{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,28]],"date-time":"2026-04-28T12:24:27Z","timestamp":1777379067543,"version":"3.51.4"},"reference-count":31,"publisher":"SAGE Publications","issue":"3","license":[{"start":{"date-parts":[[2025,2,13]],"date-time":"2025-02-13T00:00:00Z","timestamp":1739404800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Anaesth Intensive Care"],"published-print":{"date-parts":[[2025,5]]},"abstract":"<jats:p>\n                    Volatile anaesthetic agents such as sevoflurane contribute to greenhouse gas emissions, and selecting low fresh gas flows on anaesthetic machines minimises their waste. Facilitating improvements in sevoflurane use requires the education, motivation, and standardised evaluation of anaesthetists. There is currently no standard of practice related to the efficiency of anaesthetic gas delivery per case. We conducted a multi-component study termed \u2018Low With The Flow\u2019 (LWTF) to directly address these requirements by educating and motivating anaesthetists to reduce fresh gas flow and thereby sevoflurane use. We introduced a novel metric, the \u2018volatile efficiency ratio\u2019 (VER), able to be calculated on Draeger Primus\u2122, the Draeger Atlan\u2122 family and Draeger Perseus A500\u2122 machines, to audit sevoflurane use in a case-by-case fashion, and assess whether the intervention could achieve a set VER target. The LWTF intervention significantly improved the efficiency of sevoflurane delivery (VER 0.46 pre-intervention (\n                    <jats:italic>n<\/jats:italic>\n                    \u2009=\u2009518) versus VER 0.57 post-intervention (\n                    <jats:italic>n<\/jats:italic>\n                    \u2009=\u2009531), 95% confidence interval 0.092 to 0.129,\n                    <jats:italic>P\u2009&lt;\u2009<\/jats:italic>\n                    0.0001) resulting in a calculated average of 1.3\u2009kg carbon dioxide equivalent emissions reduction and approximately AUD 3.50 saving per case. Consequently, the financial and environmental outcomes from sevoflurane delivery were considerably reduced. Our LWTF intervention provides a valuable model for other anaesthetic departments to investigate and address the global environmental and financial burdens related to their volatile anaesthetic use. For anaesthetists using anaesthesia machines that do not facilitate calculation of VER, an approach using components of our LWTF intervention may still reduce the environmental and financial impacts associated with administration of volatile anaesthesia.\n                  <\/jats:p>","DOI":"10.1177\/0310057x241296574","type":"journal-article","created":{"date-parts":[[2025,2,13]],"date-time":"2025-02-13T04:42:07Z","timestamp":1739421727000},"page":"161-170","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":0,"title":["Improving the efficiency of sevoflurane delivery during general anaesthesia by educating and motivating anaesthetists to utilise the Volatile Efficiency Ratio"],"prefix":"10.1177","volume":"53","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1021-6254","authenticated-orcid":false,"given":"Samuel T","family":"Costello","sequence":"first","affiliation":[{"name":"Department of Anaesthesia and Acute Pain Medicine, St Vincent\u2019s Hospital, Melbourne, Victoria, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Blake J","family":"Vorias","sequence":"additional","affiliation":[{"name":"Department of Anaesthesia and Acute Pain Medicine, St Vincent\u2019s Hospital, Melbourne, Victoria, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5173-8548","authenticated-orcid":false,"given":"Roman","family":"Kluger","sequence":"additional","affiliation":[{"name":"Department of Anaesthesia and Acute Pain Medicine, St Vincent\u2019s Hospital, Melbourne, Victoria, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"179","published-online":{"date-parts":[[2025,2,13]]},"reference":[{"key":"e_1_3_4_2_2","doi-asserted-by":"publisher","DOI":"10.1126\/science.1176985"},{"key":"e_1_3_4_3_2","unstructured":"American Society of Anesthesiologists. The environmental impact of inhaled anesthetics https:\/\/www.asahq.org\/about-asa\/governance-and-committees\/asa-committees\/environmental-sustainability\/greening-the-operating-room\/inhaled-anesthetics (2024 accessed 2 June 2024)."},{"key":"e_1_3_4_4_2","doi-asserted-by":"publisher","DOI":"10.1097\/EJA.0000000000001862"},{"key":"e_1_3_4_5_2","unstructured":"Australian and New Zealand College of Anaesthetists. PS64(G) Position statement on environmental sustainability in anaesthesia and pain medicine practice 2019 https:\/\/www.anzca.edu.au\/getattachment\/570003dc-0a18-4837-b8c6-b9c3d2ed5396\/PS64(G)-Position-statement-on-environmental-sustainability-in-anaesthesia-and-pain-medicine-practice-2019#page= (2019 accessed 2 June 2024)."},{"key":"e_1_3_4_6_2","unstructured":"National Health Service Scotland. NHS Scotland climate emergency and sustainability strategy: 2022\u20132026 https:\/\/www.gov.scot\/publications\/nhs-scotland-climate-emergency-sustainability-strategy-2022-2026\/ (2022 accessed 4 August 2024)."