Hello, it's Anthony Chadwick from the webinar that welcoming you to our 11th annual virtual congress. I recommend that you watch this, webinar on a tablet, a laptop or a desktop rather than phone for the best quality. VC 2023 is live each night this week, as well as some afternoon sessions like today.

And any questions you have, please leave them in the question answer box and we'll make sure we get round to them during the talk today. Want to first of all thanks Mars Veterinary Health for sponsoring and partnering with us for this session. And this session is all about pharmaceutical stewardship, how we can deliver high quality care to patients through prescription medicines.

Obviously we often think about that in terms of antimicrobial stewardship, but it's much broader than that. Pharmaceuticals are a key component of how we treat and alleviate disease in pets, but we also need to treat those medicines with respect if we're going to be able to use them in the long term. And also because of potential environmental impacts that these medicines can have.

We're gonna have a series of talks today, which we'll be introducing you to as we go along. But first of all, we're going to be hearing from Ian Battersby and Margo Mosa. Ian is the global responsible pharmaceutical stewardship lead for Mars Veterinary Health, and he was appointed last year.

This is a newly created role which just shows how much, importance that Mars battery have place on this whole area and of course around sustainability. Before that, Ian has practised veterinary medicine for over 20 years and was the head of medicine at Davis Veterinary Specialists, which last year received the veterinary group practise of the year during our sustainability summit. Ian is currently also the chairman of Mission rabies, a a really fantastic charity that is doing great work to try and help to end the problem of rabies in both animals and people, and it's a really great example of one health disease.

He was also awarded a Fellowship of the Royal College in 2019 for meritorious contributions to clinical practise. And like myself, and, and it seems to be a growing fad amongst, amongst men of our age, he is a keen cyclist as well, a mammal, I think they're called. Yeah.

Marco is global director of sustainability at Mars Veterinary Health, and Mars, Marco is working to implement more sustainable practises across the whole business. That includes Anaura, Banfield, Blue Pearl, Linnaeus and VCA to improve sustainability impacts across the areas of environment, people, and pets, which we just heard talked about in the video. Margot joining Mars Veterinary Health from the field of corporate sustainability and consulting, where she worked for the past 10 years at Sustainability Inc.

She's supported dozens of large multinational clients to develop their sustainability strategies over the years, and she has also got a Master's of Environmental Management from Yale School and is also the proud pet owner of her rabbit, Hooper. So really delighted to have you both on. It's such an important area.

Thank you so much for Martha and your help for supporting us in this topic, and it's over to the two of you. Excellent. Thank you so much, Anthony.

Really appreciate those introductions and thank you to Webinar vet for the opportunity today to meet with you all, and have a really rich discussion here. So, as Anthony mentioned, I'm Margot, I'm joined by Ian. You'll hear a lot more from us over this next 2 hour period that we have together.

So I'll tee us up here and just give you a sense of what we'll be covering. In that 2 hour period, the first hour or so, you'll be hearing from Ian and myself. We will take a short break, in between, the 2 hours we've got, before we hear from a few of our other colleagues.

So, we will have a chance for questions as Anthony mentioned at the top, so please do be putting those in the chat as we go and we'll be trying to make time throughout, to answer those. So, in terms of what we'll be talking about today, Anthony teed us up really nicely. Our topic is pharmaceutical stewardship.

And that is a really broad topic. And so our goal here is to break that down in a few different ways, talk about the principles behind pharmaceutical stewardship, what all that includes. We'll talk a little bit about different types of, drugs of focus within that, and we'll also touch on some of the environmental impacts of pharmaceuticals because that is a key part of stewardship as well, of course, alongside really the quality of care for our pets.

I won't do too much more introduction to Mars Veterinary Health. I think the video teed us up really nicely, but I'll just add to that to say that this work really fits into both our quality of care but also our sustainability work. You saw our three pillars within sustainability in the video of people, pets and planet, we'll talk a bit more about that throughout our, our discussion today, because we see this topic as one that really cuts across all three, and that's why it's really a one health topic.

We'll talk more about what exactly that means, but really this is a topic that is key to our business and key to the work that we're all really passionate about doing across our different clinics and businesses. So, I've mentioned, you'll hear from a few other folks, so I'll just mention briefly later on. We'll hear from Doctor Craig Moseley who will be joining us to talk about anaesthesia specifically, and how, as one of the pharmaceuticals that we all use, there's lots we can be doing on that to manage the impacts both for pets as well as for the environment.

And then we'll also be hearing from Dr. Ellie West, towards the end of our session really about what's happening in the clinics, disposal of drugs, especially at one point that she'll head on. So really digging into some examples of best practise for pharmaceutical stewardship at the clinic level.

So we're looking forward to them joining us later on, but to begin, we'll dive in, with Ian and myself, and so first, I'll ask Ian if, if you want to do a bit more introduction for yourself, and then we'll start to, to dive into the topic of pharmaceutical stewardship, talk about how you got into the space, and then start to define it a little bit more for our audience as well. So with that over to you Ian. Cool.

Thank you, Margie, and thank you, Antony, for great introductions and thank you everybody for taking time out this afternoon. I know clinics are no doubt busy, so, thank you for listening. So, Anthony's already outlined, some of my background.

I've been very fortunate in my career, to, to, get involved in lots of different things. But I guess, about 10 years ago, I just started getting drawn to one health topics and in particular, anti anti the tongue-tied already at the start, that's not good. Antibiotic stewardship.

And that's something that I did a lot of work in initially about 10 years ago, and I was involved in developing the BSAVA Protect scheme and that, Also kind of breached over to me getting involved in, in Mission rabies. And what I've learned though, as I've aged and with experience, is that a lot of the principles, certainly for antibiotic stewardship, can be applied across all pharmaceuticals. So, you know, the principles of responsible use doesn't just apply to that one drug group, it's something that we can apply to all drug groups when we break it down and look at it methodically.

So, for me, it was fantastic. I mean, I've, I've, the transition from clinics was, was a difficult one, but to move to a, a role like this, to work with Margo and the team where we can have some real, good discussions and, and, and, and positive change in this area is, was a fantastic opportunity. I couldn't turn down.

So it's just brilliant to be involved. We're so happy to have you in as part of the team and leading all of this absolutely critical work with us so, as Anthony had mentioned you've been enrolled for 6 months or more, and so it's been so excellent to have your support and your thought leadership across this, . One piece I'd, I'd love for you to share, I, I know the story, but I would love to hear a little bit of how did you get passionate and really involved and especially the antimicrobial resistance and, antibiotic side of all of this.

I know it was, triggered by your own personal events. I'd love to kind of hear that story if you'd like to share. Yeah, it's a, it's a, it's a bit of a sliding door moment, really, for my career.

And I'm sure we will have them. . And, I apologise if there's anybody listening that's already heard this, cause I, I have repeated it a few times.

So, but, for those of you who haven't heard it, I mean, it's probably about 1012 years ago, I was in the cat ward at the practise at Davies's and, I was examining a cat that seemed quite friendly, but it had one of those kind of moments where a cat goes from being really happy to suddenly wanting to bite you. And the cat really got stuck into my hand and, and bit me quite deeply. It was such a deep bite, I had to go to the doctor's, got some antibiotics.

That didn't, you know, 2 days later, my hand was swelling up, so they tried another course of antibiotics that Didn't work and I was reacting quite badly to the antibiotics and I ended up in A&E at the hospital with a very, very swollen hand that I was really concerned about. And It wasn't my proudest moment because I was trying to ask for antibiotics, you know, lots of antibiotics for my, my hand. And the consultant who was assessing me at the time was, was incredibly patient and just outlined some of the restrictions he had for some of the drugs that I was requesting.

So I was asking for, you know, fluroquinolones, and then I think my hands really swollen. And he, he, you know, he, he was really patient explaining that for him to be able to prescribe those drugs, he would need a culture justifying that that was the only You know, drug that he could use and then he'd also need a sign off from the microbiologist in the lab. And that, you know, that had a profound effect on me.

My, my hand got better, by the way, there it is, . But it had a really profound effect on me and I started doing a little bit of digging and at the time, you know, this was a, an emerging growing, you know, topic, and particularly in human healthcare, we'd had all the MRSA issues, which everybody's very aware of. And the Chief Medical Officer of England at the time had put out a report suggesting that veterinary prescribing was contributing to this and that, you know, vets, we should, we should look into restricting prescription, you know, vet's ability to prescribe cephalosporins and fluoroquinolones.

Which again was another kind of profound, moment. So I went on the SAMSOC forum, which is a, a, a, a, a satellite group of BSABA and posted about, you know, has anybody got any prescribing policies, you know, to, to restrict use, to use, you know, responsible use, and only one reply out of 50 came back with a, with a positive, yes, we have. And really, that, You know, during that discussion, we recognised that, you know, not, there was a responsibility really of as as vets to, to use these drugs appropriately and wisely.

And also an opportunity. To demonstrate that we could use these drugs responsibly so that the threat of legislation wasn't going to be put on us. So, it's cut a long story short, essentially, I, I led a team that conceptualised and developed the BSAVA protect scheme, and that's been More successful than what I could imagine.

It's been translated into, into different languages, you know, the, the equine sector adapted it to their version. And I guess I've been banging the drum on antibiotic stewardship since then. But, you know, with time, I've started to recognise, and also with work with you, Margo, I've been, you know, increasingly recognised the importance that AMR is a, you know, is my main subject, but we also should talk about how these principles of stewardship can be applied to other drug groups as well.

Thank you for sharing that. I think such a, yeah, gateway moment to, to bring you into this, and we think, yeah, I was gonna say before we carry on, what about your? I've talked about me and my gateway.

What about your gateway moment into sustainability? Yeah. So for me, it's probably less of a singular moment and, and kind of dramatic moment for me.

But on sustainability, I've been passionate about this topic and specifically environmental sustainability, since I was a young kid. And for me, it, it really started around love of animals, which like many folks, of course, can relate to here. And just love of nature and, and being outdoors.

And as I got older, just realising the importance of That for our own health, and just needing clean air and clean water and resources to survive as, as our own species, and wanting to protect other species as well. So that's really what drove me to study environmental studies throughout my education. And then coming to Mars Veterinary Health, you know, something I learned over the years also was seeing the impact that large corporations can have on both on a Environmental and social issues globally.

And so for me, just the opportunity, if we make small changes here at Mars Veterinary Health, it can have such a large impact. And to me, that is just really exciting in a way to, to drive change. Going back to when I was a young kid wanting to protect nature, this is really, one of my, my big ways to try to do it.

So that's what got me here. No, no cat fights involved. Love, love of cats.

Yeah, love of cats. Yeah, true. So we should probably talk about pharmaceutical stewardship.

Let's dive in. Let's dive in. And I think as you were just about to, I think, get to is, you know, talking about outlining what is pharmaceutical stewardship.

