IHEEM 2019 REGIONAL CONFERENCE


childbirth, alongside water birth, hypnosis, and the various other holistic alternatives.


O cylinders were returned half-full to the gas manufacturer. He said: “All BOC then does is to vent and blow off the remaining gas. The hospital has paid for the gas, but has only used half of it. My message would be to use what you buy.” Another potential carbon-reducing step was to consider using Propofol to replace Entonox.


impact of


An engineering and control problem “In some ways,” he continued, “Entonox is a bigger engineering and control problem than it is to get it through the closed circuits you have with breathing apparatus. From a healthcare engineer’s perspective, we can be looking at things such as air-handling scrubbers, and gas recovery and recycling.” Mike Ralph said one of the things he had discovered from his recent work with BOC was that many N2


excellent sense, and I know that the AAGBI, through Cathy Lawson, Anaesthesia and ICM doctor, and Fellow in Environmentally Sustainable Anaesthesia at The Newcastle upon Tyne Hospitals NHS Foundation Trust, is talking to BOC about the possibilities for units of that size, and where one might first be trialled.”


Mike Ralph said that there had been some successful hospital clinical trials of anaesthetic gas cracking units in Sweden, adding: “It would be good – UK-wise – if we could get ahead of the game and do something very environmentally-friendly on this front.”


Entonox


The speaker’s next slide focused in more detail on some of the actions he had described to reduce the CO2 N2


O and anaesthetic agents on the environment. He said: “If you cut by 3 per cent the standardised anaesthetic hours you use Desflurane, you remove 11 kilotonnes of CO2


Swedish manufacturer, MedClair’s Mobile Destruction Unit is described as a ‘total solution for administering Nitrous oxide to the patient and collecting residual N2 from exhaled air and destroying it’.


from the atmosphere,


while using reduced flow anaesthesia – with less Nitrous oxide – you will remove 32 kilotonnes”. Eliminating the use of Nitrous oxide altogether would, he said, cut CO2


emissions by 94 Kt.” The most difficult area to address was reducing emergency use of Entonox. The current NHSI/NHSE target – from a 2017 baseline – was to cut CO2


emissions from


anaesthetics by 40%, as outlined in the NHS Long Term Plan.


‘Everybody’s issue’


Mike Ralph said this was ‘not simply an engineering or estates issue’; but rather ‘everybody’s issue’. The engineer needed to come up with solutions; midwives, anaesthetists, and nurses needed to develop different ways of working, and it was a case of ‘everybody working together, and understanding the common goal’.


Turning to focus on gas scavenging and collection, Mike Ralph said: “By using medical air and oxygen as your carrier


‘‘


There are two companies actually working on units which will recover the gas from the closed breathing circuit, extract it, and partially distil it and purify it


Installing a central cracking unit One such gas had been collected, Mike Ralph said that cracking units – he showed a compact MedClair 2100 from the Swedish manufacturer of the same name as an example – could be plugged straight into a theatre’s AGSS line, with nitrogen and oxygen, ‘slightly warm, puffed out of the back’. Mike Ralph said: “Such a system completely cracks the gas. Another option,” he explained, “is to look at installing a central cracking unit, which will accommodate gas from about 15 theatres, and costs about £40,000 to £45,000, so it is about economies of scale. The system principally comprises a filterer and a hot catalyst reactor that you pass the gas over, which cracks it and monitors it, cooling it down and pushing it out of the back. Installing a central gas cracking unit is quite a simple solution engineering-wise, but in the UK there is currently not much discussion about it. In thus US, central anaesthetic agent gas crackers are more widely used. Hospitals generally don’t have AGSS equipment, and once the gas has exited the breathing circuit, you are just left with nitrogen and oxygen To install central gas cracking units in hospitals here would make


gas – a simple step – you can potentially take the Nitrous oxide bottle off your anaesthetic trolley. As to Nitrous oxide scavenging – with it being an anaesthetic you have a well-controlled closed circuit to capture it. With Entonox – with planned use in areas such as Relative anaesthesia and dentistry – you may be able to look at some form of collection and filtering. I think we also need to look intelligently at some new ways of collecting Entonox; I think it’s a key engineering issue.”


O


He added: “A key consideration currently is how we pick up the Entonox, and what we do with it, because it accounts for two-thirds of the overall nitrous and anaesthetic agent contamination from a GWP perspective, and is probably one of the hardest gases to do something about.” Moving to anaesthetic agent recovery and recycling, Mike Ralph said such agents were both ‘very expensive and incredibly polluting’; they were also only used once, and then disposed of. He said: “There are two companies actually working on units which will recover the gas from the closed breathing circuit, extract it, and partially distil it and purify it. You can then re-use it. A test unit in use at a UK hospital is recovering about 97% of that inhalational agent.” While currently, as prototypes, such units were ‘incredibly expensive’, once the proof of concept was undertaken, Mike Ralph said he expected to see their more widespread use. “One significant obstacle I can foresee,” he said, “is whether companies which produce inhalational agents such as Desflurane are going to let hospital customers using perhaps two litres/week, at a cost of £20,000 per litre, stop doing this, and instead just recycle one batch of gas for perhaps five years. I’m not certain on this, but I can see problems with this if it is classed as drug re-manufacturing, which you cannot do unless you do it under GMP. There is thus a significant regulatory perspective that would need looking into.


“From an ethical/global warning standpoint, however, use of such a system is absolutely the right thing to do. You have a machine that would be recovering your volatile agents for re-use, with the by-product being a little bit of air, oxygen, and nitrous oxide, which would then go into your AGSS and be cracked by your central plant. We would then simply be releasing oxygen and nitrogen back to the atmosphere.” With this thought in mind, Mike Ralph concluded a thought- provoking presentation, and invited questions from the audience.


hej January 2020 Health Estate Journal 41


MedClair AB


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