2009 Report Card for America’s Infrastructure (Adapted from:ASCE, 2009)
\\n\\n
More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:{caption:"IntechOpen Maintains",originalUrl:"/media/original/113"}},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
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He worked as a Chief Researcher at the Information Technologies Institute of Turkish Science and Technology Council (TUBITAK). He also served as the vice president of the Turkish Measurement and Placement Center of Turkey and as a member of the Executive Board in the TUBITAK Public Research Group.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"306974",title:"Prof.",name:"Ercan",middleName:null,surname:"Oztemel",slug:"ercan-oztemel",fullName:"Ercan Oztemel",profilePictureURL:"https://mts.intechopen.com/storage/users/306974/images/system/306974.png",biography:"Prof. Dr. Ercan Oztemel was born in 1962 in Elazig of Turkey. He graduated from the Department of Industrial Engineering, Sakarya Engineering Faculty of Istanbul Technical University in 1984. He completed his postgraduate studies at Boğaziçi University between 1985-1987, and his doctorate study at the Department of Electrical, Electronics and Systems Engineering of University of Wales between 1988-1992. Between 1993 and 2006, he worked as a lecturer at Sakarya University. In addition to his academic life, he worked as a Chief Researcher at Information Technologies Institute of Turkish Science and Technology Council (TUBITAK), between 1993 and 2011. In this institute, he conducted research on Artificial Intelligence applications, especially in the military domain. He carried out projects that were the first of their kind, such as placing simulation systems on military training aircraft (flying simulator), Artificial combat Pilot, nurse robots, war fare exercises in the virtual world. Between 1997 and 2010, he carried out research in the Western European Union Armament Group, as well as a Member of the Executive Board in the 11th and 15th Groups, and a member of the System Analysis and Simulation (SAS) Panel within NATO between 2001-2006. On the other hand, he supported the creation and execution of many sub-projects as a Member of the Executive Board in the IPROMS (Intelligent Production and Mechanization Systems) Center of Excellence project opened within the scope of the European Union 6th Framework Program. He served as the vice president of Turkish Measurement and Placement Center of Turkey between 2011 and 2015, and as the member of the Executive Board in the TUBITAK Public Research Group between 2012 and 2017. He conducts research in areas such as artificial intelligence, intelligent manufacturing systems, management information systems, simulation and modeling, strategic planning, quality management. He has many articles, papers and books on these subjects. 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This includes not only the comforts of heat during the winter, reading lights at night, and convenient transportation options, but also items paramount to public health and safety such as water treated to standards suitable for human consumption, energy for critical operations, and transport to enable society’s functioning on a daily basis.
Researchers, professionals, policy makers, technologists, planners and others are challenged regularly to create, maintain, and operate such infrastructure to improve quality of life, while balancing the Triple Bottom Line (environmental, societal, and financial factors).This is an amazing feat to strive for in itself, but now recognition of the greater potential impacts of climate changepresent additional components of uncertainty and risk that must be applied to this highly valuable and financially- and time-intensive infrastructure investment.
Water is a significant enabler of economic prosperity and well being.Water infrastructure is the medium that enables this.This infrastructure faces numerous threats and uncertainty from climate change, which directly leads to water change and subsequent needs to adapt this infrastructure in the face of a myriad of existing drivers, constraints, and expectations of water infrastructure.This chapter aims to tangibly frame the structure for adapting water infrastructure to climate change in the reader’s mind.
This complex situation becomes additionally compounded by much of the infrastructure reaching the end of its useful life, which also provides an opportunity to renew it with much more planet-friendly approaches and designs.In many areas across the globe, megatrends add an additional layer of complex challenges and opportunities, as do applicable design standards.The impacts of these infrastructure complexities are already rippling through facets beyond utilities and governing districts that operate and maintain infrastructure to industry, banking, insurance, and policy.
The level of success that can be achieved in integrating and balancing these additional levels of complexity associated with or driven by climate change will ultimately influence the level of quality of life that can be reached or preserved for future generations and the impact on environmental assets that should not be squandered in a way that would negatively impact future generations.Several key concepts can help to optimize success, such as:
ConsideringPotential Impacts of Climate Change on Infrastructure
Examples of Infrastructure Vulnerability and Consequences
Importance and Challenges of Mitigation in Infrastructure
Importance and Challenges of Adaptation in Infrastructure
Infrastructure Asset Management Planning
Importance
Approach
Climate Adaptation - Incorporating Risk and Climate Change to Prioritize Renewal
This chapter aims to build and communicate the complex picture of the risks that climate change presents to infrastructure, largely focused on the context of water infrastructure as a specific case for analysis. It also examines how to pursue more sustainable and resilientways in which to address these challenges. Included in this chapter is a solution framework for addressing the imperative need for adapting water infrastructure to climate change. This is accomplished through an investigation ofhow successful asset management is executed and the role it can play in adaptation.Also presented is how climate change adaptation planning can be rolled in to asset management to consider risks and appropriate strategies for moving forward.
A framework is needed to identify, assess, strategize, plan, and act on the risks that this infrastructure faces due to climate change.This chapter shows how climate adaptation planning and prioritization may be incorporated as a component of risk in what has been identified as a sound, successful, and actionable risk-based asset management program.The chapter aims to connect related best practices in infrastructure climate adaptation assessment, planning, and implementation in a robust, yet flexible manner for the long term.
Key terms used in this chapter include “climate change”.For the purposes of this chapter, “climate change” is defined as “any significant change in measures of climate (such as temperature, precipitation, or wind) lasting for an extended period (decades or longer)” (EPA, 2011a).“Adaptation” in the context of climate change for the purposes of this chapter is the “adjustment in natural or human systems in response to actual or expected climatic stimuli or their effects, which moderates harm or exploits beneficial opportunities” (Intergovernmental Panel on Climate Change IPCC, 2007).
