ArticlePDF Available

The global FESSH green survey: sustainability in hand surgery



Content may be subject to copyright.
Perspectives from around the World
The global FESSH green survey:
sustainability in hand surgery
The health care sector accounts for up to 4–5% of net
global greenhouse gas emissions, which if ranked as
a country, would make this the fifth largest emitter
on the planet (Health Care Without Harm, 2019;
Lenzen et al., 2020). However, its contribution to cli-
mate change is rarely discussed. This international
survey under the patronage of the Federation of
European Societies for Surgery of the Hand
(FESSH) aims to evaluate the current opinion on cli-
mate change and sustainable healthcare within the
hand surgery community. The survey covered a
range of questions about the general attitudes and
perspectives towards climate change, their practice
in a number of common clinical scenarios and finally,
awareness of climate change initiatives within their
community. Quantitative analysis was obtained from
graded responses, while free text boxes allowed the-
matic analyses for qualitative data.
The survey was globally distributed in December
2021 via the FESSH email data base and the FESSH
social media channels (Twitter, LinkedIn, Instagram
and Facebook), with the contributions of various
European, Australian and Canadian hand surgery soci-
eties, the American Association for Hand Surgery and
the Federation Latinoamericana de Cirugia. The survey
was anonymous and accessed for data and content
analysis (SurveyMonkeyV
Rword-cloud) by the research-
ers only.
Survey results
Reflecting the worldwide distribution of the survey,
a total of 876 respondents from 62 different coun-
tries spanning six continents took part in this survey
(Figure 1; Online supplementary Table S1). The
majority of responses were received from Europe,
North and South America, with most of the
respondents practicing in the United States of
America (USA, 16.3%, n¼143), the United
Kingdom (UK, 11.6%, n¼102) and Germany (8.3%,
n¼73). The cohort of respondents, male to female
ratio of 3:1, were predominantly hand surgeons of a
senior grade (89% consultant level). Of the respond-
ents 52% practice in a teaching or university hospi-
tal setting (Online Supplementary Table S2).
Overall, there was a strong concern about climate
change, with 89% of respondents strongly agreeing or
agreeing that this is an important issue; 92%
expressed a strong desire to strive for a more sustain-
able lifestyle. Over two-thirds of respondents (73%)
have considered the environmental impact of their
practice, but only 50% have taken steps to implement
changes. The majority of the respondents (84%) feel
that health care professionals have an obligation to
raise awareness of the carbon footprint of health
care systems. There was no significant correlation
with the respondents age or seniority, when asked
about their concerns regarding climate change,
aiming for a more sustainable lifestyle or the obligation
to raise awareness of the health care sectors carbon
For the second part of the survey, respondents
were asked to rate the likelihood of modifying their
current practice due to concerns about climate
change. A number of clinical scenarios were given,
drawn from the topical literature. Importantly, the
scenarios operate from the premises that any mod-
ification of practice (as a result of climate change
consideration) would not adversely affect patients’
outcome. The questions and the respondents’ ratings
are as shown in Table 1. Overall, these demonstrate
high levels of support for measures to integrate
waste management, recycling and reduction of the
number of consumables used in the clinical setting,
but varying and lesser acceptance of scenarios
involving direct clinical care.
In the final section of the survey, we explored the
awareness within the hand surgery community of
local or national networks committed to addressing
health care’s carbon footprint. Approximately 62% of
respondents were unaware of initiatives within their
hospitals and where the hospitals had introduced
changes, the content analysis of the respondents’
comments showed that these mainly involve the
introduction of recycling (20%), waste segregation
(19%) and energy savings or sourcing of alternative
energy (up to 8%).
The majority of respondents was also unaware of
initiatives within their national hand surgery society
or their country (90% and 72%, respectively).
Journal of Hand Surgery
(European Volume)
47(9) 1–4
!The Author(s) 2022
Article reuse guidelines:
DOI: 10.1177/17531934221118658
Further exemplary subgroup analysis showed
that this even applied where such initiatives are
well established: The American initiative ’lean
and green hand surgery’ for example was only
beknown to 27% of respondents from the USA.