And if you want to talk about some of the principles of that, I can pull up that slide if now is the right moment. Yeah, that'd be great. Thank you.

All right. OK, that should be up now. There we go.

So, there's lots of different definitions of pharmaceutical stewardship. Some of them are a lot longer than this. And if I'm being honest, a lot of them are, Pretty much adapted to a particular business with a, you know, so if you've got a particular organisation with an objective, the definition will, will, will, will be modified to that.

But this is a really nice simple one, which certainly fits for us as clinicians. And really, there's two parts to it. So we've got the first part, which is, you're using the right drug, the right patient at the right time, the right dose and route.

And then causing the second part which is causing the least harm to the patient and future patients. So if we break that down, you know, the, the first part of pharmaceutical stewardship is making sure that we use these drugs optimally to get a good clinical outcome. And, you know, I, I suppose, you know, we, we're used to using formularies to ensure we've got the right dose.

You know, there's, you know, we, we, we're now increasingly using checklists and things like that to ensure that there's no underdosing or overdosing, and, you know, particularly with certain medications. So, you know, that's a, a good, example of stewardship. But also we want to put in place, you know, when we're using these drugs, we want to make sure we've got the other components of the, of, of the piece to make sure that those drugs work as efficacy, efficaciously as possible.

So, you know, a, a nice, simple example would be, you know, a pyothorax. So, You know, if we've got a, a, a patient with a pythorax, we know the antibiotics aren't going to penetrate into that area. So we put a chest drain in to facilitate the, the, the resolution of the infection.

You know, so we keep the draining to drain the, you know, the pus. We use the antibiotics at the same time in that situation, and that's the way of facilitating the drugs to work properly. But what we also should bear in mind is, you know, with antibiotics, as I'm using an example, You know, antibiotics help the body resolve an infection.

It doesn't replace the immune system. So at the same time, you know, we put measures in place, such as ensuring the patient's nutrition is adequate because with malnutrition, the immune system's not going to work as well. So pharmaceutical stewardship is not just about the dose.

I mean, it's an important part, but we also want to make sure the other parts are in, are in the puzzle to make sure that we're using these drugs, optimally. So moving on to the second part, you know, causing least harm to the patient and future patient. So I guess least harm, we're considering side effects, and we are familiar with, different drugs that, you know, have side effects and we're aware of them.

And, you know, for example, you know, we, we know some drugs can't be administered IV like vitamin K, without causing anaphylaxis and things like that. But there's other ways that we can implement stewardship. From a, for example, a, a pain management point of view.

So, a really nice piece of work that was done, at Dick White's, and then also at Davies's recently in the last couple of years while I was still on clinics, was a shift in the way that patients were given, you know, pain medication in the postoperative period. So rather than saying, oh, this, this patient's had, this operation and it will need methadone every 4 hours for the next day, and then it will be switched to X, Y, and Z. Instead, it was, you know, the medica, the pain medications given, but every time the medication's due, a pain score is, is, is done to see whether the patient needs it or whether that dosing interval can be increased or changed.

And the positive effects we saw in that was, well, firstly, we, we were using less, opioids in, in, in some cases, but also the patients were happier. They weren't getting a cumulative effect of, of side, you know, of dose and causing side effects. So, Again, that's a really nice example how you can be aware of side effects, but also you can use stewardship and clinical measures to try and enhance how you, you know, use the drugs with minimal impact on the patient.

And then when we talk about future patients with our stewardship, well, that can largely be broken down into two areas. One is, you know, whether these drugs are going to be available and you know, effective for future patients, and I guess that's what we'll, we'll talk a little bit about antibiotic resistance later on in the talk. But also about the environmental impact of these drugs, you know, and this is something that we're starting to understand and explore now.

And Margo, I think this is probably best to bring you in at this point because this is your area of expertise. Perfect, yeah. So, from, from our discussions, I mean, From my understanding, I mean, there, there's two broad areas we can talk about with pharmaceutical impacts on the environment.

First is carbon impacts and global warming. And then the second part is environmental, pollution, basically. So maybe if we start, you're you're right to start covering the, the on carbon aspects of, of pharmaceuticals.

Absolutely, and, and exactly right, and there are quite a few environmental impacts of pharmaceuticals. Well, and we'll talk about these two, that, that they're, the, the list can get pretty long. So focusing first on, on climate change and greenhouse gas emissions, as the cause of climate change here, pharmaceuticals do have a, a, a key role in this.

And so I, I pull up this simple diagram that just shows basically. The, the life cycle of creating a product, really any product here, here we're thinking about pharmaceuticals. And when it comes to greenhouse gas emissions or carbon emissions, really they are emitted at every point of the life cycle of a pharmaceutical, to different degrees.

. But just thinking through this for a moment, starting at raw materials. Any pharmaceutical has different ingredients and components that go into it. There is an extraction needed to source those ingredients and materials, and that typically is going to require the use of Energy, perhaps in the form of fossil fuels or other forms of energy, potentially renewable, but that will take energy to, gather, remove, extract, those raw materials or grow those raw materials.

At the manufacturing point, again, energy, electricity, potentially natural gas will be used to, produce that, to package it, to create the other components needed, such as packaging. And then thinking about distribution, of course, moving pharmaceuticals around the world in different ways. Again, energy, gasoline used in trucks, freight, depending on how we're moving these around in different distribution routes will again cause greenhouse gas emissions depending on the fuel types used.

In the use phase, there's also impacts there. One of the more common one is thinking about refrigeration, which is also applies to distribution if we're using refrigerated trucks, and the use phase of rest storing, different pharmaceuticals in different ways, there's likely an impact there. And certainly end of life, which we'll talk about a little bit later on in terms of some of those impacts, but there's also a carbon footprint associated with end of life depending on the disposal.

Incineration is one of the higher impact, disposal methods when it comes to greenhouse gas emissions, but landfill, other treatments also have footprints. So just a quick run through of, you know, where and where those emissions are coming from throughout the life cycle of a drug. And thinking about this, it, it really can be significant as well.

And we can talk about this in, in a couple of different ways. One example, we like to reference is just taking one drug, looking at the antibiotic vancomycin to produce 1 kilogramme of that. The emissions that are caused are 57 kilogrammes.

So we have a 1 to 57 ratio there, and most of the emissions from that are from energy use throughout the life cycle, as you can see here. It also takes a lot of materials to produce a drug. So for vancomycin, we're looking at about 585 kilogrammes of material used to create that.

A lot of that is water. So there are other impacts beyond just carbon and greenhouse gas emissions, associated with the production of any pharmaceutical that we're looking at. And this can be significant.

So this is a chart I think you'll see again later with Ellie talking about it as well. But this is a handy chart that we like to reference. This is the carbon footprint of the NHS in the UK that they published a couple of years ago.

Now this is human healthcare, but veterinary. It is very similar in terms of our impacts, and our own carbon footprint follows really along these trend lines as well. So you can see here that about 20% of their overall footprint is from medicines and chemicals, and that's all the emissions bundled up and in the life cycle I was just showing.

And I've also circled, anaesthetic gases and metre dose inhalers that I'll, I'll touch on in a moment. But to say here that, overall pharmaceuticals, when it comes to a carbon footprint, they are significant. And so we'll talk about, you know, this is one more reason why, really, why use is so important, that the, if we can optimise the way we use these, we can also get some really good benefits from reducing greenhouse gas emissions.

And I guess, because one of the things you've taught me is the 3 R's. So there's reduce, recycle, and reuse. And I guess when we're talking about pharmaceuticals, you can't really recycle them.

You can't reuse them. So essentially we're looking at reducing unnecessary use. So that's where, like you say, it's, it's removing the, the just in case medications and the potential collective effect that you've highlighted across a large group can be massive, if everybody joins together.

Exactly and and exactly that reduce or avoidance or preventing in the first place here is is so critical and, and really our most effective way at at driving change. So, especially when it comes to pharmaceuticals, as you say, we don't have as many other options we do as with other forms of waste or other impacts in our hospitals. Yeah.

And maybe just to, before we jump to the, the other part of the environment, just to touch on anaesthesia briefly here since I've, I've got it circled on the chart, . Anaesthesia, anaesthetic gases are greenhouse gases inherently. Craig, when we hear from him later on, we'll talk in a lot more detail about this, but just to flag that as well, that, when we think about the carbon footprint of medicines, some are inherently gases, and so therefore, when we're using them, there are associated emissions just from that process, let alone the production and the other parts of the life cycle that, that we talked about.

Can can touch more on, you know, some of the other ways aside from what what you just mentioned and reduction and avoidance, you know, there are other aspects when we think about this life cycle, how can we reduce emissions. A key piece of this for all of us will be working with our suppliers and our pharmaceutical suppliers and how can they be helping to reduce along this whole value chain here, where possible, whether. It's looking at packaging and how that can be optimised from a greenhouse gas emission standpoint.

Can they be using renewable electricity at any and all points throughout the production line? Things like that are really a key way in addition to reduction and prevention that that we'll want to look at. Yeah.

And I, I have to admit, the, the one thing that I've learned certainly with working with you is I, I guess initially most people think about the packaging. But actually, it's more about all the other components as well, the, the production of the drug, but also, well, it's a seamless link onto the, you know, the, the, the drug is not already, something we need to consider from a production point of view, but also the environmental point of view, you know, the potential of what happens to these drugs after we use them. So maybe you're happy to move to that bit now?

Yeah, that, that's super. So the other big impact we'll chat about now, we've talked about greenhouse gas emissions. There are other impacts of pharmaceuticals, of course.

And so one is, on the environment in terms of ecological contamination and pollution and specifically water, because we all depend on water, and it is just a key pathway that we're seeing pharmaceuticals, really flowing through the environment. This image is just giving a sense of that flow in terms of how do pharmaceuticals move. Throughout, the ecosystem that we all live in overall, so you can see there's quite a few different pathways.

I'll touch on that in a moment. But really what we're seeing is, quite a few studies coming out over the past year showing that there is contamination and there is leakage essentially of pharmaceuticals into the environment, . One study quite a few years ago already was finding that of about 700 pharmaceuticals they were testing for, over 600 were found and hitting at those detection limits, and this was global, and over 70 countries.

And they were mostly looking at surface water, so lakes and rivers, but also groundwater, and soil, and so these are showing up. And we also see from another study that about 25% of global global rivers contain pharmaceutical residues at concentrations that are proven to be unsafe for aquatic organisms, or of concern for antimicrobial resistance, which we'll talk more about. So, This is problematic for many reasons, AMR especially, which we'll talk about, but also just the, the unknown impacts of this.

How is this impacting all of us in drinking water, how is it affecting organisms beyond AMR issues, . So this is, this is problematic. And just to flag the, you know, so, so how is this happening?

There's a few ways you can see in this chart in terms of how are these entering waterways. One is simply excretion from both animals and humans. And we know that between 30 and 90% of orally administered doses, are excreted as active substances, so.