Climate change can impact infrastructure in a variety of ways, and can present significant uncertainty and risk to natural resources and related infrastructure.The Intergovernmental Panel on Climate Change (IPCC) (Bates et al., 2008) notes that climate, freshwater, biophysical, and socio-economic systems are interconnected and interdependent.It also notes that water, its availability, and quantity will be the main climate change issues for societies and the environment.
Connor et al. (2009) agrees with this general philosophy.Specifically, Connor et al. (2009) calls out these major ties between climate change and the translation of the significance of its impacts on the key medium of water:
“There is evidence that the global climate is changing.The main impacts of climate change on humans and the environment occur through water.
Climate Change is a fundamental driver of changes in water resources and an additional stressor through its effects on other external drivers.
Policies and practices for mitigating climate change or adapting to it can have impacts on water resources, and the way we mange water can affect climate.”
To emphasize the scale of the issue of climate change impacting water resources, often in a way that increases risk to society’s and natural resources’ well being note that Grey and Sadoff (2006) link water resources to being the foundation of economic well being. Below is a breakdown of all world-wide freshwater supply use purposes, as provided by the World Water Development Report (2006):
70% used for agriculture irrigation
22% used in manufacturing and energy applications
8% used for domestic applications such as consumption, sanitation, and recreation
In these applications, demand is expected to rise from 54% of available supply in 2001, to 70% in 2025 (90% if at developed country levels) (UN, 2006).The uses outlined above compete for this supply.This resource is additionally constrained by accessibility, quality, and the affects of climate change as outlined in this chapter and numerous other sources.This is especially problematic when 700M people already facing water scarcity and 900M lack access to safe drinking water.Climate change has the potential of magnifying this problematic situation and subsequently further undermining health and livelihoods (Water and Climate Coalition, 2011).
The magnitude of the water infrastructure needs in the face of climate change related to in costs (USD) is presented in Figures 1. and 2. (North America/US is outlined in subsequent tables of this chapter):
Water adaptation to climate change, generally = US$ 9-11B by 2030 (United Nations UN, 2007), up to US$ 20B in developing countries (Water and Climate Coalition, 2010B).
Water adaptation to specific scenarios of climate change = US$ 13.7B in drier scenarios, US$19.2B in wetter ones for water supply and flood management (World Bank, 2008)
Having the proportion of people without access to safe drinking water and sanitation (generally, without specific climate change adaptation considered) = US$ 10B/year through 2015 (Toubkiss, 2006).
Annual adaptation costs (Source:
With the resource put at risk (i.e., uncertain changes in water availability, quality, and timing), its infrastructure is also put at risk.Climate change impacts are expected to become increasingly severe, with the risk of more abrupt and large-scale changes at higher temperature (Stern, 2007).With high uncertainty and severe shifts, adaptation must enable infrastructure to be more dynamic and resilient, while playing within the bounds of much infrastructure being time and financially expensive, relatively static in many instances, and a direct enabler and potential risk (if neglected or inadequate) to the public’s and environment’s health and well-being. As noted from various sources, (Bates et al. 2008 and Water and Climate Coalition Coalition, 2010b), climate change is ultimately water change.For these reasons, this chapter is largely focused on infrastructure that serves water needs and concerns as they relate to climate change for this infrastructure that serves societies public health and livelihood needs.
Bates et al. (2008) calls out the following evidence that freshwater sources are vulnerable and have the potential to be strongly impacted by climate change, with wide-ranging consequences for human societies and natural ecosystems:
“Observed warming over several decades has been linked to changes in the large-scale hydrological cycle.
Climate model simulations for the 21st century are consistentin projecting precipitation increases in high latitudes (
By the middle of the 21st century, annual average river runoff and water availability are projected to increase as a result of climate change at high latitudes and in some wet tropical areas, and decrease over some dry regions at mid-latitudes and in the dry tropics.
Increased precipitation intensity and variability are projected to increase the risks of flooding and drought in many areas.
Water supplies stored in glaciers and snow cover are projected to decline in the course of the century.
Higher water temperatures and changes in extremes, including floods and droughts, are projected to affect water quality and exacerbate many forms of water pollution.
Globally, the negative impacts of future climate change on freshwater systems are expected to outweigh the benefits (
Changes in water quantity and quality due to climate change are expected to affect food availability, stability, access and utilisation.
Climate change affects the function and operation of existing water infrastructure – including hydropower, structural flood defences, drainage and irrigation systems – as well as water management practices.
Current water management practices may not be robust enough to cope with the impacts of climate change.
Climate change challenges the traditional assumption that past hydrological experience provides a good guide to future conditions.
Adaptation options designed to ensure water supply during average and drought conditions require integrated demand-side as well as supply-side strategies.
Mitigation measures can reduce the magnitude of impacts of global warming on water resources, in turn reducing adaptation needs.
Water resources management clearly impacts on many other policy areas.
Several gaps in knowledge exist in terms of observations and research needs related to climate change and water.”
Total annual cost of adaptation and share of costs (Source:
To further develop the profile of impacts and why to be concerned about climate change impacts on water, it is worth noting that with an intensifying water cycle, seasonal and annual water supply variations will determine the consequences of climate change in the form of droughts or floods.Billions of people will be exposed to either having more rainfall or less, which can lead to greater water availability (although not always quality or the ability to capture it) or scarcity, respectively (Stern, 2007). This can serve as the foundation for the conclusion that the impacts of climate change will be felt most strongly through the changes in water, its variability in availability, quantity, and subsequently quality to serve health and livelihood needs (Water and Climate Coalition, 2011).