Similarly, only 26% of the UK respondents were
aware that the National Health Service (NHS) has
committed to achieving a net zero carbon footprint
by 2040.
Further analysis of the survey’s responses accord-
ing to geo-political grouping was not possible due to
the somewhat disproportionate numbers of replies
from the individual continents and countries.
Analysis of results
Encouragingly, the survey was met with a high level
of engagement, which revealed the level of interest
Figure 1. Distribution of respondents by continent.
Table 1. Percentage of affirmative responses to clinical scenario question.
Clinical scenario questions
Affirmative responses
(number) (%)
Encouraging staff to integrate waste management & recycling in the theatre setting n¼730 (85%)
Reducing/limiting the use of drapes and gowning for simple soft tissue procedures, e.g.
carpal tunnel decompression
n¼629 (74%)
Discussing the different environmental impact of general anaesthesia versus WALANT
with patients
n¼439 (51%)
Consider the environmental impact when deciding whether to prescribe prophylactic
n¼418 (49%)
Use virtual clinic appointments instead of face-to-face appointments to reduce the carbon
footprint of my clinics
n¼335 (39%)
Limiting use of NSAIDs to reduce the impact of water pollution n¼263 (31%)
Choosing a surgical technique with lower environmental impact such as the use of
Kirschner wires over ORIF
n¼249 (29%)
Each question was prefixed with the statement: Assuming that there was no current evidence to suggest that the outcome for your
patients would be affected, which of the following measures would you consider taking?’
WALANT: wide awake local anaesthesia no tourniquet; NSAIDs: non-steroid anti-inflammatory drugs; ORIF: open reduction internal
2Journal of Hand Surgery (European Volume) 47(9)
in the community of hand surgeons at large to work
towards a more sustainable and environmentally
considerate practice. The majority of respondents
expressed concerns about climate change, strive
for a more sustainable lifestyle and consider the
carbon footprint of their own practice. A full thematic
analysis was not performed but some qualitative data
was obtained from the comments. Interestingly,
comments such as climate change is not a hand
surgery problem or that health care comes further
down the line in prioritizing planetary health, were
largely balanced by others expressing frustration
how addressing the challenges of climate change
have been relegated to an afterthought or how
health care professionals are forced by law and leg-
islation to use environmentally damaging practices’.
These contrasting views showed how climate change
remains a subject that requires more discussion and
The World Health Organization’s (WHO) ’opera-
tional framework for building climate resilient
health systems’ sees a clear role for professional
societies in creating an environment where safe
and climate-friendly surgical ...techniques can be
used’. The survey data suggests that either only a
few organizations have engaged with this, or that
awareness of existing initiatives is limited. Further
contents analysis however showed that two areas
of change waste management and recycling as
well as the reduction of consumables are common-
ly adopted on an individual as well as an organiza-
tional level. This might not be surprising as these
concepts have permeated through everyday life and
are easily transferrable into health care. Recent
work by Lalonde et al. (Yu et al., 2019) on field ste-
rility and Van Denmark’s concept of ’lean and green
hand surgery’ (Van Demark et al., 2018) have also
helped by demonstrating that sustainable hand surgery
can be practiced economically while maintaining safe
surgical standards. Accordingly, the clinical scenario
questions addressing waste management & recycling
in the theatre setting’and’reduction/limiting the use of
drapes and gowns for simple soft tissue procedures
have achieved the highest support.
In contrast, responses for clinical scenarios
involving areas of direct patient care had less sup-
port. Approximately 50% of respondents opted to
discuss the different environmental impact of gen-
eral anaesthesia versus WALANT (wide awake local
anaesthesia no tourniquet) with patients and to con-
sider the environmental impact when deciding
whether to prescribe prophylactic antibiotics’.