Once they move through us, they are then, you know, active in the environment and in our waterways. Another way is improper disposal, and Ellie will talk about that later on as to how we can manage and avoid that. But then there is also from the very top of this chart, the pharmaceutical production, there are issues with leakage from the manufacturing process as well.

So quite a few touch points, but that also means a few touch points where we can be managing and and intervening on this, so it, it. It is a, a tough part of all this and kind of goes back to, you know, what we talked about earlier, I just avoidance and prevention overall, as well as some of these other interventions, but if we can be really wisely using these in the first place, we avoid some of these downstream problems. Absolutely.

And I, I guess one of the things I always Increase my understanding on is this, is this area, you know, for example, as you highlight in our drinking water, the Certainly, from what I'm aware of, the wastewater treatment is, you know, to, remove biological agents, but they don't remove pharmacological agents. So there's residues in, in, in the products that we're drinking, potentially. But also, I, I, I mean, I hadn't until recently understood how toxic, for example, paracetamol and ibuprofen were to aquatic life.

And you know, the, the acidification of the oceans, you know, I was quite, naive in that I didn't, you know, I, I guess I've reflected on, I was always taught at high school, you know, it's, it's the, it's the rainforests that produces all the oxygen, but actually 80% of the oxygen that we breathe is produced by sea plants, and the, the, the sea is slowly acidifying because of all the things that we're putting into the sea and it'll become a point where Those plants will, you know, they, it's so complex, just like this, this diagram here, it's like it's a true circle of life kind of one health issue where every action has a, has a, has an impact. Exactly. And, and I think, you know, we don't know all the impacts because ecosystems are so complex that we're only really seeing some of the impacts of what we're doing, both on, you know, pharmaceuticals here, but all other ways that human civilization has been impacting the environment.

We only know some of those impacts, so that, that, that's the other piece to keep in mind is, we don't yet know, the, the consequences of some of the actions that we're, we're taking now. Absolutely. And we've, and we've touched on antibiotics as part of what I've talked about with the environmental impacts, touched on AMR when I mentioned, you know, it going, drugs going into waterways.

Why don't, why don't we shift there, since antibiotics are such a Key part of pharmaceutical stewardship. They're a major group and you've spent tonnes of your time and career on them and on AMR specifically. So, why don't we, you know, take the lens of pharmaceutical stewardship and apply it to antibiotics, you know, if you wanna talk us through that.

And, I can pull up the other slide when you're, when you're ready. Yeah, so I guess, you know, I always, when reflecting on antibiotics, you know, I guess I always think about the public health aspect and the, you know, the resistance to the drugs not working anymore, and I normally ask people to reflect on, you know, imagine not having those drugs available to do your clinics now, you know, we, we're so used to prescribing them and having them help. You know, manage clinical case load, getting infections resolved, you know, undertaking complex surgeries that require, you know, antibiotics intraoperatively and perioperatively and things like that.

And you know it's such a long time now since since the pre-antibiotic era that it's hard for us to manage, imagine that. And You know, you know, the antibiotics, you know, Fleming discovered penicillin, and that was eventually, you know, used in, in military hospitals actually, initially during World War II, and it's actually one of the, not only did it have a big impact on, on human healthcare, but it also, but with some historians, they suggest that antibiotics actually had an influence on the outcome of World War II as well, because Allied troops were able to recover quick or recover from infections that normally weren't treatable. But even Fleming, you know, he, in his Nobel Prize winning speech, you know, he even highlighted that if you don't use these drugs sensibly, resistance will develop, the bacteria will become resistant, and within 10 years, approximately 80% of Staphylococci isolated in human hospital microbiology labs were resistant to penicillin.

But that was all right because, you know, at the time, because there was an explosion, as you can imagine, of, of everybody looking for new antibiotics, and there was new classes of antibiotics, you know, discovered and, and every time there was a resistance to one particular drug became prevalent, it's OK cause there's another one here. But unfortunately, when we got to 19, you know, mid-1980s, from there, there's been no new class of antibiotics identified, but the bugs haven't stopped. You know, the bugs haven't stopped evolving and developing ways of resisting them.

And some of the ways that we've been using these drugs, we've put a selection pressure on the bacteria to develop resistance. You know, we've been using them, you know, just in case, in a lot of situations, when we reflect on it. And essentially we've, you know, we've, you know, we, we've put a pressure on the bacteria to work out a way to evolve, and they have.

And, you know, I was only reading a report this morning that now estimates that by 2050, they're suggesting that 10 million people may die with an association of antibiotic resistant infections. And to give you context for that, 10 million people, that's a huge number, and that's the same number of people. In 2020 that die of cancer.

So, you know, if it's left unchecked, this issue, it's gonna spiral and spiral and spiral. So, you know, we need to reflect on all that, you know, not just in the veterinary, but also in the human healthcare, environmental sectors and things like that, how we use these drugs and how we've stopped these drugs getting into the environment, because a lot of, you know, a lot of waterways have multi-drug resistant bacteria in them because of all the antibiotics that end up in there. And it's a really complex.

Issue, you know, highlighted by some of the diagrams you just put from the way that the drugs residues into the, into the system. You know, we've got prescribing in lots of different sectors, veterinary, medical, but even agricultural because antibiotics are used in, in crops to prevent certain infections, developing. So really there's a, there's a, there's got to be a combined effort really across all sectors and, you know, that's best highlighted by, you know, the, the, the high-level global leaders group that's, that's developed now between the WHO, the AIE, and the environmental agencies and the food agencies to try and work out ways for governments and also organisations and professions to work together really because no single profession is going to be able to crack this on their own.

Now, there has already been some impressive work within the veterinary sector. you know, in the UK, the farm animal sector, over the last 8 years, has managed to reduce the amount of antibiotics they use in those patients in purchase for use of farm animals by 52%, which is phenomenal, really. I'm a companion animal vet, so I'm quite I think that's inspiring.

You know, we need to step up and, and, and see whether we can make, you know, changes to improve things as well. So, you know, it's, it's, it's, it's an evolving space, but there's a lot of opportunities there. And maybe if we, Margo, could you bring up the, the pharmaceutical stewardship principle, slide?

So with this slide, this is essentially the same slide that we talked about for a general principle of pharmaceutical stewardship, but what I've done instead is I've I've been, you know, I've put in place antibiotics and I'd encourage you to think about other drug groups as well, putting, you know, whether it's a certain non-steroidal or, or any other kind of pharmaceutical we use to, to kind of evaluate the different aspects that that, that drug might have. But using antibiotics, you know, we've talked about antibiotics, using them at the right time to get a good in, you know, outcome for the patient with an infection. When we talk about side effects, well, we're, we're familiar with certain drugs, you know, you know, for example, TMS causing dry eye and things from, from a long-term harm.

And something that we're beginning to understand now in our patients is, and, and in human healthcare is the importance of the microbiome, the gut bacteria, and the studies in human, the human sector that show that antibiotics given to children when they're in their infancy, those, those children have a much higher incidence of things like asthma in a later life, which shows the importance of the microbiome. In, in the developing immune system, for example. So, what I don't know and what we'll have to investigate is whether using antibiotics in our patients has a similar long-term health effect, because certainly, again, in human healthcare, there's increased understandings of the impacts of antibiotics early in life with body condition and obesity and things like that.

We've touched on the, impact of the environment and, and, you know, Margo's highlighted. You know, all the carbon aspects, there's a, and, and, and, you know, if we're using these drugs when they're not needed, we're, we're essentially using resources that aren't needed, but also these drugs end up in the environment and they're biologically active. So the less we use unnecessarily, the better it is for the environment.

And then, of course, there's the, there's the antimicrobial resistance, you know, issue that we've, we've highlighted. And thank you and I, I, I'm wondering a little bit about, so I think understanding how this applies to antibiotics here is really helpful. The example you mentioned on the really impressive reduction on farm animals, .

How, so how, you know, we know we need to optimise and use wisely. How are we actually seeing some progress like that example you mentioned? Is this really more legislatively driven?

Are these voluntary schemes that, are proving successful? Well, I mean, the, the, the, the achievements in the farm animal sector was actually, you know, more of a voluntary, you know, kind of, collaborative approach. It didn't require legislation to achieve that.

I mean, it may be, I mean, probably one of the factors was the concern about legislation coming in, but it was led by, the responsible use of medicines, Alliance RUMA, and they were able to educate and, and, and facilitate the farm animal sector. Looking at ways to reduce unnecessary use, but also put in husbandry mechanisms to reduce use, you know, to, to, you know, for example, dry cow tubes and things like that, you know, we, we, we're phased out in a lot of places. So that's an example of collaboration, really, which is fantastic.

There are situations where there have been restrictions in legislation, so some of the listeners may be aware now in the EU there are a class of, you know, groups of antibiotics, so the high priority, critically important antibiotics that they've classed such as vancomycin and the carbapenems. Veterinarians are no longer allowed to prescribe those to animals. So that's a form of legislation that's restricting, our ability to prescribe.

And they've also now put restrictions in, in place for veterinarians not able to, use them prophylactically. So that obviously in different settings has different impacts. So, you know, the fantastic impact by, you know, by rumour was, was more collaboration.

But there are restrictions, that are being imposed, and I guess different government agencies are starting consultations on this. So there is a second arm to this in that, you know, if we don't show responsible use for these drugs, it may be that legislation is brought in, on, you know, and, and essentially, if we can demonstrate responsible use, we can regulate ourselves. I think that's such a great incentive, right, to, to really maintain that choice and licence really to, to be.

You know, practising medicine as, as we see fit, and, and thinking about you more at the hospital level, wondering, are there examples that, that you've seen, of good stewardship of, you know, we kind of zoom in a little bit to the level of the clinic, you know, what have you seen works well there are practical things. So there is, there is research, in this area, understandably, not only in human healthcare, but also in the veterinary sector as well. So first of all, looking at the human sector, there's, there's large, I mean, there's multiple studies now looking at how prescribing policies can be implemented successfully.

There's also a lot of work in the human healthcare sector looking at studies to try and reduce the courses that are typically prescribed for certain conditions. So studies, for example, comparing 1 day of antibiotics versus 10 days of antibiotics for a tighter medi in in children. And that's because if you look at a lot of the courses that are recommended and prescribed in veterinary textbooks and human health, textbooks, for a long period of time, there were multiples of 5 or multiples of 7, which are more just convenient numbers really, you know, weeks, for, for patients to remember to take them by.

This is an area where there's a few studies in, in, in, so I'm only aware in companion animal. There's a few, I couldn't say for other, aspects because I'm mainly, you know, a companion animal. But, you know, it's certainly an area where, you know, we have a, a real opportunities to get involved in studies.

