K. Harvey-Kelly1, H. Lewis2, J. McArdle3, Paediatric Anaesthesia Trainee Research Network4, K. Brooks5, J. Groome5

1Great Ormond Street Hospital, London, UK

2Evelina Children's Hospital, London, UK

3Great North Children's Hospital, Newcastle-upon-Tyne, UK

4APAGBI, London, UK

5Barts Health, London, UK


Anaesthesia contributes 2% of the NHS carbon footprint. Anaesthetic gases are often targeted as the major culprit, however, there are multiple other parts of anaesthetic practice that contribute to its environmental impact (1). Disposal of single use items for drug administration, airway equipment, monitoring and vascular access generate landfill, microplastics and pollutants. Disposal and excretion of medications can also cause ecological contamination (2). A 2021 working group for the World Federation of Societies of Anaesthesiologists carried out a consensus process to identify a set of achievable principles for environmentally sustainable anaesthesia. The first step is to consider how to safely reduce the amount of equipment, medications, energy and water used in anaesthetic practice(3).

This survey looks specifically at the preparation of emergency drugs in paediatric anaesthetic practice.


A Microsoft Forms questionnaire was designed by the Paediatric Anaesthesia Trainee Research Network (PATRN) and the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) Scientific committee. Thirteen questions focussed on preparation of emergency drugs in paediatric anaesthesia and availability of pre-filled syringes. The survey was sent to PATRN and APAGBI members and distributed at the 2023 APAGBI conference.


A total of 183 results were received. The majority of respondents were consultants (n=148; 81%). Most people draw up emergency drugs, either always (n=77; 42%) or dependent on the case (n=86; 47%). Only 10% (n=19) stated they never drew up emergency drugs. Atropine (n=124; 68%) and propofol (n=130; 71%) were most commonly prepared, followed by muscle relaxant (56%; n=104). High risk cases e.g. neonates (45%), solo (20%) and remote working (22%) were the main reasons for routinely drawing up emergency drugs. Two thirds of respondents had pre-filled syringes available at their institution either in every anaesthetic room (45%; n=83) or on the resuscitation trolley (16%; n=29). Atropine, adrenaline and ephedrine were the most common pre-filled drugs. Display of emergency drug doses was not routinely carried out and there was no clear preferred method when it was done. Almost half of respondents had no method to display emergency drug doses or volumes (47%; n=87). Methods utilised included a whiteboard, reference chart and online app.


Pre-emptive preparation of emergency drugs is commonplace in paediatric anaesthesia, particularly for high risk cases, when working solo or in a remote location.

This is a complex area in terms of balancing patient safety and working to minimise the unnecessary use of disposal and single use plastics, packaging and medications. Clearly displaying individualised emergency drug doses and volumes in theatre and anaesthetic rooms, as well as stocking of pre-filled syringes could safely help to reduce waste associated with routinely drawing-up emergency drugs. A reduction in use would also reduce cost and the waste associated with manufacture.


  1. Putting anaesthetic-generated emissions to bed: https://www.england.nhs.uk/greenernhs/whats-already-happening/putting-anaesthetic-generated-emissions-to-bed/
  2. Shelton C L, Knagg R, Sondekoppam R V, McGain F. Towards zero carbon healthcare:anaesthesia BMJ 2022; 379 :e069030 doi:10.1136/bmj-2021-069030
  3. White, S.M., Shelton, C.L., Gelb et al. (2022), Principles of environmentally-sustainable anaesthesia: a global consensus statement from the World Federation of Societies of Anaesthesiologists. Anaesthesia, 77: 201-212. https://doi.org/10.1111/anae.15598
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