An examination of potential climate change-induced water impacts on water infrastructure is worthwhile to better understand the criticality and magnitude of the issue of risk that water infrastructure (and subsequently quality supply faces).First, the simple issue of supply exists; that is, is enough water of a sufficient quality available to address the needs of the community and the environment that it serves.Availability relates to several important components; is the water supply consistent, sufficient in quality, protected from natural and humanistic disasters, economically viable to claim and transport, allocated appropriately among users, and part of a dynamic supply system that can adapt to changing needs, seasons, political drivers, etc.?If so, then is the necessary infrastructure in place to obtain the additional supply, and is that infrastructure managed in such away to maintain the investment in that infrastructure and the levels of service expected from the supply?
Next, is the quantity of the supply of water adequate and managed in a way to serve the needs of people without detracting from other natural resources?If more water is needed regularly or during particular seasons, is infrastructure in place to enable access to additional supplies?What about storing the supplies during high precipitation or runoff seasons – is infrastructure in place for this?Can additional benefits be achieved such as through claiming clean and substantive hydropower through streamflow or reservoir dams?Can runoff be captured and channeled by infrastructure to capture the necessary supply for community and environment uses and management in a way that protects, maintains, or enhances water quality to the levels necessary for society’s use?These are all important issues and highlight how critical infrastructure is to providing water, as well as why it is important to protect, maintain, and adapt this infrastructure investment to changing conditions so that it can continue to serve society’s water needs and provide for its well-being.
A few, more specific examples are worth considering to make the concepts of infrastructure criticality and vulnerability more tangible.As mentioned earlier, more severe water droughts and floods are expected.These directly impact the quantity and quality of water available for various forms of consumption.Depending on the particular local scenarios of climate change, runoff impacts, and various water infrastructure, the potential to overwhelm this critical infrastructure exists, subsequently jeopardizing critical water supplies, especially on an annual basis.
For instance, reservoirs and other types of infrastructure units are often used to store annual supplies of water captured during the high runoff season.If climate warms significantly in the area, increasing the ability of the atmosphere to contain moisture and subsequently leading to fewer but more severe precipitation events, rivers, canals, pipelines, reservoirs and other water infrastructure may not have sufficient capacity to capture the supply necessary for annual consumption; the water could simply top-out the infrastructure and flow downstream and the reservoir subsequently may not be able to meet demands over the course of the dry season when the reservoir has no replenishment refilling it.
A similar scenario could develop with increased temperatures and short winters in areas of glacial and snowpack water sources, frequently located in mountainous regions.With shorter winters and higher temperatures, the snowpack might not develop as greatly which would reduce the supply initially.
The same factors could lead the snowpack to melt more and melt sooner in the year, which could overwhelm water infrastructure in volume, leading to the demise of the supply’s annual quantity due to the inability to store or convey the planned annual amounts allowing a portion of the supply to pass downstream, possibly resulting in flooding and subsequent risk to life.To provide an idea of the scale of this issue, more than one-sixth (1B people) of the world’s population living in the impacted river basins could be affected (Stern, 2007 and UN, 2008).Additionally, the demise of the quality may be encountered as overall there could be less annual supply, and the earlier runoff may have encountered greater turbulence and pollutants from the watersheds, resulting in a higher concentration of quality degradents.
These issues associated with snowpack are specifically identified as a forecasted issue for the Indian sub-continent, over 250B people in China, and 10 of millions in the Andes.The issue can be exacerbated with long run dry season water disappearing permanently once the icepack has been completely terminated (Stern, 2007).If the snowpack would instead continue to melt more gradually as for which the canals and reservoirs were designed, a more consistent supply would be available through much more of the year.This would help to enable the infrastructure to more feasibly meet expected supply levels.
In some instances, these runoff supply issues may also be present in coastal areas.However, coastal areas are exposed to additional risks as well.For instance, more severe precipitation events could exceed soil and shallow aquifer abilities to retain runoff, if their available capacities are exceeded over the course of these events.The freshwater rainfall would just run out to sea and less would be stored and available in the dry season.
Another challenging risk is salt water intrusion into freshwater delta and wetland systems and aquifers.Rising sea levels bring rising pressures and elevations of sea water, which could potentially penetrate freshwater reserves lying geographically close to coastal waters, or those which lie at low elevations near coastal waters.This risk is further magnified if climate change in an increase of civilization’s historic records of temperature has already caused delta and wetlands freshwater levels to drop through increased evaporation.The UN has identified that a high probability exists for rising sea levels to contaminate and subsequently reduce adequate freshwater supplies in Bangladesh, Egypt, and Thailand (UN, 2006).Bloetscher et al. (2010) includes a case focused on mitigating climate change impacts on coastal water supplies and infrastructure.
Additionally, with ice cap melting and subsequent sea level rise, stormwater infrastructure at low-lying, shallow elevations may not have the capacity to contain the rainfall events themselves, nor convey the rate of stormwater flow to outfalls, nor be physically capable of discharging if sea levels rise significantly enough to obstruct stormwater outfalls.As most stormwater pipe networks are not continuously pressurized, rising sea levels could complicate their ability to discharge, or worse, yet, result in backflow contamination or public health hazards and nuisances as stormwater backs up in combined sewer systems (those that convey both wastewater and stormwater flows) into neighborhoods, streets, households, and businesses.These scenarios or others could lead to the vulnerability of millions of people in low-lying coastal areas being at greater risk of flooding by storm surges over the course of the present century (Connor et al., 2009).
Another issue can arise when water supplies are over-allocated.For instance, it is common knowledge that the watershed and subsequent water supply to the Colorado River in the United States is overallocated.The allocation of the river’s water supply was based on unusually wet years, as exemplified by tree ring data (Barnett and Pierce, 2009).Additionally, climate change is expected to compound the problem with warmer, shorter winters, and reducing snowpack and accelerating runoff, as shown in research on the river’s Upper Basin by Hamlet et al. (2005) and Stewart et al. (2004).In general across the western part of the US, decline in snowpack has been commonly identified over the period of 1925-2000, especially near the middle of the century (Mote et al., 2005).This further decreases the projection of availability of the already over-allocated water supplies.
