Episode #247 Nudge Your Way to Greener Pediatric Anesthesia

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We are continuing our interview series on safe and sustainable pediatric anesthesia care with experts in the field. We talk about the scope of the problem and what anesthesia professionals can do to make sustainable and safe anesthesia care part of their practice for all patients. Our guest on the show today is Dr. Eva Lu-Boettcher. Stay tuned for our conversation about this important topic.

Before we dive further into the episode today, we’d like to recognize Eagle, a major corporate supporter of APSF. Eagle has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Eagle –we wouldn’t be able to do all that we do without you!”

And now, my conversation with Dr. Eva Lu-Boettcher.

Can you introduce yourself? Tell us about your anesthesia training, career, and current role?

[Lu-Boettcher] My name is Eva Lu-Boettcher, I’m a pediatric anesthesiologist at the University of Wisconsin in the United States. I completed my residency and fellowship at the University of Michigan and have been practicing in the field of pediatric anesthesia since. I am currently the director of anesthesia quality and safety at the children’s hospital. At our institution, I’ve been focusing our QI efforts on initiatives to reduce carbon emissions, which has led to a significant shift in our practice.

[Bechtel] Today, we are going to be talking about pediatric anesthesia and sustainability. What got you interested in pediatric anesthesia sustainability?

[Lu-Boettcher] My interest in pediatric anesthesia sustainability started years ago initially due to conversations with coworkers who, like me, were starting to notice the impact of climate change on our daily lives. We live in the northern part of central US. Ice cover on the Great Lakes is at a record low, affecting the severity of our winter snowstorms. In the spring and summer, floods and wildfires have significantly impacted our friends and families’ lives. In the summer of 2023 alone, pollution from wildfires was so severe that it limited my children’s ability to play outside. At one point, we had the worst air quality in the world right here in Wisconsin. As a parent looking to protect our children from the effects of climate change, I wanted to dive much deeper into what we can do to limit our contribution to climate change, even at work.

In the US, the healthcare sector contributes around 8.% of the total U.S. greenhouse gas emissions, higher than most developed nations. In pediatric anesthesia, high fresh gas flow used during mask inductions, volatile waste during mask only anesthetics, and the frequent use of nitrous oxide (N2O) are all potential areas to reduce our carbon footprint.

[Bechtel] Now, we are going to be talking about how to make changes in anesthetic practice to a more sustainable anesthetic. Can you tell us more about behavioral sciences and nudges in anesthesia? How does this work? How can anesthesia professionals use this method for making changes in their department?

[Lu-Boettcher] Yes, of course! Nudge theory is based on the idea that our choices are influenced by how these choices are presented to us.

This concept coined by Thaler and Sunstein encourages us to understand how people think and make choices, incorporating behavioral economics insights to “nudge” people toward a particular decision or outcome.

Nudges are all around us. In the operating room, for example, by setting lower default tidal volumes on our anesthesia ventilators, we can help increase compliance with lung protective ventilation during our anesthetics. This is an example of default nudge.

In another operating room example, real-time reminders via electronic anesthesia records to re-dose antibiotics can lead to a significant increase in correctly administered second doses of antibiotics. This is an example of a prompting nudge.

These are just a few examples of how nudges can be utilized in anesthesia to guide our behaviors towards safer and higher quality care within our practice.

[Bechtel] Now, if we put the two together, can you tell us about your work with sustainability and nudges? How can anesthesia professionals practice more sustainable anesthesia, especially with pediatric anesthesia?

[Lu-Boettcher] Absolutely. My work in sustainability leverages nudge interventions to help guide anesthesia professionals toward greener OR practices. Lately, we have been focusing on mask inductions.

During mask induction, excessively high fresh gas flows lead to volatile waste. The key is to use fresh gas flows that do not exceed a patient’s minute ventilation. In general, when using induction fresh gas flows that approximate a patient’s minute ventilation, we can prevent rebreathing, which can potentially slow down induction speed. As FGF is increased above minute ventilation and rebreathing is eliminated, there is no increase in induction speed, just increased volatile waste.  For purposes of mask induction, pediatric minute ventilation can be estimated to be 150 ml/kg. This is approximately 3L/min fresh gas flow for patients under 20kg and up to 6L/min for patients above 40 kg.

