The 2023 intensive care society cauldron: Five ways to tackle sustainability

Introduction

‘The Cauldron’ is a tradition unique to the Intensive Care Society, and occurs at their annual State of the Art Conference. It is an opportunity for trainees to get on the big stage, and highlight their worthy ideas, perspicacity, wit and verbal dexterity. This is further facilitated by an exuberant audience, and a panel of ‘curmudgeon’ judges. Theses presentations are always insightful, popular and worth sharing. The 2023 debates took place in Birmingham on June 28th. The topic was ‘sustainability’, namely the ability to maintain the work we do and to avoid depleting natural resources.

The 2023 Cauldron was ably chaired by Dr Segun Olusanya. The judges were Professor Shondipon Laha, Dr Catherine Chalifour, Rosie Cervera-Jackson RN and Professor Peter Brindley. We are grateful to the Journal of the Intensive Care Society for the opportunity to share the work of such talented young healthcare professionals. The following abstracts were written by the presenters, and compiled and edited by Peter Brindley.

Presentation 1: Richard Kirkdale

The cost of being environmentally friendly: A new metric, the POCK – ‘Price of a CO2 Kilo’

We want to make environmentally sound choices. For example, we favour low flow vapours and avoid ‘polar bear killers’, such as desflurane or nitrous oxide. Similarly, Sevoflurane is likely better for the environment than desflurane, because it has a lower global warming potential over 100 years (GWP₁₀₀). However, it gets confusing with intravenous anaesthesia. For example, how much does it ‘cost’ the environment to make Propofol, or 50 ml syringes? Perhaps a 250 ml bag of fluid and 5 ampules of Noradrenaline is less environmentally damaging than single ampules in multiple 50 ml syringes, but what if large amounts are thrown away?

Home dishwashers and washing machines include energy efficiency labelling. This facilitates environmental decision-making, but what about a Drager Evita versus a Maquet Servo-I? Regardless, our goal should be to balance clinical risk against environmental impact. To date, we have had few resources to assess the environmental impact of our clinical choices. Accordingly, I propose a novel metric, the ‘Price of a CO2 Kilo’ (POCK).

The GWP₁₀₀ of a ton of CO₂ is an accepted benchmark for environmental impact. The energy required and CO₂ generated while processing raw materials (e.g. metals, paper and plastics) is available, ² as is the impact of manufacturing (i.e. wire drawing for needles, injection moulding of syringes), ² as are the estimated transport costs. With these data we can assign an estimate of GWP₁₀₀ to many treatments. From this we can approximate how much it will cost your department to be more environmentally friendly. The provocative unanswered question remains, namely, how much we are willing to pay?

Presentation 2: Rasmus Knudsen

Prioritise doing good, deprioritise the environment?

To mitigate our environmental impact, we should focus on good outcomes rather than good intentions. This is because only a realistic, economically-sound, approach will work. We should stop seeking ‘popular’ interventions if they have a poor scientific or economic basis. Instead, we should focus on how we can objectively improve more lives and decrease our environmental impact.

We should embrace three things that Intensivists are good at: reflection, critical appraisal of evidence and pragmatic action. Moreover, we actually want to do more than just reduce greenhouse gases or global temperatures; namely we wish to reduce human suffering, and particularly for those with the greatest need. While biodiversity matters, we should also accept that environmental change disproportionally impacts the poor. Moreover, lower income countries have less capacity to adapt, and aggressive reductions in emissions may even further increase their poverty. ¹

The United Nations has surveyed large numbers of people regarding their priorities. Notably, tackling climate change is repeatedly near the bottom, whilst the economy is near the top. Accordingly, we need to focus on measures that are evidence-based AND cost effective. For example, if we invested £24,095 (an amount that equates with 75% of ICS subscribers donating 5% of their dues), this could offset 4077 tons of carbon dioxide, thereby yielding a benefit of £6,564.^{2 –4} Alternatively, thousands of mosquito nets could be provided, which would yield £867,420. ⁵

In conclusion, if we reprioritized, we could improve lives, reduce poverty and increase environmental resilience. The ICS should encourage its members to use their skills in reflection, critical appraisal and communication to promote priorities that not only sound good, but do good.