From a, a stewardship point of view, I guess, broadly speaking, there's, there's two different types of stewardship policies that you can put in place within your hospital. You can either be restrictive. So an example would be just, you don't use these drugs, a bit like what the EU have put in place.

You could have, policy similar to, like the doctor that treated me at the initial, where with certain drugs, you have to have a culture and a sign-off from another member of the, of the hospital. And I know that, that's present in human hospitals. I know that that was something put in place before I left Linnaeus because I was involved in, in putting that in place, .

Then there's empowerment for, you know, that, you know, the restrictive really, hopefully you're only put in place for those really critically important ones for human healthcare, but the empowerment is education and and developing culture. And there's been a number of studies, and there's a study in Holland that showed that, you know, a real positive effect was having regular discussions at hospital meetings where everybody reflected on the prescribing and learned off each other. There was a, a really nice, study with the SASET Group published in The Lancet, I think about last year, where they showed the value of discussion and education, but also active feedback with auditing of, of, of the actual amounts of antibiotics used within a clinic.

So, you know, and that was shown to be more powerful. In maintaining positive change, but also highlighting learning opportunities and maybe we've got a couple of slides from some of the work that we've been doing that we could potentially bring up here. So, these have all been anonymized.

So at the moment, we're doing some benchmarking, looking at the amounts of antibiotics used by our different hospitals. So just to give you a, a, a, an overview of what, you know, each bar represents a different hospital. We've ratioed the amount of antibiotic per vet per week, on the, on the Y axis.

And then each of the different colours reflects different antibiotics. And I'm not going to go through them because there's obviously a, a large number of antibiotics. But as you can see, there's, This is a, a, a group of hospitals that do similar types of work, but as you can see, there's different amounts of antibiotics that they're using.

So it's not saying that people are using them wrong, it's just we need to understand why we've got that different, that different pattern. Are the learnings to be had. You know, why one practise is using significantly more than the other, are the, the policies and protocols that can be learned and shared, or are there actual valid reasons as to why they are using much more antibiotic than another hospital?

And if we use the, the next slide as well, Margo. So again, this is where we've got a bit, a little bit more specific, where we, looked at some hospitals, and each hospital's represented by an individual dot. And as you can see, we've got CEAV in here, which I'm sure a number of you are familiar with.

And we've got some hospitals that are using a lot more than others. So we want to understand why, discuss, you know, why there's that difference, see if there's any ways that we can. Put positive change in place and if there's an opportunity to reduce that.

And again, similarly with, this is one of the high priority critical antibiotics, Marropenin, you know, trying to have conversations and discuss why these, these, the, the differences between hospitals that are doing very similar types of work. So we're finished with that slide now. I put this down.

Thanks and and you know, I think it's just one example of showing what you know, one approach we're taking at Mary's Veterinary Health to be monitoring, to be first, as you said, understanding what's happening across our practises and there, then what are some of the interventions we may wanna take to make sure we're using our our pharmaceuticals optimally. I'm wondering, so aside from our monitoring and the studies that we're doing, if you want to speak to some of the other actions you've seen us take or others take at the hospital level. So if the hospital wants to know, you know, what, what can I be doing, monitoring is one that we just talked about.

What else would you point, a clinic to? So I've been very fortunate to work with a couple of clinics, as they've been on the antibiotic stewardship journey. And, you know, the first challenge really is developing the guidance and the guidelines, and it takes a lot of time, to do that properly and do it as, you know, as robustly as you can.

So the first thing I'd advise any hospital is, You know, looking at the, the, the already produced guidelines out there. So, you know, the one I was involved with was the BSAVA Protect scheme, which is out there already. It's freely downloadable, and you've got the option to, you know, choose which antibiotics you, you want to use.

Yeah, there's the, at University of Guelph, Scott Wies has produced an amazing app on your phone, first line app where you can have all the antibiotic recommendations for different conditions on your phone, so it's easily accessible. There's the International Society of Companion Animal Infectious Disease, so that's ISA. They've got really comprehensive guidelines for respiratory.

Urinary and dermatological advice on how to use antibiotics in these situations. So, you know, the first thing really is accessing those resources and deciding on which areas you want to, to look at and discuss within your, your, your, your hospital. And the, the, the hospitals that have done it really well have done it in a really kind of non-judgmental, you know, kind of positive culture kind of way, sitting and discussing in hospital meetings, you know, about why this is an important issue and what everybody's going to have a, a consistent approach on, because one of the things that I regularly get feed, fed back on.

Is what I do, you know, I've, I've followed the guidelines and I've not used antibiotics in this situation, but somebody else has, and it's undermining. The owners don't understand why. So a collective approach, but important that it's culture that everybody, you know, change is really difficult, you know, I think, so it's important that everybody is really understanding that there's different people will make changes at different speeds, really.

You know, even, you know, I, you know, as we've outlined, I'm all over this. I'm, I'm really passionate about antibiotic stewardship, but the first time I was in a tricky situation, I was like, well, I know that I used to give two antibiotics, but I know that I only need to give one. It's still tough, even with me being so, so passionate about the subject.

So it's got to be supportive, you know, and understanding and not judgmental. And you know, for me, really simple opportunities out there to start simple with some clear situations where we know that, you know, from these are companion animal examples, by the way, where we know that antibiotics are not indicated. So if everybody within a clinic collectively agreed that they weren't going to prescribe antibiotics, you know, in uncomplicated diarrhoea, that would be, you know, a big, a big thing.

Kennel cough as well. And then also examples such as feline lower urinary tract disease. We know that it's very unlikely in those cases they've got a bacterial infection and they may respond just to analgesia alone.

So, you know, having that collective approach really, is important. Sorry, I waffled a bit. I can talk a lot about this as you can get that.

No, it's excellent. And, you know, while we've been, you know, talking mostly about antibiotics and AMR for the past little bit here, I think so much of what you just described applies to other pharmaceuticals as well. so I think just for everyone keeping in mind, you know, the same principles that we started off our discussion with really fall into place here as well.

So in that cultural approach, I, I think and supportive approach, I think is critical across the board. Also just noting, and apologies, I didn't pull this up at quite the right moment, but sharing a bit of the different intervention points. I think we've, we've touched on.

Many of these, but I think to in what you're describing is, you know, there are different, intervention moments here, a lot of it what you just described in the practise, in the clinic, you know, ways that we can be making changes here, but also just a reminder about these different moments both environmentally, to manage those impacts, but everything else we've just been talking about with, patient outcomes as well, . Anything else that we wanna highlight here and while we have this up? No, I mean, I think, I think you summarised it quite well, you know, really well.

I mean, it's essentially there's, there's all the production side that, but as clinicians, we can really influence these impacts, you know, these kind of points that when we're prescribing, but also on how we collect and dispose of them. Those are the areas that as clinicians we can have a real impact in the drug life cycle. And I think we'll we'll hear even more about that, especially from Ellie when talking about some of the examples, from her view in the clinic practise on both disposal of drugs but other aspects as well so we'll we'll get into some more detail there, .

I'm watching time here. I know we're, we're just hitting quite perfectly actually at our halfway point, so I'd suggest if unless anything further Ian and I'd suggest we take just a 5 minute break so that everyone has a moment that also gives . And and myself a chance to look at the questions and the chat, and I know we've had quite a few coming in, so I appreciate that.

When we come back, we'll take a couple minutes to answer a few of those questions, and then we'll shift to our next speakers of, of Craig and Ellie. Anything else, I, before we take this break? All good.

Comfort break is due. So right, so we'll see everyone in just about 5 minutes, so please come back about 3 minutes past the top of the hour. All right.

We are back now, so, thanks everyone for joining us so far. What we'll do now is just take a couple of minutes. We have read through, as many of the questions as we can, so thank you for entering those in.

So we'll answer a couple of those, and then we'll jump in with Craig and then Ellie after that. . So one of the questions we got was really around reduce, reuse recycle, and really asking about, you know, what's the correct order of that should reuse be before recycle, and really asking about, you know, or or commenting on materials can be reused often many times, before they need to be recycled.

It's an excellent point. So I wanted to just touch briefly on this. And yes, the, the order of the waste hierarchy, as we call it, really has that prevention or avoidance at the very top, which is, you know, aligned with reduce and then reuse.

It is before recycle. So absolutely. And Ellie is actually going to pick up on this.

I know one of her slides shows, the waste hierarchy. So we'll take a look at that and, and she'll, talk a little bit more. But absolutely.

And, that's one of the challenges I think, with recycling is that It is not the first choice, but it's often the first thing that people think about when talking about sustainability and, you know, how can we drive improvements. Recycling is a good solution, but it's not the very first thing we want to go to. We want to look at avoidance, and then reuse before we're thinking about recycling.

So we'll touch more on that. And I know Ellie will also talk a little bit about reuse opportunities with different materials in clinics. So more to come on that, but appreciate the, the question.

It's an important point. And somewhat related to that that I'll touch on someone else raised packaging and how that is a you know a big issue and big opportunity and, and we agree, you know, with all of these supplies that we use in our clinics every day there's packaging associated with all of them. And this is really an area for us that we want to be collaborating on with our suppliers, and in the positive, light there is a lot of progress being made there.

We need a lot more, but overall we really want to be shifting as much as possible and as much as it's safe to do so, to recycle a bowl and recycled content, of materials, whether we're talking about paper, plastic, . All the different types of materials used in packaging for both pharmaceuticals but also other supplies, so it's definitely an area of focus for us again, it is largely collaborating with suppliers is is the best way that we have to tackle that, so that we as the then receivers of that waste we're the ones who have to handle and manage it. So working with our suppliers is a key part of that avoidance, before it even becomes an issue for us in our clinics.

So I think we'll, we'll leave it there. Please do keep the questions coming and we'll try to chip away at those throughout the rest of our time together. .

But for now, we'd like to switch over to Doctor Craig Moseley, who I know is with us here. So Craig, if you wanna come on screen, for everyone, we're really excited to, to have a chance to do a bit of a deep dive, on anaesthesia. As you heard from my earlier talking about environmental impacts of pharmaceuticals, this is a key area.

So I touched on anaesthesia as part of that, carbon footprint of the NHS. And similarly, in veterinary medicine, like with human medicine, it has a significant impact here as well. It is a smaller part of our overall carbon footprint when looking at any veterinary practise, but it is part of it.

And so there's a big opportunity to drive some change there. Craig has been working closely with us, On this topic, he's an anesthesiologist, with our VCA Canada business, and he's been really part of working groups and efforts that we've been underway with the past couple of years on anaesthesia and its impacts on climate change. So he's passionate about this area, extremely skilled, and, lots of expertise, and has some really specific guidance and thoughts from.

All of his years of practising and anaesthesia as to what can we do, in this area between, adjusting our flows to thinking about which gases we're using. So, Craig, I'll hand it over to you. Happy for you to further introduce yourself.