In all of the infrastructure vulnerability examples cited above, the common consequence of increased flooding with subsequent risk to public health and well-being, decreased supply and quantity, and subsequent rising costs for mitigation, adaptation, management, insurance, etc. are all inherent.AWWA (2005), EPA (2008c), and IPCC (2007) provide additional examples of climate change impacts on water and its infrastructure and subsequent implications.
Water is critical for adaptation and mitigation of climate change, as climate change is to a great extent water change (Water and Climate Coalition, 2010a).As mentioned earlier, water has been identified as the primary medium through which society and the environment will be impacted by climate change (Bates et al., 2008).The drivers, constraints, stakeholders, and various scenarios imposed on water resources are numerous.The
A Schematic of Water Resource Drivers, Constraints, and Issues (Source:
Additionally, it provides a synopsis of challenges and stakeholders on the cover of the report, which help to provide additional context, as shown in Figure 4.
A snapshot of water challenges and stakeholders (Source:
At the United Nations Framework Convention on Climate Change’s (UNFCCC) 16th Session of the Conference of the Parties (COP 16) in Cancun (UN, 2010), the Water and Climate Coalition (2010b) called out important fundamental concepts about water change due to climate change to be considered in further climate change examination (Water and Climate Coalition, 2010b).These are grouped in three categories:Climate Change Adaptation, Climate Change Mitigation and Water, Climate Change Finance and Water as interpreted below. These key philosophies are important to reflect upon in developing a deeper understanding of climate change adaptation and mitigation needed via water and its infrastructure.
Climate Change Adaptation and Water
Climate change is water change.
Resilience should be achieved through Integrated Water Resources Management (IWRM).
National Adaptation Programmes of Action (NAPA) and IWRM should be integrated.
Regional cooperation is necessary to respond to climate change impacts on transboundary waters.
Adaptation that is eco-system based is necessary for the foundation of adaptation.
Water supply and sanitation resilience must be strengthened in the face of climate change.
Adaptive water management is important for life and livelihoods.
Risk reduction strategies must be integrated with water resources management to address severe water events.
Climate Change Mitigation and Water
The reciprocal relationship between climate change mitigation and water (and its eventual nexus with energy) must be recognized.
The carbon (and energy) footprint of the water sector must be addressed, as it is a high contributor.
Climate change mitigation should be integrated with water resources management to achieve “no regrets” scenarios.
Avoid assumptions about future water availability, and fundamentally revisit plans.
Energy efficiency must be enhanced in the water sector, and “smart” infrastructure can help to achieve this.
Recognize the mitigation impacts of adaptation actions and vice versa in the water sector (i.e., scarcity drivers of desalination with large energy/carbon footprint).
Climate Change Finance and Water
Economic resources need to be developed and grown for water adaptation infrastructure, especially in developing countries.
Additional funding is needed to meet the United Nation’s Development Program’s Millennium Development Goal 7 of halving the proportion of people without access to safe drinking water and sanitation by 2015, as even just the costs of climate change (US$ 10B/year through 2015) (Toubkiss, 2006) greatly exceed the sole costs of basic supply and sanitation at US$ 9-11B by 2030 (UN, 2007), or US$ 13.7B in drier scenarios, $19.2 in wetter ones for water supply and flood management (World Bank, 2008).
EPA (2008c) examines the water infrastructure adaptation to climate change in a similar light.In 2008, it developed the National Water Program Strategy on a response to climate change.This strategic response outlines the priorities of the EPA in terms of helping and enabling the U.S. to address climate change adaptation, mitigation, and finance (via research and other means) of water.This program is a supporting facilitator for water infrastructure adaptation that aligns well with the Coalition’s key philosophies.
The Water and Climate Coalition (Coalition, 2010b) elaborates on its key philosophies.In its Water and Climate Change Roadmap for introducing a program on water and climate change under the UNFCCC, the Water and Climate Coalition (2010 a) distills these thoughts into generally recommended approaches. In its discussion, the Coalition explains that participatory water governance and function IWRM are essential for building social, economic, and ecological resilience to climate change (Water and Climate Coalition 2010a & 2010b). IWRM is important for recognizing, planning for, and actively balancing needs, allocations, and consumption, taking into account changing land use.
IWRM should be aligned with NAPAs and regional efforts to sustain freshwater supplies and ecosystems.As with many existing basic water management practices and plans, allocations should be optimized (i.e., efficient use), users should be prioritized based on need, and regular monitoring, evaluation, and adjustment should be made.
As mentioned in the Coalition’s (2010a) key concepts, regional cooperation and collaboration is necessary to manage and adapt in addressing climate change impacts on transboundary supplies in the face of various laws and conventions.Such supplies are most effectively managed at a basin level (Aspen Institute, 2009), which may include dynamic, hydraulically interconnected basins strategies to help to alleviate the impacts of water change caused by changing climate.Such infrastructure has been used to harden water resources against climate change, as well as to incorporate sustainability and other numerous key criteria into decision making (Conner et al., 2009).
The Coalition (2010b) also distills the key points of mitigation and water.Bates et al. (2008) importantly points out that water adaptation and mitigation to climate change have a reciprocal relationship, in that the same efforts that are used to adapt water in the face of climate change, may be counter to mitigation of climate change, and vice versa.Options and benefits must be carefully considered and balanced in this context.Examples of this reciprocal relationship include:
Desalination to adapt to water scarcity and cost, which subsequently creates the mitigation challenges of greater energy and carbon footprints, especially if undertaken by a large number of countries.