},{"key":"e_1_3_4_7_2","unstructured":"Trainee-Led Research and Audit in Anaesthesia for Sustainable Healthcare (TRA2SH). Desflurane is a potent greenhouse gas. https:\/\/www.tra2sh.org\/refuse-desflurane (n.d. accessed 2 June 2024)."},{"key":"e_1_3_4_8_2","unstructured":"St John of God Health Care. Environment the big winner in national decision by St John of God Health Care https:\/\/www.sjog.org.au\/campaigns\/microsites\/media-centre\/media-releases\/2024\/environment-the-big-winner-in-national-decision-by-st-john-of-god-health-care (2024 accessed 2 May 2024)."},{"key":"e_1_3_4_9_2","first-page":"1","article-title":"Low-flow anaesthesia","volume":"8","author":"Nunn G.","year":"2008","unstructured":"Nunn G. Low-flow anaesthesia. CEACCP 2008; 8: 1\u20134. doi:10.1093\/bjaceaccp\/mkm052.","journal-title":"CEACCP"},{"key":"e_1_3_4_10_2","doi-asserted-by":"publisher","DOI":"10.1213\/ANE.0b013e31824eee0d"},{"key":"e_1_3_4_11_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.bja.2020.06.055"},{"key":"e_1_3_4_12_2","volume-title":"The quantitative practice of anesthesia: use of closed circuit","author":"Lowe HJ","year":"1981","unstructured":"Lowe HJ, Ernst EA. The quantitative practice of anesthesia: use of closed circuit. Baltimore, MD: Williams & Wilkins, 1981."},{"key":"e_1_3_4_13_2","unstructured":"Australian and New Zealand College of Anaesthetists. Environmental sustainability audit tool https:\/\/www.anzca.edu.au\/resources\/environmental-sustainability\/eswg-audit-tool-(1).aspx (n.d. accessed 22 February 2024)"},{"key":"e_1_3_4_14_2","doi-asserted-by":"publisher","DOI":"10.1007\/s005400050050"},{"key":"e_1_3_4_15_2","doi-asserted-by":"publisher","DOI":"10.1111\/j.1399-6576.1981.tb01657.x"},{"key":"e_1_3_4_16_2","unstructured":"Practice Greenhealth. Anesthetic gas https:\/\/practicegreenhealth.org\/topics\/greening-operating-room\/anesthetic-gas (2024 accessed February 2024)."},{"key":"e_1_3_4_17_2","doi-asserted-by":"publisher","DOI":"10.1007\/s12630-019-01348-1"},{"key":"e_1_3_4_18_2","doi-asserted-by":"publisher","DOI":"10.1177\/0310057X19843304"},{"key":"e_1_3_4_19_2","doi-asserted-by":"publisher","DOI":"10.1177\/0310057X1304100116"},{"key":"e_1_3_4_20_2","doi-asserted-by":"publisher","DOI":"10.1097\/00000542-199904000-00033"},{"key":"e_1_3_4_21_2","doi-asserted-by":"publisher","DOI":"10.1136\/bmjoq-2022-001867"},{"key":"e_1_3_4_22_2","doi-asserted-by":"publisher","DOI":"10.1111\/anae.15598"},{"key":"e_1_3_4_23_2","doi-asserted-by":"publisher","DOI":"10.1097\/ALN.0b013e3182829de0"},{"key":"e_1_3_4_24_2","doi-asserted-by":"publisher","DOI":"10.1007\/s10877-014-9639-6"},{"key":"e_1_3_4_25_2","doi-asserted-by":"publisher","DOI":"10.1097\/ALN.0000000000003967"},{"key":"e_1_3_4_26_2","doi-asserted-by":"publisher","DOI":"10.4103\/2045-9912.285558"},{"key":"e_1_3_4_27_2","doi-asserted-by":"publisher","DOI":"10.1111\/pan.13582"},{"key":"e_1_3_4_28_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.bjane.2021.11.004"},{"key":"e_1_3_4_29_2","volume-title":"Nudge: improving decisions about health, wealth, and happiness","author":"Thaler RH","year":"2009","unstructured":"Thaler RH, Sunstein CR. Nudge: improving decisions about health, wealth, and happiness. London: Penguin, 2009."},{"key":"e_1_3_4_30_2","first-page":"CD000259","article-title":"Audit and feedback: effects on professional practice and healthcare outcomes","author":"Ivers N","year":"2012","unstructured":"Ivers N, Jamtvedt G, Flottorp S, et\u00a0al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012:CD000259. doi:10.1002\/14651858.CD000259.pub3.","journal-title":"Cochrane Database Syst Rev"},{"key":"e_1_3_4_31_2","first-page":"CD003030","article-title":"Continuing education meetings and workshops: effects on professional practice and healthcare outcomes","volume":"9","author":"Forsetlund L","year":"2021","unstructured":"Forsetlund L, O'Brien MA, Fors\u00e9n L, et\u00a0al. Continuing education meetings and workshops: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2021; 9: CD003030. doi:10.1002\/14651858.CD003030.pub3.","journal-title":"Cochrane Database Syst Rev"},{"key":"e_1_3_4_32_2","doi-asserted-by":"publisher","DOI":"10.1177\/0310057X221102469"}],"container-title":["Anaesthesia and Intensive Care"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/0310057X241296574","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/full-xml\/10.1177\/0310057X241296574","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/0310057X241296574","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,28]],"date-time":"2026-04-28T09:13:05Z","timestamp":1777367585000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.1177\/0310057X241296574"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,2,13]]},"references-count":31,"journal-issue":{"issue":"3","published-print":{"date-parts":[[2025,5]]}},"alternative-id":["10.1177\/0310057X241296574"],"URL":"https:\/\/doi.org\/10.1177\/0310057x241296574","relation":{},"ISSN":["0310-057X","1448-0271"],"issn-type":[{"value":"0310-057X","type":"print"},{"value":"1448-0271","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,2,13]]}}}