To put this into perspective, for an uncomplicated 10kg patient, when the Sevoflurane vaporizer is set to the maximum value of 8% for a 3 min mask induction, the carbon emissions difference between using minute ventilation based FGF and 10L/min FGF is equivalent to driving 6.5 miles in a car. If you think about the number of 3-minute mask inductions we perform in a year in pediatrics, this is a significant contribution to our carbon footprint.

At our children’s hospital, we instituted minute ventilation-based mask induction strategies utilizing several nudge interventions in conjunction with provider education.

First, we set our default FGF during induction to 3L/min on our ventilators with quick button options to increase FGF based on the patient’s weight. This has resulted in a 41% increase in compliance with minute ventilation based fresh gas flows during induction.

Second, we utilized monthly provider email feedback indicating their individual compliance with minute ventilation-based induction FGF compared to their colleagues, which is a form of social norm nudge. This resulted in an 11% increase in compliance.

Third, we instituted reminders in the electronic intra-op records at the beginning of the case to display the appropriate induction fresh gas flow based on patient’s minute ventilation. This resulted in an additional 10% increase in compliance.

Interestingly, changing defaults at our institution seemed to have affected provider behaviors evenly across the board amongst faculty, trainees, CRNA’s and anesthesia assistants. However, provider feedback and reminders seemed to have affected trainee behavior more than the other groups. All of these behavioral changes have been relatively sustained as well.

[Bechtel] Is sustainable anesthesia compatible with safe anesthesia? How can anesthesia professionals provide safe and effective sustainable anesthesia especially during induction?

[Lu-Boettcher] Absolutely, sustainable anesthesia can be very much part of safe and effective anesthesia.

We talked briefly about minute ventilation and how this can affect our mask inductions. We can discuss a bit about priming here as well.

During mask induction, without priming, much of the anesthetic initially supplied by the fresh gas flow is diluted by existing gas in the breathing system. As mask induction proceeds, fresh gas fills the inspiratory limb during inspiration, and the internal components such as the absorbent canister and the reservoir bag, during exhalation. The inspired anesthetic concentration rises with each breath. Priming will increase the concentration of anesthetic in the internal components of the breathing system before induction, which will reduce the dilution of anesthetic in the fresh gas once induction begins and speed up induction.

When done correctly, priming does not necessarily contribute to significant volatile waste. The priming method we practice at our institution that balances patient comfort and the goal of a rapid induction is to empty the reservoir bag at the same time the vaporizer is turned on, then applying the mask to the patient as soon as the bag is full. This approach can ensure that some anesthetic is in the gas taken from the internal components during inspiration and reduce the dilution of the dialed in anesthetic concentration.

[Bechtel] What do you hope to see going forward when it comes to sustainable and safe pediatric anesthesia care?

[Lu-Boettcher] I hope to see pediatric anesthesiologists engage in more quality improvement initiatives involving sustainability and take advantage of local resources to help with these initiatives. May that be sustainability interest groups, technology aides, default changes, or other measures to help bring attention to this important area.

[Bechtel] What’s next for your research or projects?

[Lu-Boettcher] Our next area of focus is to incorporate other aspects of sustainability decision support into our EHR and anesthesia workstation. In addition, we are also working to incorporate sustainability education into anesthesia training in order to educate the next generation on our initiatives.

[Bechtel] Is there anything else that you want to share that we have not talked about already?

[Lu-Boettcher] Thank you for having me on this podcast!

[Bechtel] Thank you so much to Dr. Eva Lu-Boettcher and Dr. Liz Hansen for joining me on the show for the past two weeks. We hope that you enjoyed these conversations and can use some of the considerations and resources that we talked about to help make your anesthesia practice safer and more sustainable.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

There is still time to apply for the APSF Learner Advisory Council, which is a multiprofessional group of anesthesiology trainees and students whose mission is to provide trainee perspectives to guide and support the APSF Board of Directors, Patient Safety Priority Groups, and other associated committees, workgroups, and task forces. This position is open for medical students, anesthesia residents, student registered nurse anesthetists, or student anesthesiologist assistant who are in training at the time of application. It is for a 2-year term. There is still time to apply. Application deadline is March 31^st, 2025. So, what are you waiting for?!? We hope that you will consider applying or supporting an anesthesia learner in their application!

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

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