These ratings could be explained by the widely
shared concept of antibiotic stewardship, if taking
into account the impact of antibiotics on the
environment (Richards et al., 2004), and the evolving
evidence showing that avoidance of inhalation anaes-
thetics significantly reduce the carbon footprint of
theatres. The effect of a single inhalation general
anaesthesia is estimated to be equivalent to releas-
ing approximately 22 kg of CO
into the environment
(MacNeill et al., 2017; Ryan and Nielsen, 2010) and
using alternative techniques such as WALANT, or
similarly blocks, regional or intravenous anaesthesia
would have a significantly lesser impact on the envi-
ronment. Similarly, although virtual clinics would
reduce the carbon footprint by cutting down the
need for patients to travel to hospital, the survey
showed that these would only be considered by
40% of respondents. Virtual clinics have seen a
surge during the COVID-19 pandemic and related lit-
erature showed that they overall have been met with
high patient satisfaction and acceptance by the clini-
cians (Hendrickson et al., 2021; Vusirikala et al.,
2021), but perhaps by the time of the survey was
conducted, a certain fatigue with this technology
had developed and further research will be required
to establish the future role of these clinics.
The two changes to clinical practice with the lowest
ranking in the clinical scenario category were limiting
the use of non-steroidal anti-inflammatory drugs
(NSAIDs) to reduce the impact of water pollution
(31%) and choosing a surgical technique with
lower environmental impact such as Kirschner wires
(K-wires) over open reduction and internal
fixation (ORIF) (29%). Despite being one of the most
prescribed drugs globally, surgeons might have lim-
ited awareness of the impact of NSAIDs on water pol-
lution and toxicity to non-target organisms (He et al.,
2017) which might have influenced the survey results.
The decision to use K-wires versus ORIF is at
times a complex one; the question was designed to
consider the surplus of waste generated when
performing an ORIF. This additional waste stems
from the requirements, according to recent legisla-
tions and standards (such as the International
Organisation for Standardization EN ISO 13485) that
each medical implant, that is each osteosynthesis
screw should be traceable through the processing
system and hence needs to be individually packaged.
The multiple layers of packaging are often unsuitable
for recycling and were widely criticized in the sur-
vey’s comments. This question of K-wires versus
ORIF received the least consent and also generated
the most vigorous responses from some of the
survey participants, expressing concerns regarding
possible litigation and the ethics of such considera-
tions. But even if current evidence determines a
single best method, a surgeon’s choice of technique
often simply comes down to experience and
Witt et al. 3
preference (Ferlie et al., 1999) or is influenced by
local and geographical variations and constraints
(Grove et al., 2016).
This global survey allowed a useful glimpse into the
perspective of hand surgeons and highlighted the
overall strong concern about climate change within
the hand surgery community. The majority of
respondents agreed that health care professionals
have the obligation to raise awareness of the contri-
bution of the health care sector to climate change.
Finding sustainable solutions to ensure that we can
maintain surgical quality care with lower carbon
footprint should be addressed in future research.
Declaration of conflicting interests The authors
declare no potential conflicts of interest with respect to the
research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following
financial support for the research, authorship, and/or pub-
lication of this article: the authors received support in the
distribution of the survey from the office of the Federation
of European Societies for Surgery of the Hand (FESSH).
Supplemental material Supplemental material for this
article is available online.
ORCID iD Elisabet Hagert
Ferlie E, Wood M, Fitzgerald L. Some limits to evidence-based
medicine: a case study from elective orthopaedics. Qual
Health Care. 1999, 8: 99–107.
Grove A, Johnson R, Clarke A, Currie G. Evidence and the drivers of
variation in orthopaedic surgical work: a mixed methods sys-
tematic review. Health Syst Policy Res. 2016, 3: 1.
He BS, Wang J, Liu J, Hu XM. Eco-pharmacovigilance of non-
steroidal anti-inflammatory drugs: necessity and opportunities.
Chemosphere. 2017, 181: 178–89.
Health Care Without Harm Climate. Smart health care series
Green Paper Number One, 2019.