Hydropower which aims to mitigate carbon footprints, while often relying on non-readily adaptable water resources in some ways, and environmental requirements and strategies.
Biofuels which aim to mitigate carbon footprints, but do not always necessarily incorporate energy efficiency strategies, and which are frequently water intensive.
In general, water purification and treatment facilities which are used to guard public and environmental health are enormously energy intensive and have high carbon footprints. In fact, water services (treatment, pumping, etc.) contribute about 4% of the global GHG emissions (Coalition, 2010a), which is on the same order of magnitude as air traffic.Additionally, they are often the largest energy consumers of municipalities and local governments (Coalition, 2010a), consuming 30-60% of a city’s energy bill through 2006 (Energy Information Administration, 2007 and United States Environmental Protection Agency EPA, 2008a), in the US equaling 3% of its national energy use among 60,000 water systems and 15,000 wastewater systems (Carlson et al, 2007). However, Carlson et al. (2007) and EPA (2008a) present some solutions to addressing high energy usage at treatment plants via benchmarking and energy reduction approaches and strategies.A breakdown of electricity use at treatment plants is provided in Fig. 5.
Breakdown of electricity use at treatment plants (Source:
Note that all of these reciprocal relationship examples may often require a high capital investment, and may require additional significant investment to become more dynamic and subsequently resilient against climate change, or at least provide energy to these water investments.
Now that relationship of water change to climate change, infrastructure importance, and infrastructure vulnerability and footprints has been established, a suggested framework is outlined in followingsections to examine how to specifically go about assessing, planning, and implementing infrastructure adaptation.
With the case established for the significance of adapting water infrastructure to climate change, utilities, water managers, regulators, designers, operators, and other stakeholders need a practical method for addressing it.A structured approach for managing such infrastructure is known as asset management.Asset management may be the best framework on which to support and enable climate adaptation risk management for infrastructure in a realistic and capable fashion. Cromwell et al. (2010) also supports this notion.
Understanding some important definitions are important for context and greater comprehension. New Zealand Asset Management Support (NAMS 2011) defines infrastructure assets as, “…stationary systems (or networks) that serve defined communities where the system as a whole is intended to be maintained indefinitely to a specified level of service by the continuing replacement and refurbishment of its components.” Assets also are defined as having a life of greater than one year (Urquhart et al., 2007).
In the context of discussion in this chapter, examples would include canals and pipelines, lakes and reservoirs, dams (may include hydropower), water purification facilities, water distribution networks, wastewater collection systems, wastewater treatment facilities, stormwater and other flood controls such as levees and combined sewer overflows, fisheries, and other such water infrastructure. NAMS (2011) also notes that the assets of infrastructure networks are interdependent, both within a particular asset network, as well as from one network to another (water supply and water purification), and across different types of infrastructure networks (i.e., water distribution and transportation).
Another important term is “asset management”. Asset management may be defined as, “the combination of management, financial, economic, engineering, and other practices applied to assets with the objective of providing the required level of service to customers and the environment at acceptable levels of risk and in the most efficient manner” (Urquhart et al., 2007). NAMS (2011) notes that “customers” should include the consideration of both present and future customers. In the context of this chapter, the set of assets under consideration is the water one noted in the discussion of defining infrastructure assets
The key elements of infrastructure asset management are (NAMS, 2011):
Utilizing a lifecycle approach
Developing cost-effective management strategies for the long-term
Providing a defined level of service and monitoring performance
Understanding and meeting the impact of growth through demand management and infrastructure investment
Managing risks associated with asset failures
Sustainable use of physical resources
Continuous improvement in asset management practices
Asset management is applied to (IPWEA, 2011):
Determine how to meet the increasing demand for new and upgraded infrastructure
Determine how to choose to prolong the life or renew existing infrastructure
How to pay for these
Asset management is a core component of effective utility management.It helps to mitigate potential risks and is often targeted towards addressing a major concern, such as regulatory compliance or critical asset failure (Baird, 2011).Such potential risk and failure could be associated with water change due to climate changes.
Other reasons for undertaking asset management efforts include aging infrastructure, more defensible budgets and utility rates in the face of limited funding, and workforce transitions (Parton et al., 2011), evidence of prudent leadership, transparency of sound financial management, protecting credit scores, gaining better interest rates for issuing debt, and helping to gain access to low-interest-rate loans and grants (Baird, 2011).These additional reasons tie directly into addressing climate change because they ultimately are important enablers for water infrastructure climate change adaptation.The benefits align well with the Aspen Institute’s (2009) recommendations for making water systems more sustainable.
The underlying benefits of asset management help to enable several important components for the adaptation of water infrastructure for climate change. Parton et al. (2011) notes that underlying benefits of quality asset management include more transparent and defensible budgeting, more efficient and effective knowledge transfer, improved performance management and reporting, better communication with staff and stakeholders, as well as improved customer responsiveness and service.
Additionally, quality business enhancements associated with asset management in an organization can lead to better understanding and communication of near term and long term system risks and capital needs and better efficiency in business and data management (MWH, 2009).Through achieving these benefits associated with asset management, and incorporating climate change within the asset management process, utilities will be able to better adapt their water infrastructure to climate change, making it more sustainable over the long term to serving the water supply and quality needs of its customers.
Recalling the water infrastructure investment needs mentioned earlier and considering the tremendous undertaking of adapting water infrastructure to climate change, society must look for opportunities in these challenges. One such opportunity is with respect to infrastructure in the U.S.Although sophisticated, robust, well-designed and well-constructed, infrastructure in the U.S. is generally in poor condition, and much of it is generally near the end of its design life.