I did just a brief intro for you, but excited and, and grateful to have you here to tell us more about this, and bring your expertise to the topic. That's great. Thank you, Margot, and it's great to be here.

As Margo mentioned, you know, I'm an anesthesiologist and I'm also, keenly interested in sustainability. And, you know, it's really one of the highlights for me to get to talk about this topic, in particular, and I do talk about it fairly regularly at this point. A lot of times I'm asked to speak on sustainability and of course anaesthesia.

And so, yeah, I've, I've had a little bit of time to think about this and, and really focus on it. So I, what I'm gonna do, and I've only had about 20 minutes or so that I, I'm, I have allotted, but I wanted wanna talk about reducing the greenhouse gas impacts from our anaesthetics. And I think, you know, usually when I'm talking on this topic, this is usually the first question I start with, and I get a show of hands from people, and I ask people, you know, when you came in here naively, not knowing anything about what the topic was, how many of you knew that anaesthetic gases are also potent greenhouse gases?

And I'll be honest, when I first started speaking about this, or I first mentioned it, and I started mentioning this to students, you know, 10 years ago even, but it was just more of a curiosity. But when I mention it now, I usually see between 5 and 10% of the audience will put up their hand. And so I think awareness is coming up, but I think there's a lot we need to do, and we do need to talk about this a lot more.

You know, if we do look at the volatile anaesthetics and we compare them for their greenhouse gas impacts, we can look at the index of chemical or or substance that we look at, which is carbon dioxide and carbon dioxide has greenhouse warming potential of one, and that's what we index most other gases too. And if we look at things like isofluorine, you can see that it's 510 times more potent as a warming gas than carbon dioxide. If you look Something like Des fluorine, which fortunately we don't use very often in veterinary medicine, and even in human medicine, it's being, sort of phased out.

You'll see that it's 2500 times more potent as a greenhouse warming gas. And that's up in the neighbourhood of where some of the refrigerants are that are still used in supermarkets for, cooling and so forth. And if we think about another common gas that Talk a lot about methane, for example.

Methane is around 27, in terms of its, global warming potential over 100 years. So isoflurane, sevoflurane, and the other anaesthetic gases are quite potent, and we can do something about that, and we should be thinking about what we can do to reduce, our usage of these chemicals and putting them into the environment. So I think as Margot mentioned, and you know, again, this is, I think you've seen this slide probably.

But if we look at the anaesthetic gases as the overall carbon footprint of a hospital, it is a very small percentage. And, you know, I think for those of us who've been in this area for a long time or have been in anaesthesia for a long time, we always assumed it was a very small percentage of the overall carbon footprint. Of running a medical organisation.

And if you look at a lot of the, the carbon footprint, it's associated with all those things that we buy and all the things that we use in our hospitals. And, you know, the reason I think that talking about anaesthetic gases is important is that even though it's a small part of the overall pie, it's actually a very large part of the internally controlled pie, the internally Controlled carbon footprint. So if we look at just the anaesthetic gases and we look at things that we can control in our hospitals, so the energy that we use in our buildings, our wastewater, how we get to the hospital, you know, in terms of, do we have mobile vehicles and, and that we're out doing, mobile services and so forth.

Suddenly, anaesthetic gas has become a much bigger part of our overall carbon footprint. And as an in a hospital, this is something you actually have a lot of control over. In fact, I would argue this is the number one thing in your hospital that you have the most control over compared to anything else on this whole carbon footprint.

Because I, I'm, I can tell you as an individual, I'm probably not going to be able to sway how packages or how products are packaged. But as a group and as a, as a, as a whole, industry, we can have an impact, but as an individual, I certainly can reduce my anaesthetic waste gases and the amount that goes out into the environment. So I have a lot of control over that, and that's why I like talking about it because it does empower you to do something today.

And even when we talk about things like the energy in our buildings, unless you're the owner of the practise, you probably aren't the one who's making this. Decision on where you're buying your electricity from. And you know, in a lot of countries, for example, here in Canada, we can buy green electricity and it's not necessarily the electricity that we use in our facility is generated green.

It's that that money goes to invest green projects, so wind and solar and so forth. So, so we do have some of these as options. So just as a little bit of perspective, cause, you know, sometimes it's hard to get your head around, you know, what do these numbers mean?

What does it translate into things that we think about every day. You know, this is just an example of, you know, converting our anaesthetic use into, you know, driving equivalency or in CO2 equivalency. And so if we look at CO2 or driving equivalency, if we did 8 hours worth of anaesthesia in our hospital, and I would say that in an average, you know, 23 doctor practise, 8 hours of anaesthesia.

Isn't unreasonable, especially with the numbers of dentistries that we're doing and the durations that a lot of those procedures are going. 8 hours would be, you know, kind of normal. And if we do 8 hours of anaesthesia at a relatively high flow rate, so 2 litres per minute, and we run our vaporizer at a, a relatively, you know, predictable percentage, so around 1.5 to 2%.

We actually will consume more, we'll use a nice enough isofluoran that we could have driven 304 kilometres a day. And if you convert that into over a year, we're talking about almost 80,000 kilometres a year, which would be like driving around the equator of the earth twice. So it's a lot of, of, of waste.

And if we look at it in terms of sort of killing. Grammes of carbon equivalency in a year. You can see that the number is pretty high, 16,000 per year for doing 8 hours worth of anaesthesia in your hospital a day.

And if you look at the average carbon footprint of a person, you can see that here in Canada, our carbon footprint is actually one of the highest in the world. And a lot of that has to do with the fact that we drive long distances, we are a big country. We're also a cold country.

And so we have a lot of heating and so forth in the winter to, to maintain our houses and so forth. But you can see that's the, that's larger than the average Canadian would consume and it's much larger than the average European carbon footprint. So again, these are, these are numbers that although they don't seem big in the big scheme of things, they are fairly significant, and they are things that we have a lot of control over.

And so if we start looking at this and we start thinking about our carbon footprint and what we want to do, it kind of goes back to the reduce, reuse and recycle thing that we talked about the hierarchy of, of, sustainability. And the number one thing you can do is just useless inhaling. And there's things we can do to use.

Less inhaling. We can also waste less inhaling, and I'll talk a little bit about this because I don't think people always realise that we waste a lot of gas, and then we can also capture it and then we could either recycle it or destroy it and I'll talk about each of these options, over the next sort of 15 minutes or so. We can also switch our inhalant to the lowest carbon impact inhalant.

So see fluorine, as we'll learn or as we've seen, is lower than isofluorine. We'll talk a little bit about that. And then I think another big thing that I'm a huge advocate for, and I talk a lot about is the proper selection and use of consumables.

You know, we use our circuits in veterinary medicine multiple times over. We use ourotracheal tubes multiple times over. In human medicine, these products, you know, in the endotracheal tubes, for example, are really basically a single.

Time use item. And in circuits, they may use it for a day on the machine and then it's, it's switched out. But we don't do that in veterinary medicine.

We use them over and over again. So I think we're already on that reuse side. And if we look at the risk of, inhaled or respiratory-related illnesses in veterinary medicine, they're far lower than what we would see in humans.

And so the real risk of cross contamination, is quite low from using the same circuit over and over on various patients. And then we think about other things like syringes in the packaging that they come in. I mean, they used to have these plastic syringe cases, you know, that were just ridiculous the amount of plastic that we waste, and now they're coming in just smaller foil packages which are are much better.

So let's talk about using less. And you know, one of the things I often talk about when we talk about sustainability is the number one thing we can do is just useless, buy less stuff. That would do a lot to reducing our environmental impacts, but it's also not the most sexy thing, I guess, if you, if you want to say because people like to have stuff.

So let's talk about reducing use of our inhalants. If we can do things like simple things like proper premedication, which I think a lot of us are doing. I think most people recognise the value of premedication.

But by using proper premedications, we reduce our reliance on the inhaled anaesthetics and depending on what premedications we use, we can reduce it by up to 50%. And so if you're a practise that uses Aceromazine, for example, as your standard. Pre-med, and you switch to something like dexametatomidine, you'll reduce the amount of inhalant that you actually need to use in your hospital because dex meatomidine has a much greater MAC reducing effect than what we get from Aromazine.

So, you know, just proper selection of our, our premedications can make a big difference. And I always throw up this slide with the DeRA app that has been developed in collaboration with the Association of Veterinary. Anaesthetist.

I'm actually not a fan of sort of these recipes, that you'll see where someone will say, I've got a dog with this. What drugs should I use? Because rarely is it the drugs that are actually the most important thing.

It's really understanding the pathophysiology of the disease and, you know, the considerations associated with that disease and how anaesthesia impacts the disease. And this app does a really nice job at sort of talking about some of these things, but it also helps recommend premedications. And they also talk about local regional techniques, and that is something that for those of you who aren't using local regional techniques, I would strongly encourage you to think about these every single time.

I mean, there is not a handling procedure that I would do today that wouldn't have some kind of a block. And by blocking out that area of the body and dental blocks are the similar effects, again, we reduce our reliance on the inhalants and so we don't need to use as much, . Which is a great thing.

Another option would be to consider things like partial or total intravenous anaesthesia, where we actually supplement the anaesthesia with other intravenous anaesthetics, which helps us reduce the amount of inhalant that we have to use. You know, although this seems like something that would be great, we get rid of all the inhalants and we just switch to propofol infusions. I can tell you as someone who's done a lot of propofol infusions and alfaxolone infusions, and I've done a lot of total.

Anaesthesia. It is not the same as doing an inhalant anaesthesia. You can't change depth nearly as quickly.

There's some different challenges, associated with it. And then there's also the other things we need to think about what happens to all these drugs after we've used them and they're metabolised and then they're excreted into the environment. What happens?

So how do we get rid of the, the disposal and then what equipment is required for it. So it's, it's not as simple. Is just saying, hey, let's get rid of these inhalants and let's switch to total intravenous anaesthesia and that would eliminate all this greenhouse gas impact.

There would be some significant challenges, I think, in doing that. And again, but we could start supplementing our anaesthetic with a propofol infusion or nalfaxolone infusion or a ketamine infusion, which will again help reduce our, reduce our reliance on our inhalants, and we can turn our gases down. So, you know, just as in summary, I think, you know, again, we can reduce our use.

It, it can be quite significant, and I would argue that we get a better overall anaesthesia. It's more balanced when we're using, you know, different drugs to accomplish different things throughout the anaesthetic period. I think the challenge with, you know, going too far on one direction and doing just a total intravenous anaesthesia is that it's a very different style of anaesthesia.

And, you know, to do a constant rate infusion with But a syringe driver is a little bit more tricky. I think the other thing we always need to be cognizant of, especially as a company that is in multiple different countries, is that there is some drug availability and licencing and species limitations depending upon the country in which you reside. I'm fortunate in Canada, we have very limited restrictions on our access to, various products, whether they're licenced for animals or not.