ClimateFootprint_092319.pdf (accessed April 2022).
Hendrickson SA, Witt P, Watts A. Telephone clinics for follow-up in
hand surgery: an effective model after COVID-19? RCS Bull.
2021, 95: 258–62.
Lenzen M, Malik A, Li M, et al. The environmental footprint of
health care: a global assessment. Lancet Planet Health.
2020, 4: e271–9.
MacNeill AJ, Lillywhite R, Brown CJ. The impact of surgery on
global climate: a carbon footprinting study of operating thea-
tres in three health systems. Lancet Planet Health. 2017, 1:
Richards SM, Wilson CJ, Johnson DJ et al. Effects of pharmaceu-
tical mixtures in aquatic microcosms. Environ Toxicol Chem.
2004, 23: 1035–42.
Ryan SM, Nielsen CJ. Global warming potential of inhaled anes-
thetics: application to clinical use. Anesth Analg. 2010, 111:
Van Demark RE Jr, Smith VJS, Fiegen A. Lean and green hand
surgery. J Hand Surg Am. 2018, 43: 179–81.
Vusirikala A, Ensor D, Asokan AK et al. Hello, can you hear me?
Orthopaedic clinic telephone consultations in the COVID-19 era
a patient and clinician perspective. World J Orthop. 2021, 12:
Yu J, Ji TA, Craig M, McKee D, Lalonde DH. Evidence-based
sterility: the evolving role of field sterility in skin and
minor hand surgery. Plast Reconstr Surg Glob Open. 2019, 7:
Paulina Witt
, Egemen Ayhan
Elisabet Hagert
and Zafar Naqui
Department of Plastic Surgery, Royal & Devon Exeter
Hospital, Exeter, UK
Department of Orthopaedics and Traumatology, University
of Health Sciences Turkey, Diskapi YB Training and
Research Hospital, Ankara, Turkey
Karolinska Institutet, Department of Clinical Science and
Education, Stockholm, Sweden
Aspetar Orthopaedic and Sports Medicine Hospital, Doha,
Hand Surgery Unit, Department of Trauma,
Orthopaedic and Plastic Surgery, Salford Royal Hospital,
Manchester, UK
Corresponding author:
4Journal of Hand Surgery (European Volume) 47(9)
ResearchGate has not been able to resolve any citations for this publication.
Full-text available
Background Health-care services are necessary for sustaining and improving human wellbeing, yet they have an environmental footprint that contributes to environment-related threats to human health. Previous studies have quantified the carbon emissions resulting from health care at a global level. We aimed to provide a global assessment of the wide-ranging environmental impacts of this sector. Methods In this multiregional input-output analysis, we evaluated the contribution of health-care sectors in driving environmental damage that in turn puts human health at risk. Using a global supply-chain database containing detailed information on health-care sectors, we quantified the direct and indirect supply-chain environmental damage driven by the demand for health care. We focused on seven environmental stressors with known adverse feedback cycles: greenhouse gas emissions, particulate matter, air pollutants (nitrogen oxides and sulphur dioxide), malaria risk, reactive nitrogen in water, and scarce water use. Findings Health care causes global environmental impacts that, depending on which indicator is considered, range between 1% and 5% of total global impacts, and are more than 5% for some national impacts. Interpretation Enhancing health-care expenditure to mitigate negative health effects of environmental damage is often promoted by health-care practitioners. However, global supply chains that feed into the enhanced activity of health-care sectors in turn initiate adverse feedback cycles by increasing the environmental impact of health care, thus counteracting the mission of health care. Funding Australian Research Council, National eResearch Collaboration Tools and Resources project.