Of particular concern to the discussion of this chapter, water infrastructure in U.S. has received a grade of “D” or below in the American Society of Civil Engineers’ Report Card on America’s Infrastructure (ASCE, 2009), which translates to a condition rated as “poor”, as noted in Table 1. Of the $2.2T in estimated infrastructure needs in the U.S. (breakdown shown in Table 2.), at least US$ 367B is needed for water infrastructure over five years (ASCE, 2009).The U.S. is not alone; other modern, developed countries are experiencing a similar challenge, such as Australia (Institute of Public Works Engineering Australia IPWEA, 2011).
Why are these ratings and costs important to take into consideration when examining approaches for adapting water infrastructure to climate change?These are important to consider because they present an opportunity; if this magnitude of infrastructure investment is needed, then this investment should be designed and managed in such a way that takes into account climate change and the ways in which water infrastructure can best be adapted within what is determined to be an acceptable level of risk.
Risk assessments, strategies and plans, and implementation and processes will need development and to be executed to successfully and sustainably enable this. The next sections delve into some of the approaches for delivering these in an effort to adapt water infrastructure to climate change.The first examines proven components of successful asset management.The second section, considers how to integrate climate adaptation planning for infrastructure into proven asset management approaches.
Aviation | D |
Bridges | C |
Dams | D |
Drinking Water | D- |
Energy | D+ |
Hazardous Waste | D |
Inland Waterways | D- |
Levees | D- |
Public Parks & Recreation | C- |
Rail | C- |
Roads | D- |
Schools | D |
Solid Waste | C+ |
Transit | D |
Wastewater | D- |
Note:Each category was evaluated on the basis of capacity, condition, funding, future need, operation and maintenance, public safety, and resilience | |
A = Exceptional, B = Good, C = Mediocre, D = Poor, F = Failing |
2009 Report Card for America’s Infrastructure (Adapted from:ASCE, 2009)
Estimated 5-year investment needs in the US in billions of dollars (USD) (Source:
Becoming familiar with a realistic, proven approach to managing such infrastructure is important to enable better understanding of how a framework for climate adaptation planning for water infrastructure may be structured, and the underlying foundation on which it must rely for many important components such as strategic direction, communication and buy-in, identified areas of improvement, useable data, and process implementation for execution and ongoing evaluation and revision.This section examines some key components for quality asset management.
Asset management planning can be envisioned in three major steps:service planning, asset management planning, and financial planning (Baird, 2011).Strategy must be developed based around business drivers, such as those mentioned earlier, and desired service levels of the assets, as well as an awareness of present strengths and weaknesses of the organization and its asset base.Service levels are “defined measures of performance or benefit as received by the community and environment.They usually relate to quality, quantity, reliability, responsiveness, environmental acceptability, and cost” (Urquhart et al., 2007).The State of Victoria Department of Treasury and Finance (Victoria, 1995) diagrams the myriad of considerations in effective asset management. An agency’s asset management program should encompass all of the activities illustrated in Fig. 6.
To account for and coordinate the implementation of these many complex components in a comprehensive and cohesive manner across a utility, more robust asset management endeavors are implemented via a programmatic approach for an organization.A programmatic approach can also help to enable asset management to be managed as an ongoing effort, revisited and revised as necessary, and communicated across a utility on a regular basis.Managing assets in a programmatic manner can help to best realize the benefits of asset management.(Parton et al., 2011)
Components of an effective asset management plan (Source:
Major objectives of quality asset management problems are for their analysis to look into the future, rather than the past to determine budget needs, and to be proactive.Being proactive is important to optimize a utility’s expenditure by determining the most appropriate time for refurbishment or replacement to maintain the levels of service at an acceptable level of risk and budget (Urquhart et al., 2007).These risk and budget components will need to evolve to take into consideration issues associated with changes in water due to climate change.Once the business drivers and service levels are defined for the asset set, then an assessment can be performed to identify the capabilities of the business processes of the organization and the capabilities of its assets. EPA (2008b) provides a general approach that is based on seeking the answers to “5 Core Questions of Asset Management Framework”:
What is the current state of my system’s assets?
What is my required sustainable level of service?
Which assets are critical to sustained performance?
What are my minimum life cycle costs?
What is my best long-term funding strategy?
The flow chart in Figure 7 shows the relationships and dependencies between each one of these core asset management questions (EPA,2008b).
Relationships and dependencies among the core framework questions (Source:
Asset management can evolve to more sophisticated analysis (Urquhart et al., 2007):
Condition-based
Performance-based
Service-based (service-driven)
Risk-based
Risk assessment is defined as “the process of identifying sources of hazards, estimating risk, and evaluating the results” (American Bureau of Shipping ABS, 2003).Note that “risk-based” asset management is regarded as the highest level of sophistication.This is important, as “risk” is defined as accounting for both condition- and criticality-based failure of assets (Association of Local Government Engineering New Zealand, Inc. INGENIUM, 2006). The condition analysis takes into account the likelihood that an asset would fail, based on the health, applied type of use, time in use, and typically-accepted life expectancy of that asset.These components can help to construct the declining functionality of an asset, as represented by the following curve in Figure 8 representing an asset’s probability of failure (“P-F”) over its lifespan:
Asset condition deterioration curve (Source:
The criticality analysis considers how crucial the asset is to meeting the business drivers and levels of service, as well as enabling its system and its components to also meet these.For instance, if the asset fails, what is the consequence to service, public safety and health, and how would it impact the rest of the system, integrated water resources infrastructure, or the environment if it were to fail?Combining these condition and criticality components helps to define risk for assets and numeric scales may be utilized to quantify this risk (ABS, 2003, INGENIUM, 2006, Urquhart, 2007). Risk can be expressed quantitatively as a measure of loss per unit time or presented qualitatively (ABS, 2003), as shown in Figure 9.