We have a lot of extra label drug use, . Which really gives me a huge licence to use a lot of different products responsibly, as long as there's enough evidence to show that these drugs are safe. So I think there are some cons that we need to be thinking about in terms of getting rid of the inhalants.

I think, you know, realistically, we're probably not going to get rid of the inhalants, anytime in the near future. Although switching to lower carbon inhalants is probably a good idea, or switching away from the high carbon ones in particular. So the other thing we can think about is useless, but also waste less.

And I think one of the things people don't remember is that really, when we give isoflurane to an animal, they do not metabolise that drug. They basically take that drug in, it anaesthetizes them, and then they breathe it out and they recover. And during the anaesthesia, as we're delivering our anaesthetic, most of that inhalant is actually.

Going out of your pop-off valve every minute, and that is just going straight out into the environment. Basically, when you use a bottle of isofluoran in your patient, you may as well be turning it and dumping it on the floor in terms of its environmental impact because that drug is not being metabolised. It is not being converted into something else.

It is going freely into the environment after it anaesthetizes our patients. And part of this is related to the high fresh gas flows that we use. And we do use relatively high fresh gas flows in veterinary anaesthesia, and I'll talk a little bit about why that has been historically, but we can reduce our fresh gas flow rates and by reducing our fresh gas flow rates, we'll proportionately reduce the amount of anaesthetic waste.

And, you know, in my hospital, for example, where I work, we use really, really low flow rates, but we're, we're really well trained on how How to do that. And we have good monitoring and everything else. And so we're able to do that.

But, you know, if you reduce your flow rate by 50%, you'll basically reduce your greenhouse gas, impact by about 50%. You know, it's not exactly, but it'll be relatively close. So, reducing fresh gas flows is important.

Now, you know, the next question that usually comes up and when people ask or when I talk about this is they say, Well, how low can I go, Craig? Like, You know, what's what's too low. And so I think that the, the natural question from that becomes, what's the purpose of the fresh gas flow?

And you know, when I really delve into this, it's amazing how many people don't really understand, you know, they understand how to use fresh gas flow and how it impacts their energy. Anaesthesia to an extent, but they don't really understand what is going on in terms of fresh gas flow. And so I like to break it down and make it quite simple.

Really, there's 3 things that we have fresh gas flow for. First is sufficient oxygen delivery. I mean, we usually use some kind of oxygen.

Mixture or oxygen, 100% oxygen, as a delivery gas for our patients. And really, when we talk about oxygen, we only need to deliver enough oxygen to meet that patient's metabolic oxygen consumption, which is about 3 to 5 mL per kilo per minute, which is exceedingly low in relation to the kinds of fluorrates we're using. So if we think about this.

In a 20 kg dog, the amount of oxygen that I actually need to deliver every minute to that patient is between 60 and 100 mL per minute, oxygen, if it's 100% oxygen. But that's never the flow rate that we're using. Our flow rates are probably gonna be 12 litres per minute, as a minimum in, in a lot of hospitals.

So we definitely could lower it in terms of our oxygen. We, we are way over delivering the amount of oxygen that we need in our patients, but there's other reasons that we have higher fresh gas flows. I think in veterinary anaesthesia, the historical reason we probably have used higher flow rates is that it gives more predictable gas delivery.

So the other thing that our fresh gas flow does is it carries our inhalant to the patient. And the higher our fresh gas flow is, the more predictable the dose of inhalant coming from our vaporizer is that the patient is actually breathing in. So in other words, when I use high fresh gas flows, if I have my vaporizer set at 2%, my patient is probably breathing in 2%.

Whereas if I go really low flow rates, that amount. Patients breathing in may be significantly lower than 2% because of the low fresh gas flow and the amount of dilution that happens in a rebreathing circuit. So one of the reasons we use these high fresh gas flows is so that we can change anaesthetic planes really quickly and so that our vaporizer percent actually is reflective of what the patient's breathing in.

The other reason we have higher fresh gas flows in some instances is that they are required to prevent rebreathing. So if you're using a non-rebreathing system, I like to refer to these as flow dependent systems because they only work properly if we use a sufficient flow. These are non rebreathing.

In other words, the only way that they eliminate rebreathing or the rebreathing of CO2 is through these high fresh gas flows, which basically flush the surface. Out of the CO2 that the patient exhale. And so we need to use these high flow rates, flow rates in these non-rebreathing systems in order for them to work correctly.

So in a non-rebreathing system, you can only bring the flow rate down so low before it now becomes a rebreathing system and we don't want the patient to be able to rebreathe CO2. Now, we also have rebreathing systems, which I refer to as independent, and these allow for rebreathing of gases, but they allow for it because there's one-way valves that make sure the gas only goes through one direction, and there's a CO2 absorbent that removes the CO2 from the, the, the patient's exhale gases, which allows for the patient to rebreathe. And they're also going to rebreathe in some of that inhalant that they exhale, which again is a nice way of recycling it as opposed to straight out the pop-off valve.

So, again, how low can you go? These are sort of my guidelines and my recommendations. In terms of a rebreathing system, I probably, well, I do turn the flow rate down below 500 mL per minute, but most of the times I don't have my technicians turning the flow rate down below 500 mL per minute.

But that is what we have standardly use on almost any size of patient, even up to a 50 kg dog, I can easily run at 500 mL per. Minute, on a 50 kg dog. It's just that my vaporizer is not going to be very reflective of what that patient's breathing in.

And so I may be running my vaporizer at 3 or 3.5%, which might seem very excessive to a lot of you, but when you actually measure the amount of gas that patients inspiring, it's gonna be closer to 1.2%, because of that low flow rate.

Where we run into problems though in the really small patients, and I actually, my minimum patient size for a rebreathing system is about 3 kg. And again, I actually go even lower than that on my own patients, because I have special low dead space breathing circuits, and, and Title CO2 adapters that I can use. And I also actually have a very, low volume, circle system that's been designed specifically for small patients and for exotics.

And so you do want to think about dead space, and you know, I just show a couple different circuits over here because that will become an issue if you're using this large circuit on say a 3 kg dog, this area here of that breathing circuit is going to be . Contributing to dead space, and that's a fairly large volume on a very small patient versus this system over here which plugs directly into the endotracheal tube and there's basically no dead space associated with this system that's much greater than the endotracheal tube adapter. So, so different systems you'll want to think about.

Now, one of the other things you may hear people mention is the resistance to breathing and it is true that if I measure the resistance to breathing in a circle system, or a rebreathing system and a non-rebreathing system. At the circuit interface, so at the, the adapter that plugs to my endotracheal tube, there is a marginally increased resistance to breathing in a circle because of the valves and because of the turbulence created as the gas goes through the CO2 cancer absorbent. Having said that, that is not where the patient is actually breathing from, where the patient is actually breathing from is that little tiny endotracheal tube that you enter.

Patient intubated the patient with, and that's where all the resistance to breathing comes from in a small patient. And so that resistance to breathing is what is really significant. The resistance associated with the equipment is far, far, far, far less than that associated with that tiny endotracheal tube.

So that's kind of one of those things that's been mentioned historically, but has been largely disproven in recent literature. In terms of a non rebreathing system, you know, I never use these on patients above 5 kg. So basically, if the patient is 5 kg and above, I can tell you I'm always using a, a rebreathing system.

I would not use a ban because it becomes excessively wasteful. And on all my non-rebreathing systems, I'm probably using a 1 litre per minute non-rebreathing flow rate, which will exceed that 200 mL per kg per minute which is needed to prevent rebreathing. And again, if you kind of do the math here, you'll see that a 5 kg patient maxes out at 1 litre per minute, and I don't really ever want to go above 1 litre per minute in my patient at any time during anaesthesia.

I compensate for the lower flow rates, in the rebreathing systems by just turning up my, my flow, my vaporizer setting. So a couple of other things, you know, when we talk about fresh gas flows, and I wish I had more time to go into that in more detail because it is kind of complicated at times. And I think because we learned this stuff in veterinary school, and then we haven't really thought about it, we've just done it by habit.

It's hard for us to kind of go back and remember all the pharmacokinetics and pharmacodynamics of how inhaled gases come into the body and so forth. But a couple other things you'll hear people talk about is the accuracy, and they'll say, well, if you go really low flow rates on our vaporizers, they're not as accurate. And, you know, why?

This is true outside of sort of, you know, 250 mLs or 0.25 litres and above 15 litres per minute, that the vaporir output does change, slightly. But I would say it's not largely clinically significant, because in the end of the day, we're not dosing our anaesthetic based on the vaporizer setting, but we're dosing the anaesthetic based on what we see in our patient and So, you know, if my vaporizer is delivering, delivering 1.2% when I have it or say say let's say at 2%, I have it turned to 2% and instead of delivering 2%, which vaporiser is supposed to do, it's delivering 2.1%.

It's not going to be clinically significant. The other thing we'll hear a little bit about in using low-flow anaesthesia if you're using. Fluorine is a potential for nephrotoxicity associated with compound A production.

And I'm gonna talk about that and why that's probably not as big of a concern as it would have been historically, again, because of new information that we have. So lowering fresh gas flows, I mean, we can get a significant reduction and in my hospital, we've reduced our fresh gas flows and our usage of isofluorine by about 75%. Just by turning down our fresh gas flow rates.

Now I'm going to not lie, I'm a little bit excessive about it, and I also have really good monitoring in terms of I have equipment that will monitor my end title isofluorane, so I can actually measure exactly what I'm delivering in terms of my isofluoran regardless of what I have my vaporizer turned at and my flow rate. Another big thing about this is it lowers costs and saves money. At the end of the day, I'm using 75% less oxygen, I'm using 75% less inhalant that does reduce our overall costs.

Losing fresh gas, low fresh gas flows does change the anaesthetic delivery characteristics. Changing plane doesn't happen as quickly. It takes a little bit more time, or you need to think about if I'm gonna change plane, I need to turn up my flow rate transiently to get that plane changed.

And so there is some education and training, and there's also some equipment costs associated with, improving this. It's, you know, certainly improved monitoring is very important and capnography in particular, especially if you're using lower flow rates with non-rebreathing systems, it's really, really important. So another area, another thing that I think is really awesome is to think about is capture and recycle or destroy.

And this really is the full circular economy where we would take the exhale gases, we we capture those and then we'd redistillate the exhale gases out and then we put them into the anaesthetic machine. And the technology is being developed. There's a number of different companies out there that are doing this.

And, and it's not quite there yet, but another option would be to just capture it, and we do have these large charcoal absorbers, which will hold up to 200 grammes of isofluorine. And if we actually incinerated those properly phar pharmaceutically, we'd release about 1.5 kg of CO2 equivalency, whereas if I just released that 200 grammes of isofluorine into the atmosphere, that'd be about the equivalent of 100 kg of CO2 into the atmosphere.