Full-text available
Field sterility is commonly used for skin and minor hand surgery performed in the ambulatory setting. Surgical site infection (SSI) rates are similar for these same procedures when performed in the main operating room (OR). In this paper, we aim to look at both current evidence and common sense logic supporting the use of some of the techniques and apparel designed to prevent SSI. This is a literature review of the evidence behind the ability of gloves, masks, gowns, drapes, head covers, footwear, and ventilation systems to prevent SSIs. We used MEDLINE, EMBASE, and PubMed and included literature from the inception of each database up to March 2019. We could not find substantial evidence to support the use of main OR sterility practices such as head covers, gowns, full patient draping, laminar airflow, and footwear to reduce SSIs in skin and minor hand surgery. Field sterility in ambulatory minor procedure rooms outside the main OR is appropriate for most skin and minor hand surgery procedures. SSIs in these procedures are easily treatable with minimal patient morbidity and do not justify the cost and waste associated with the use of main OR sterility.
Full-text available
Health care in the United States is both expensive and wasteful. The cost of health care in the United States continues to increase every year. Health care spending for 2016 is estimated at $3.35 trillion. Per capita spending ($10,345 per person) is more than twice the average of other developed countries. The United States also leads the world in solid waste production (624,700 metric tons of waste in 2011). The health care industry is second only to the food industry in annual waste production. Each year, health care facilities in the United States produce 4 billion pounds of waste (660 tons per day), with as much as 70%, or around 2.8 billion pounds, produced directly by operating rooms. Waste disposal also accounts for up to 20% of a hospital's annual environmental services budget. Since 1992, waste production by hospitals has increased annually by a rate of at least 15%, due in part to the increased usage of disposables. Reduction in operating room waste would decrease both health care costs and potential environmental hazards. In 2015, the American Association for Hand Surgery along with the American Society for Surgery of the Hand, American Society for Peripheral Nerve Surgery, and the American Society of Reconstructive Microsurgery began the "Lean and Green" surgery project to reduce the amount of waste generated by hand surgery. We recently began our own "Lean and Green" project in our institution. Using "minor field sterility" surgical principles and Wide Awake Local Anesthesia No Tourniquet (WALANT), both surgical costs and surgical waste were decreased while maintaining patient safety and satisfaction. As the current reimbursement model changes from quantity to quality, "Lean and Green" surgery will play a role in the future health care system.
Full-text available
Background Climate change is a major global public health priority. The delivery of health-care services generates considerable greenhouse gas emissions. Operating theatres are a resource-intensive subsector of health care, with high energy demands, consumable throughput, and waste volumes. The environmental impacts of these activities are generally accepted as necessary for the provision of quality care, but have not been examined in detail. In this study, we estimate the carbon footprint of operating theatres in hospitals in three health systems. Methods Surgical suites at three academic quaternary-care hospitals were studied over a 1-year period in Canada (Vancouver General Hospital, VGH), the USA (University of Minnesota Medical Center, UMMC), and the UK (John Radcliffe Hospital, JRH). Greenhouse gas emissions were estimated using primary activity data and applicable emissions factors, and reported according to the Greenhouse Gas Protocol. Findings Site greenhouse gas evaluations were done between Jan 1 and Dec 31, 2011. The surgical suites studied were found to have annual carbon footprints of 5 187 936 kg of CO2 equivalents (CO2e) at JRH, 4 181 864 kg of CO2e at UMMC, and 3 218 907 kg of CO2e at VGH. On a per unit area basis, JRH had the lowest carbon intensity at 1702 kg CO2e/m², compared with 1951 kg CO2e/m² at VGH and 2284 kg CO2e/m² at UMMC. Based on case volumes at all three sites, VGH had the lowest carbon intensity per operation at 146 kg CO2e per case compared with 173 kg CO2e per case at JRH and 232 kg CO2e per case at UMMC. Anaesthetic gases and energy consumption were the largest sources of greenhouse gas emissions. Preferential use of desflurane resulted in a ten-fold difference in anaesthetic gas emissions between hospitals. Theatres were found to be three to six times more energy-intense than the hospital as a whole, primarily due to heating, ventilation, and air conditioning requirements. Overall, the carbon footprint of surgery in the three countries studied is estimated to be 9·7 million tonnes of CO2e per year. Interpretation Operating theatres are an appreciable source of greenhouse gas emissions. Emissions reduction strategies including avoidance of desflurane and occupancy-based ventilation have the potential to lessen the climate impact of surgical services without compromising patient safety. Funding None.