Components of risk which can be evaluated as a function of time (Source:
Risk is the product of condition deterioration and criticality (ABS, 2003, INGENIUM, 2006, Urquhart, 2007).This is expressed in Equation 1. as likelihood and criticality.
This product may be further evaluated based on detectability.“Detectability” indicates how easy or difficult the identification of a symptom of failure is, preferably before it occurs or before a process enabled by the asset is affected.Sydney Water Corporation (SWC) has applied detectability in its asset management practices (Urquhart et al., 2007).Incorporating climate change via water change impacts on infrastructure should be a component included in this risk analysis.This is addressed later in this chapter.
Asset data and asset systems have an important role in asset management, and when climate adaptation is overlain upon it.Data must be accurate and complete.Data systems must be useable, consistent, and up-to-date, and usually include computer maintenance management systems (CMMS) and geographical information management systems (GIS) in conjunction with an asset database at a minimum.Sound business processes must also be refined, integrated, and communicated across utilities striving for successful asset management programs.Life cycle management planning is important to maintain the value of the infrastructure asset investment and to sustainably operate it in a manner that meets service level expectations within the constraints of business drivers.
Additional approaches, details, and cases of asset management best practices are included within, ASCE (2008), Bloetscher et al. (2011), INGENIUM (2006), Urquhart et al. (2007), and other sources.
As noted earlier, the Water and Climate Coalition (2010b) stated that one of the key philosophies related to climate change adaptation and water is that “risk reduction strategies must be integrated with water resources management to address severe water events”.Now that an understanding of how successful asset management of water infrastructure is conducted has been achieved, this section examines how to fold-in climate adaptation planning on such an asset management platform to enable water infrastructure to be adapted to climate change.As Cromwell et al. (2010a) notes, asset management may be the best approach to climate adaptation risk management.
As mentioned earlier, climate vulnerability ratings of water infrastructure should be assigned during the risk analysis step of asset management.A framework is needed to facilitate the roll-in of climate change risk into this risk analysis.
Cromwell et al. (2010a) presents an approach for evaluating the vulnerability of water infrastructure. Additional studies also provide further specifics that complement this approach well.The approach is based on the typical risk management paradigm:
Risk identification – what constitutes a risk
Risk assessment – defining what risks exist, and to what degree information and data competencies are important
Risk management – deciding what to do about the risks at hand to achieve “low regrets” situations and implement a strategy forward for adaptation
The challenge of identifying climate change risks on infrastructure is broken into pieces, or “deconstructed”, for individual analysis and possible action.Deconstruction is initiated with the use of cause-effect climate change impact tree diagrams to provide a framework for understanding the full scope of the challenges at hand and to organize relative information.The tree diagrams represent four major “chains” of causation expected from the global warming scenario, including:
Sea level rise
Warmer and shorter winters
Warmer and drier summers
More intense rainfall events
An example of cause-effect tree diagrams for use in climate change risk evaluation:“Impacts and implications of warmer and shorter winters for wastewater agencies” (Source:
An example of the cause-effect tree diagrams is shown in Figure 11. A similar platform could be considered for additional scenarios of climate change. Tracing through the cause-effect logic of the trees shows how climate changes produced by the global warming scenario may result in impacts on hydrologic and environmental processes that may have implications for water infrastructure (Cromwell et al, 2010b).
Next, an assessment of the magnitude and timing of the various potential climate change impacts and subsequent implications should be performed to use in a risk assessment of the water infrastructure (includes both human-made infrastructure and natural assets such as lakes and streams, etc.).The IWRM (Integrated Water Resource Management) can help in this analysis.
As noted earlier, the Water and Climate Coalition (2010b) called out IWRM as a key philosophy of climate changed adaptation and water.Others agree as well (Bogardi et al., 1994, Kindler, 2000, Miller et al., 2005). IWRM can be the most effective method for assessing adaptation options for water infrastructure and their implications in the context of an evolving regulatory environment that inherently presents competing demands (Miller et al., 2005).
IWRM is defined as a systematic approach to planning and management that considers a range of supply-side and demand-side processes and actions, incorporates stakeholder participation in decision processes, and continually monitors and reviews water resource situations.It must simultaneously address the biophysical system and the socio-economic management system that both influence water management.The associated analysis relies on hydrologic models for physical processes and must account for the operation of hydraulic structures (i.e., dams and diversions) and institutional factors that govern the allocation of water between competing demands.(Miller et al., 2005).
In the face of the high amount of uncertainty presented by climate change on water infrastructure planning, important in the analysis of climate change implications on infrastructure is what is known as the “top-down” and “bottom-up” approaches (Miller et al., 2005), as summarized in Figure 11.
Bottom-up and top-down approaches to climate change assessment (Source:
The bottom-up approach relies on water system managers’ knowledge of their operations to assess the wide array of practical consequences of climate change, especially over the course of years or a couple of decades, that cannot be predicted by climate models.The typical climate models have analyses based on larger geographical and time horizons.The staff knowledge of water management organizations is used to consider the performance characteristics and tolerances of its water systems in extreme operating conditions.(Cromwell et al., 2010a).