So by capturing it and incinerating or capturing and recycling, which would be the the best idea. We get a large and rapid reduction. It doesn't require us to change our anaesthetic practises, true circular economy, but we're not quite there.

We still need some research, and development on this, and there's also some logistics and then some unintended consequences. And we talked about incineration, it does feel like a step backwards. And I do realise I'm running out of time, so I'm gonna go a little quick.

Through some of this, but of course my slides would be available, should you want to go back and look at them. I'm just gonna quickly talk about Siva fluorine because that is something that's a hot topic that, you know, if I was opening up a practise today, I would absolutely use Siva fluorine in my hospital. I would not use an isofluorine vaporizer.

As you'll see here, the greenhouse warming potential is significantly lower associated with sevofluorine. Now the astute reader or listener would see, oh, but we have to use twice as much almost, right? So is it really that much better?

Well, even if you double this number, we're still lower and so sevofluorane certainly has less environmental impact than what we get with isofluorine. The challenges with this though is that it is relatively expensive, and you use twice as. Much.

And so if I switched to sevofluorine in my hospital tomorrow, I'd increase my drug cost here in Canada by about 6 times. There's also a concern about, compound A production, which is potentially nephrotoxic, and this results from the interaction of the sevofluorane with a strong base in the carbon dioxide absorbent. And I'll be honest, this has been sort of a more of a theoretical issue than a true toxicity issue.

There's really been no clinical evidence of toxicity in humans or animals, but yet the label in several countries does recommend no lower than a flow rate of 2 litres per minute. And I can tell you that that's probably unfounded in that we can actually use carbon dioxide absorbents that don't contain any strong base. The strong bases were added to carbon dioxide absorbance as an accelerant or as a catalyst to allow that reaction to occur more quickly, but we don't have to have those in them.

And if we eliminate the strong Basis from carbon dioxide absorbent, there is no risk of nephrotoxicity associated with compound A production because there is no compound A production. So I think this is something that's really important. And again, this is more recently learned stuff that we've learned.

So switching is relatively easy to do. Isofluorine and Cl fluorine are very similar, . But there are other costs associated with it.

So this is my last slide, and then I'm gonna finish up here. You know, other things I just think, you know, what can you do tomorrow? And a lot of things I talk about are just trying to encourage staff and, and our, our clients to think about how they're getting into the hospital and then also setting up things like virtual rechecks.

Like if I can do a virtual recheck, that certainly saves the planet from having a car drive 20 or 30 kilometres, to get there. I see Margo's coming on probably to be like, Craig, you're done. And I do have a bit of a problem of over talking in a lot of, I get very excited about this topic and I and I do love it.

The last thing I'll say to Margot and then I'll stop, is just, you think about the way that we practise medicine as well and don't just think about, you know, we've done it this way because it's what we do, but, you know, excessive preoperative testing, that's using more stuff. Do we really need Need to do that. Does the animal really need to be in the hospital for 3 days after a routine TPLO, or could it go home the next day?

So we need to start thinking about these other things because if we can reduce the use of all the stuff, it's not sexy, but it has a massive, massive impact on our environmental footprint. So with that, I'll end. Thank you very much.

Margo, I'll, I'll pass it back over to you. I'm really sorry I went over a little. Yeah.

All good. Thank you so much, Craig. You went through so much great content.

I hope folks in the audience, this has been useful. I, I know it has been. I think, Craig, there's so much, and you've had on so many ties to what we teed up at the start in terms of pharmaceutical stewardship overall.

And really the crux of so much of this is just using less and really being mindful about how and what we're using. That can just reduce. Problems from the very start, whether we're talking about environmental impacts, other impacts, like AMR, etc.

So you, you echoed that throughout, focusing on anaesthesia, and gave some really practical tips and advice for what exactly to do between choosing which gases to use and then how to be using them. You've even touched on some of the questions that have been popping up that I've been watching. One was on opportunities to recycle and reuse.

You touched on that and, and what we're exploring there, a few others, but you, you've largely hit on those as well. So in the interest of time, we won't do more questions right now, but thank you so much, Craig. Such great intel for us on anaesthesia and probably open the eyes of, of some of the audience in terms of those climate change impacts.

As you said, it's often something that, folks are not aware of. So thank you for helping to, to bring light to that. Absolutely, thanks a lot for having me, everyone.

Enjoy the rest of the sessions. Thank you, Craig. All right.

And with that, Craig's last slide actually was a great transition to Ellie, and her talk, because some of the things that Craig had up there are ones that Ellie will go into more detail on. So I'll keep this brief so that Ellie can have as much time as possible, but really excited to have Ellie West here. Ellie, as you can see on her side here is an anaesthetist.

And also is the environmental sustainability lead for Linnaeus, which is one of the Mars veterinary health businesses. And so Ellie brings extensive experience and has really been one of the pioneers in the field of veterinary sustainability. So some of you, I'm sure know her and have seen her publications and the work that she's done at Linnaeus to really Patchet up sustainability across the board, many different impacts and areas of sustainability.

And today, Ellie will be talking and picking up on some of the themes we've touched on, on pharmaceutical stewardship in terms of disposal and practise, and other ways of really, being mindful stewards of pharmaceuticals, and I know she'll touch on a few different angles, in different areas within that. So no further ado, Ellie, I will pass it over to you. Thanks very much.

Can I just check that you can see the screen that I think that you should see? Yep, we can, yep. It's a good start.

So thank you to the webinar vet for, giving us this opportunity to explore this area. And this is, not one of my super polished talks, because this is an area which is really interesting, really in its early stages of the evolution. So, I hope you can follow the journey that we're on.

So I've tried to map this talk to what's perhaps a more familiar hierarchy, which is the waste hierarchy. And this is from the government, guidance around how we should approach waste management. Starting with prevention, then talking about how we can reuse, and then finally looking at the more traditional disposal methods, and finally ending up with your actual chucking something away.

Because pharmaceutical stewardship is essentially a story of dealing with the waste from a single-use product. And so, I'm going to be mapping, as I said, through how we prevent that waste, how we can reduce that waste if we do need to do it, what reuse options we've got, and that's why you'll have to be a little bit, you know, following me on, on, on, on my thought process there. How we can look at recycling and how we can improve, and, and where we need more information in the future.

The first step always is to prevent waste. And to start with, we can look at the problematic areas and the areas that we know globally to be of significance. And across the range of environmental impacts, we know that we have problems with certain drugs because they either have high impact on ecosystems, including the human ecosystem, or high carbon emissions.

And the graphic On the right shows you what the Stockholm Institute came up with, which is the idea that there are 9 planetary bound boundaries for, for humanity to exist safely within. And the green zone is safe, and you can see that we've exceeded 5 of those boundaries. And the, the newest one that we've exceeded in 2022 is for microplastics and chemicals within the novel entities group.

And I think we should probably look at all pollutants, including pharmaceuticals in that category. So we need to look at can we take some of these drugs out of the systems that we're using. And the European Commission has highlighted that parasiticides, antifungals, antibiotics, and some of the endocrine disruptors are of particular concern globally for, for global health.

And this is a global problem. If you look at pharmaceutical pollution in rivers, around about 25% of the rivers around the world are polluted to an extent where they, you, you've got a risk of development of antimicrobial resistance, or there is ecosystem harm documented at the levels of pollutants that you find. And we're not just looking at single pollutants here.

We have to remember it's actually the, the, the mix of all of these chemicals and all of these drugs, and climate change, and all of these boundaries are interacting with each other, so that the safety within one boundary is affected, by the resilience within the other. So, obviously, these things are, are, are kind of, complicated by their nature. What we need to ask is, what is the evidence base for the drugs that we're using?

And we need to apply that rigorously, and, and use the best practise that we have to support that. What that means, what I mean that to be, is that we need to see the pharmaceuticals that we have used appropriately. And as I said, I think the word's not just in case.

So, I, I, I, I wish these were all these, but they aren't, the right diagnosis. And so making sure that we're actually treating the condition that we think we are treating or responding quickly if it's, apparent that, that the, the drug is not effective. Looking, making sure we've got the right drug for, for that condition, the right dose, the right route, the right interval, and the right course length, which I realised could have been duration.

So, there is a lot of work to do around making sure that we've actually got the information that we need. So, for example, the Small Animal Medicine Society, ably led by Fergus Salaton and colleagues, are running the stop on Sunday, trial to try and figure out what is the length of, of antibiotics that we need in order to treat. Female canine cystitis, UTIs.

So, if you want to enrol in that study, please, look, look out for my email address later, and I would love you to put you in, in the direction of, of helping to contribute to that, because maybe we can just half the dose, or the, the milligrammes of drug that we're using by having the evidence base to know how long the course should be, and that would be fantastic. There's also, guidance coming out and from ENAAD, which is an international group looking at peroperative antibiotics and what we should be using. And I think the main message of that is, is there's very few clean procedures that need any, post-operative antibiotics.

So immediately we've got a whole category that we can look at and more evidence base leading to better, better stewardship. Now I know you've seen this graphic from from Craig already, but the, the National Health Service in England produced this carbon footprint. And what was astounding to me is that about 50% of the whole value chain, so not just the direct operations, but all of the things that the NHS buys, or all the downstream impacts, of NHS activity.

About 1/5 of that comes from the medicines that the NHS purchases. So we're talking about, the emissions that sit in the manufacture and the logistics of the stuff that we buy. So, we've seen medicines and chemicals are in their medical equipments in there, non-medical equipment's in there.

So it's all the supply chain impacts. So we need to see that our pharmaceutical suppliers, and indeed all our suppliers are working towards the same targets with regard to carbon as us. And I think it's a really useful idea to think about carbon because it's quantifiable, as a way to measure, how we, how we're managing our, our stewardship.

So there are, a lot of companies, pharmaceutical companies in particular, that are working towards net zero. And there are about 80 global pharmaceutical and biotech companies that currently have science-based, targets. But there's also, we're not just thinking about carbon, we're thinking about biodiversity.

And there are also groups like the AMR Alliance that look at, predicted no effect concentrations from the factories. So if you're producing antibiotics, it's really great if you're also signed up to the AMR Alliance's work around reducing residual contamination from, from that end. So that's the responsibility of our suppliers, and we can ask them to do that if we're also taking our part, and that that's really what the rest of this talk is about.

I did want to mention waste. Waste does have a carbon impact. And I wanted to say that pharmaceutical waste is particularly impactful because it sits in the high temperature incineration waste category, which is not only the most expensive, but also the highest carbon emissions of the waste disposal options.

So where we can stop contamination, with pharmaceuticals, or we can reduce, the, the amount of pharmaceuticals we're disposing of, all the better for carbon footprint. The very, very last piece of new information I wanted to share is from this paper Huital, and what they've done is carbon footprinted based on assumed manufacture processes for, either fluorine, superflurane and and Des fluorine. And what we know to be true is desfluorine is a high impact drug, and that's because of the orange segments from the atmospheric release of the drug.