Full-text available
There has been growing interest in recent years in the application of the principles of evidence-based medicine (EBM), although implementation is complex. Scientific, organisational, and behavioural factors all combine to shape clinical behaviour change. Case study based qualitative data are presented which illuminate such processes within one clinical setting (elective orthopaedics), drawn from a larger study. It is suggested that (1) there are alternative models of what constitutes "evidence" in use; (2) scientific knowledge is in part socially constructed; and (3) clinical professionals retain a monopoly of technical knowledge. The implication is that there may be severe obstacles to the rapid or broad implementation of EBM.
Introduction Telephone clinics were adopted for follow-up appointments in our plastic hand surgery department during the COVID-19 pandemic. They may pose advantages in cost, efficiency and environmental impact compared with face-to-face consultations. The aim of this study was to assess the success rate of telephone clinics in hand surgery to determine benefit of continuing the practice. Methods A prospective cohort study of all hand surgery follow-up telephone clinics was conducted over a six-week period. The primary outcome measure was success of the consultation, defined as achieving the same outcome as could have been achieved in a face-to-face clinic. Secondary outcome measures included duration and environmental impact. Results During the study period, 177 consultations were scheduled. Twenty-nine patients (16%) were not contactable. Of the remaining 148 consultations, 111 (75%) had a successful outcome. The highest success rate (85%) was achieved for first postoperative consultations when the patient had already received hand therapy. On average, consultations lasted 8 minutes but required an additional 16 minutes of preparation, documentation and administrative work. An estimated 5,939km of patient travel (1.25 tonnes of carbon dioxide emissions) were saved during the study period. Conclusions The rate of successful outcomes following telephone consultation in our cohort of patients was lower than for face-to-face clinics. However, the service was set up with little time for preparation. The success rate and duration could be improved with appropriate patient selection, especially for those who have undergone straightforward operative procedures. The duration of consultations and the ‘did not attend’ rate should reduce as administrative processes improve.
Background: The coronavirus disease 2019 (COVID-19) pandemic has resulted in seismic changes in healthcare delivery. As a result of this, hospital footfall required to be reduced due to increased risk of transmission of infection. To ensure patients can safely access healthcare, we introduced orthopaedic clinic telephone consultations in our busy district general hospital. Aim: To investigate patients' and clinicians' perspective of telephone consultations during COVID-19, and whether this method of consultation could be a viable option in the post- pandemic future. Methods: This is a single centre, prospective study conducted in a busy National Health Service district general hospital. In May 2020, 100 non- consecutive adult patients were contacted by independent investigators within 48 h of their orthopaedic clinic telephone consultation to complete a telephone satisfaction questionnaire. The questions assessed satisfaction regarding various aspects of the consultation including overall satisfaction and willingness to use this approach long term. Satisfaction and perspective of 25 clinicians conducting these telephone consultations was also assessed via an online survey tool. Results: 93% of patients were overall satisfied with telephone consultations and 79% were willing to continue this method of consultation post- pandemic. Patients found telephone consultations to reduce personal cost and inconvenience associated with attending a hospital appointment. 72% of clinicians reported overall satisfaction with this service and 80% agreed that telephone consultations should be used in the future. The majority found it less laborious in time and administration in comparison to face to face consultations. Patients and clinicians expressed their desire for video consultations as a method of further improving their experience with remote consultations. Conclusion: Our study has shown that telephone consultations are a safe and rapid method of adaptation to the COVID-19 pandemic, achieving the aim of reducing hospital footfall. This method of consultation has resulted in immense clinician and patient satisfaction. Our findings suggest that this tool has benefits in post pandemic healthcare delivery. It has also highlighted that telephone consultations can act as a steppingstone to the introduction of the more complex platform of video consulting.
