical synthesis. Int J Life Cycle Assess. 2010;15(2010):294-303.

American Society for Health Care Engineering. ASHE sustainability guide. Chicago, United States of America: American Society for Health Care Engineering (ASHE); 2023.

Lewis D, Tranter G, Axford AT. Use of videoconferencing in Wales to reduce carbon dioxide emissions, travel costs and time. J Telemed Telecare. 2009;15(3):137-138.

Turley M, Porter C, Garrido T, et al. Use of electronic health records can improve the health care industry’s environmental footprint. Health Aff (Millwood). 2011;30(5):938-946.

Van Norman GA, Jackson S. The anesthesiologist and global climate change: An ethical obligation to act. Curr Opin Anaesthesiol. 2020;33(4):577-583.

Ryan SM, Nielsen CJ. Global warming potential of inhaled anesthetics: Application to clinical use. Anesth Analg. 2010;111(1):92-98.

Van Zundert A. The green footprint of anaesthesia. Anaesth Crit Care Pain Med. 2021;40(4):100872.

Campbell M, Pierce JT. Atmospheric science, anaesthesia, and the environment. BJA Educ. 2015;15(4):173-179.

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(9):e381-e388.

Stockholm County Council. Environmentally classified pharmaceuticals 2014-2015. Stockholm, Sweden: Stockholm County Council; 2014.

Mankes RF. Propofol wastage in anesthesia. Anesth Analg. 2012;114(5):1091-1092.

McGain F, Muret J, Lawson C, Sherman JD. Environmental sustainability in anaesthesia and critical care. Br J Anaesth. 2020;125(5):680-692.

Favetta P, Degoute CS, Perdrix JP, Dufresne C, Boulieu R, Guitton J. Propofol metabolites in man following propofol induction and maintenance. Br J Anaesth. 2002;88(5):653-658.

Yüksel I. Hydropower for sustainable water and energy development. Renew Sustain Energy Rev. 2010;14(1):462-469.

McGain F, Sheridan N, Wickramarachchi K, Yates S, Chan B, McAlister S. Carbon footprint of general, regional, and combined anesthesia for total knee replacements. Anesthesiology. 2021;135(6):976-991.

Chew WZ, Teoh WY, Sivanesan N, et al. Bispectral Index (BIS) monitoring and postoperative delirium in elderly patients undergoing surgery: A systematic review and meta-analysis with trial sequential analysis J Cardiothorac Vasc Anesth. 2022;36(12):4449-4459.

Izumi NH, Ng KT, Ili SJA, Nadzrah SY, Hashim NHM, Shariffuddin II. Anaesthetic drug wastage in operating theatre: A quality improvement project. Med & Health. 2021;16(3)(Suppl):56.

Eckelman MJ, Sherman J. Environmental impacts of the US health care system and effects on public health. PLoS One. 2016;11(6):e0157014.

McGain F, Story D, Lim T, McAlister S. Financial and environmental costs of reusable and single-use anaesthetic equipment. Br J Anaesth. 2017;118(6):862-869.

Hinterberg J, Beffart T, Gabriel A, et al. Efficiency of inhaled anaesthetic recapture in clinical practice. Br J Anaesth. 2022;129(4):e79-e81.

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