So if you smash the bottle, let the vapour rise, it's a greenhouse gas. But we also have impacts, carbon impacts in the manufacture of those drugs. And depending on the manufacturing pathway, those, those could be more or less significant.

And so you, you can see, because of the scale of the desfluoran impact, if we ignore desfluorane, you can see that actually for some ways of manufacturing Siva flurane, you have a bigger impact than, than isofluorane. So we need to understand the manufacture pathways. And in general, the more steps there are in the manufacture pathway, the more emissions there are, carbon emissions there are in production.

So, that, that's something which is very much, new, and we need to figure out what, what impact that actually has. But we don't have that data for the vast majority of, of the drugs that we're using. We are starting to see these concerns reflecting in the legislation.

And so we have already had quite a lot of controls around antibiotics, and indeed, in, in the EU they've had a ban on certain antibiotics since 1999. But actually, very, very recently, the NHS England, announced that it was decommissioning Des fluorine. So they're taking it out.

So our healthcare systems are starting to remove access, to particular drugs that have high impact, and I think that will be increasingly, a popular option, particularly where there are clinical equivalents, currently available. And we're seeing that also for nitrous oxide, there's concern, particularly because of the health and safety risks, but because of the abuse potential of nitrous oxide. And so, nitrous oxide is a drug which, has undergone regulatory, scrutiny recently.

And so the government is starting to look around who should be using these drugs, who should have access to these drugs, how should they be using them? So, I, I think that we're gonna see more and more of this type of legislation. It'll be interesting to see that, for instance, the Swedish legislation currently contains restrictions on the use of fluoroquinolones and 3rd and 4th generation capitalistorins, to exceptional cases.

And you, you've got to do culture and sensitivity testing, and there's a few exceptions. But, but we may see that start to roll out elsewhere, and, and that'll be a really, really interesting progression. So this is coming a bit, a little bit more to what you can do in the clinic floor from tomorrow.

So, stock control. We all know that if you have drugs on the shelf that pass their expiry date, you can't use them. So if you are rotating your stock appropriately, particularly if you open medications, then you will be reducing the wastage before it's ever reached, anybody's hand or ever gone near a needing a syringe.

You can reduce the volumes that you prepare, and this is particularly true where you've got propofol with preservative in, because we know that the vast majority of propofol is chucked away before it again, ever gets near a patient. So, if you can look where you are wasting these drugs, and this is particularly true of emergency drugs. So I know in, in medical hospitals It's a bit different than in our hospitals in that, they will very often draw a dose of adrenaline, a dose of atropine, a dose of lidocaine for every patient.

We don't tend to do that, but if that is the practise, then look at pre-filled syringes, and that can have a big impact in safety benefits, actually, for reducing patient error, as well as time and, and, and cost savings, of course. But where we can really have impact, I think, is looking at these really robust stewardship programmes. And the one thing that, when I think about stewardship, it's not just about reducing waste and, and the environmental and the quality impacts.

We're also saying, for a patient that's receiving a drug, which maybe isn't the best drug for them, or isn't necessary, or maybe, is, is not actually gonna, is gonna be masking the symptoms, it's gonna be delaying the appropriate therapy, then actually, pharmaceutical stewardship will improve the quality of care for the patient, and we should be doing it for that reason, if that reason alone. There's a lot of interest around parasiticides, and there's, there's some evidence base which is evolving, and there are regulatory consultations ongoing at the moment through the BMD. So for the minute, I've just put the, stewardship resources that I'm aware of for parasiticides there so that you can take a look at those at your leisure.

What I wanted to present today, was some of the practical examples that I know of and that I'm involved in, across the nest. So we have run our safeguarding antibiotics programme since 2021. And that involved, to start with, sending out protect posters to all our sites, and asking them to fill them in as a vet team.

And this meant, I, I said, I, I want you to scribble on these posters. I want a picture of the scribbled on poster, and I wanna see that poster up on the wall. And I, what I love about this photo is you can see the edge of the poster is gnarled, which means it's been in use.

So we put in a whole range of, support and active activities for vet teams to do to actually start to think about how they're using the antibiotics. And, I put one of the quotes there, about, about the antibiotic prescriptions. But what we, we ran, another survey, and, one of the quotes was, and the survey was a good reminder that we all need to try, in all cases, to avoid prescribing antibiotics if we can.

What did emerge from the survey was that, 6 out of 10 patients had their temperatures taken for acute diarrhoea, so there's room for improvement. So I think where you can actually start to think, what are we doing? Is everybody doing the same thing?

What are the opportunities? So that's a really, really, valid way of moving forward with stewardship. So, we saw as a result of this sort of, engagement, a 15% reduction in the purchasing across the group in one year.

And that has a big carbon impact and is a is a part of any, any net zero plan as well. Moving on to, anaesthetic gas stewardship, we also ran a We go for low flow campaign. And, there were many stages to this, and it was identifying what was the deficit in the teams that we needed to support, whether that was training or resource.

And there's a lot of work going in, in, in the VM teams, particularly around this. But again, we've seen reductions, real time, for two years in a row now, in the use, despite the business growth. So we've actually decoupled the use of anaesthetic acids from business growth.

The resources that we created, we put onto the website. And so if anybody wants to follow what we did with their programme with their own teams, then, then please feel free to access those. So, we use, this is where you may need to sort of stretch your imagination a little bit, because it's, it's a less obvious map from our traditional, waste hierarchy.

So I'll try to explain what I mean. We rarely have the opportunity to reuse drugs, obviously, but we can reuse the skills and the knowledge and the expertise that our teams have. And so many of the diseases that we treat have adjunctives or alternatives available, and we can look for preventative care options to avoid the environment of our, of our clinic, which ultimately is a high carbon, high waste, high pharmaceutical environment.

So we need to move towards this model of preventative care, rather than reactive care. And we've got, professionals within our industry who have the ability to support with this. So, so let's use those people.

I've given some examples of the skills that we can share, and you can see how those would map to clinical services, particularly around diseases like chronic pain, diabetes, obesity, which is a very, a very significant cause of cancer in people. Where sometimes drugs are not the only choice or not even the right choice sometimes. The one I would draw your attention to is green prescriptions.

So, well-being and health through nature is an area the NHS is, investing in very heavily due to the many benefits to so many types of diseases. And I think that we can look to accessing that, that, green prescriptions model, not only to help, our clients and our, our, sorry, our pets, but also our clients. And Craig mentioned it already, but I think the recapture of volatile anaesthetic agents is not so far off.

We do then need to look at licencing the recaptured products so that we can bring it back into a circular economy. We have to remember that we can't recapture 100% of, of, of that which, we put into a patient, because the patient ultimately stores some of it in their body. So it's, it's not a, it's not a perfect model.

There's lots of things to iron out, but I think that that, that recapture is, is certainly technically possible, and we'll see that in practise in the next few years, I hope. Recycling, hopefully a little bit more familiar. And if we follow the waste regulations, we should automatically reducing, be reducing the environmental impacts from waste disposal by putting the right thing into the right waste stream.

And actually, a, a large proportion of the waste that we create in our clinics, whether it's pharmaceutical or the packaging from the pharmaceuticals, can be classed as domestic. It's non-contaminated, and it can be recycled. And if you look at the UK waste infrastructure, 00 waste landfill is actually achievable.

But within recycling, I want to look at what, what other options. If we can't recycle it, what other options for waste disposal have we got? And we ran an antibiotics amnesty, and this was picked up nationally by a lot of groups, where we're just encouraging clients to bring back their unused drugs, bring back their, their out of date medications, and we will dispose of them correctly.

We don't want those ending up in a domestic waste stream. And that will become part of the practise Standards scheme from June 23, at GP level. We can also talk to owners because a lot of our drugs are actively metabolised by our patients, and they're excreted in urine and faeces.

So where it's fecally excreted, then we should be promoting proper disposal of, of faeces into appropriate waste streams. So these are looking at the extended responsibilities that we, we have and the influence that we have available to us. And my last category is improve.

So what do I think we need to improve? I think we need to look at owner compliance, and I don't think we understand owner compliance very well. If you look at what the information from the medical world, there's a large proportion of patients, people who don't take the medicines that they're prescribed.

So, and according to WHO estimates, over half of the medicines sold around the globe are prescribed or dispensed inappropriately. So I think that we've got a lot of work to do around understanding why and when don't people give their animals the drugs that we prescribe for them. We can also look at the choices of drugs that we have, and you can have lower impact choices.

So, topical roots in, in, in general, will have a lower impact than, systemic roots. We can look at how we administer them. So if you have to sterilise a drug, as part of the manufacturing.

Process, that creates carbon emissions that are embedded in the product, then. So, if you can give an entero or, or an oral dose of something rather than an IV dose or an IM dose, then it's likely to have lower carbon emissions. And, and there's some evidence to show that the proportion of that.

But we can also look to making choices based on the least environmentally harmful, but clinically equivalent drug. And there's work going on to create formularies for, for those type of decisions, so that you say, all for the same antacid, I'm gonna choose that one, purely because it has a lower environmental profile. So there's work going on in the medical sector to try and identify those drugs, and then we probably need to tag on to that, the veterinary products that we use.

But drugs like propofol already have an environmental profile available. So here is my summary, of what we know at the moment, and I try to operate by a, a quote from Maya Angelou, which is, do the best you can until you know better, and then when you know better, do better. So this is a massively evolving field.

We need to share the best practises. Please feel free to get in touch. And it's just, left for me to say thank you very much to Webinar back, and here's my email address if you have any interest in any of the topics we've discussed today, I'll, I'll hand back to Margot.

Thank you so much, Ellie. There's so much good information in your talk and so thank you also for sharing your emails so folks can follow up with you. We've covered so much in the past 2 hours and we're just about at time.

We've had a bunch of questions in the chat. Ian has been, trying to answer as many as we can that were from the, the former part of the session, so we'll, we'll close this out now, if you do have more follow up questions for Ellie, you've got her email now, Ian and I are available as well, and feel free to contact webinar vet to get in touch with us. I think in, in closing, I think Ellie, you had a great summary there that actually really nicely summarises, the whole topic and, and what we've talked about today.

And in a way, in summary, it's, let's be mindful of how we're using, everything in our practises, whether it's pharmaceuticals or other supplies, where we can, use less. The great news is it Often has a benefit across the board for pet health outcomes, environmental outcomes, and human health outcomes. When we think about so many of these things is if we can be reducing use and really optimising and using in the best way, we get a win, win, win across the board.

So that's a positive that, you know, it's often not looking at too many trade-offs. We actually get a, a win on all of them. So with that, that's my best attempt at summarising everything we've covered.

Hopefully, this gives everyone some really tactical ideas, but also some of the principles behind pharmaceutical stewardship. And thank you all for joining us and thank you, webinar vet for having us during your session today.