Eco-pharmacovigilance (EPV) is a practical and powerful approach to minimize the potential risks posed by pharmaceutical residues in environment. However, it is impracticable to practise rigorous and unitary EPV process for all the existing and new pharmaceuticals. Here, we focused on non-steroidal anti-inflammatory drugs (NSAIDs), and discussed the necessity and potential opportunities of practising EPV of NSAIDs. We found that the consumption of NSAIDs is huge and ubiquitous across the globe. NSAIDs were worldwidely reported as one of the most dominant and frequently detected groups in environmental matrices including wastewater, surface water, suspended solids, sediments, groundwater, even drinking water. Besides, there is definitive evidence for the adverse impacts of NSAID residues on scavenging birds and aquatic species. These data suggested the necessity of implementing EPV of NSAIDs. From the perspective of drug administration, we identified some things that can be done as management practice options for EPV implementation on NSAIDs: ● Improving knowledge and perceptions of pharmacy/health care practitioners about EPV of NSAIDs. ● Emphasizing the control of NSAIDs pollution sources, including preventing unnecessary consumption and unrational use of NSAIDs; promoting the safe disposal of medicines among the general public; controlling the manufacturing-related releases. ● Identifying high-risk areas of NSAIDs pollution and associated risk factors. ● Identifying high priority NSAIDs to be monitored in environment. ● Lifting the world-wide ban on the production and sale of veterinary diclofenac in support of meloxicam, the only NSAID currently considered safe for vultures. ● Designing and constituting a multidisciplinary framework for EPV of NSAIDs.
Inhaled anesthetics are recognized greenhouse gases. Calculating their relative impact during common clinical usage will allow comparison to each other and to carbon dioxide emissions in general. We determined infrared absorption cross-sections for sevoflurane and isoflurane. Twenty-year global warming potential (GWP(20)) values for desflurane, sevoflurane, and isoflurane were then calculated using the present and previously published infrared results, and best estimate atmospheric lifetimes were determined. The total quantity of each anesthetic used in 1 minimal alveolar concentration (MAC)-hour was then multiplied by the calculated GWP(20) for that anesthetic, and expressed as "carbon dioxide equivalent" (CDE(20)) in grams. Common fresh gas flows and carrier gases, both air/oxygen and nitrous oxide (N2O)/oxygen, were considered in the calculations to allow these examples to represent common clinical use of inhaled anesthetics. GWP(20) values for the inhaled anesthetics were: sevoflurane 349, isoflurane 1401, and desflurane 3714. CDE(20) values for 1 MAC-hour at 2 L fresh gas flow were: sevoflurane 6980 g, isoflurane 15,551 g, and desflurane 187,186 g. Comparison among these anesthetics produced a ratio of sevoflurane 1, isoflurane 2.2, and desflurane 26.8. When 60% N2O/40% oxygen replaced air/oxygen as a carrier gas combination, and inhaled anesthetic delivery was adjusted to deliver 1 MAC-hour of anesthetic, sevoflurane CDE(20) values were 5.9 times higher with N2O than when carried with air/O2, isoflurane values were 2.9 times higher, and desflurane values were 0.4 times lower. On a 100-year time horizon with 60% N2O, the sevoflurane CDE(100) values were 19 times higher than when carried in air/O2, isoflurane values were 9 times higher, and desflurane values were equal with and without N2O. Under comparable and common clinical conditions, desflurane has a greater potential impact on global warming than either isoflurane or sevoflurane. N2O alone produces a sizable greenhouse gas contribution relative to sevoflurane or isoflurane. Additionally, 60% N2O combined with potent inhaled anesthetics to deliver 1 MAC of anesthetic substantially increases the environmental impact of sevoflurane and isoflurane, and decreases that of desflurane. N2O is destructive to the ozone layer as well as possessing GWP; it continues to have impact over a longer timeframe, and may not be an environmentally sound tradeoff for desflurane. From our calculations, avoiding N2O and unnecessarily high fresh gas flow rates can reduce the environmental impact of inhaled anesthetics.