This leads back into the specific methodology proposed by Cromwell et al. (2010a) for determining climate change risk to which water infrastructure is exposed, which also aligns well with the decision-making approach recommendations for water utilities in the U.S. as presented in Means et al. (2010).Once defined through the course of the rest of this approach, the risk component could then later be integrated into the risk analysis and subsequent planning components of a successful asset management program.The first fundamental question of assessing the risk of climate change on a water asset is now presented (Cromwell et al. (2010a):
Once the potential risks to assets have been defined in terms of a critical threshold, Cromwell et al. (2010a) presents the second guiding question:“What is the likelihood of seeing a threshold level of change in the combination of climatic, hydrologic, and environmental parameters that would constitute a significant challenge – an unacceptable failure risk – to existing or planned facilities and operations within capital planning or other meaningful time horizons?” The answerto this second question will need to consider climate change science to determine what climate changes and subsequent impacts and implications could exceed the thresholds defined in the first question, including the likelihood (remember the defining equation of risk) of occurrence and timing.Much of the best science, if it is even known for the particular issue, often encompasses such a high uncertainty, that the best scientific answers may be presented in the form of ranges.(Cromwell et al., 2010a)
With this high degree of uncertainty present, Cromwell et al. (2010a) emphasizes not to freeze planning decisions to await more refined scientific information, which will take much time to develop.This point is where the top-down approach depicted in Figure 10 comes into consideration.The top-down approach involves refining predictions of climate change, downscaling of climate models to apply them to local geographies and streamflow situations, and eventual IWRM planning (Miller et al., 2005).Some of this downscaling of models to local streamflows has progressed, including developing a transferable model of the process to expand applications (Bloetscher et al., 2010, Colorado Water Conservation Board CWCB, 2011, King County, 2007, and Means et al., 2010).
To address the high uncertainty associated with the timing and possible magnitude thresholds of climate impacts, Cromwell et al. (2010a) proposes a third questions to guide the analysis:“What is the overall adaptation strategy that leads to more sustainable infrastructure over the course of this century – the sustainable path?” This question can be broken down into two considerations for analysis:“How can the consequences of an anticipated threshold level of impact be avoided or mitigated through adaptive responses?”, and, “How are short term adaptation options different from longer term choices, and what is the strategic path that leads from one to the other?”Cromwell et al. (2010a) presents this third set of questions to help formulate adaptation decisions by distinguishing between the short term and long term responses to a climate change threat to give the progression of the decisions some traction.With the high degree of uncertainty inherent in such decisions, and pursuing low- or no-regret actions to adapt infrastructure to climate change, the key is to keep the selected strategies flexible. To keep them flexible, such decisions are often targeted with incremental, short-term solution.Very important, these incremental steps should keep options for the longer term open without restricting the ability to adapt the infrastructure in a way to respond to new revelations and changing conditions among climate, water, targeted service levels, and the regulatory environment. (Cromwell et al., 2010a).
In Figure 12, Cromwell et al. (2010a) depicts the framework of its components of the above overall suggested approach of this section in Figure 12. Its structure reveals how each of the climate change impacts identified in the cause-effect trees can be distilled into possible adaptation strategies via the methodology described above to keep water infrastructure on the “sustainable path”(Aspen Institute, 2009) in the face of climate change.
The impacts can be grouped into “threat bundles” to be evaluated as a package to asses which specific influences are likely to be the most critical to a water manager’s assets to consider adaptation options in a composite approach, rather than piecemeal (Cromwell et al. 2010b).These likelihoods, consequences, risks, and possible solutions can then be overlain with the same components in the asset management planning mentioned earlier to roll-up into overall strategies, budgets, communications, and organizational business for the water utility.
At the high level, Cromwell et al.’s structure may be massaged at this point into further detail and analysis to consider life safety, cost/benefits, and initial categories of action, including “must do”, “investigate further”, etc. as shown in Figure 12. Other criteria that can be incorporated at this point include commitment, regulations, readiness, catalysis, sustainability, complimenting opportunities, and other important considerations (DeGeorge et al., 2008).
Additional structural details for identifying and prioritizing adaptation (
As criteria and solutions continue to build in complexity, formal, proven decision making approaches and tools may be necessary to aid in analysis, prioritization, feasibility, transparency, communication, reconciliation, opportunity identificationand efficient and effective comparisons and breakdown analyses.An outline of how to apply such decision making is presented in Conner et al. (2009).
Additionally, the criteria and solutions enable important sustainability considerations such as:
Gray vs. green infrastructure
Low Impact Development (LID)
Sustainability visions and plans
Life Cycle Analysis (LCA)
Opportunity identification could include such strategies as (Conner et al., 2009):
Energy recovery
Enhanced water quality
Supply optimization (i.e. water rights) and reuse
Shared infrastructure/finance
Conservation
Environmental impact mitigation
Finding the sustainable path in adaptation planning (
While continuing to tie together suggested methodologies for adapting infrastructure in a cohesive manner in this chapter, Bloetscher et al. (2010) presents another subsequent step.Bloetscher et al. (2010) assesses vulnerable infrastructure for climate change impacts and presents specific strategies that could address the effects of climate change on that infrastructure. Once the adaptation options have been determined, Bloetscher et al. (2010) develops very specific strategies for addressing climate change impacts on the community on which their case focuses.
The community examined in the case is Pompano Beach, Florida, a coastal city which could encounter various effects of climate change on their water assets.The implications examined include those arising from the impacts of sea rise and more intense rainfall events, such as sea level rise, salt water intrusion, hydrodynamic barrier challenges, and programs involving new wells, reclaimed water, and aquifer recharge.The conclusions of the case align well with Cromwell et al. (2010),Water and Climate Coalition (2010b), and others that regional solutions will be needed and long-term water management should consist of vulnerability analysis, short- and long-term applicability of current practices.Additionally, a toolbox of technical and management solutions and a planning framework for increasing resilience and sustainability using adaptive management to deal with uncertainties was found to be necessary. Table 3. shows the specific implementation program of adaptation alternatives and supporting analysis that is considered when evaluating solutions and choosing the path forward for the community’s water infrastructure and vulnerabilities.
Bloetscher et al.’s (2010) implementation program of adaptation alternatives provides an example of how to structure the consideration, analysis, and action related to specific climate change implications on local water infrastructure.The researchers examined very specific strategies, barriers, costs, and strategy changes.These could be generally included in the “hybrid” classification of scenarios as mentioned as an adaptation alternative in Cromwell et al., 2010) for evaluating implications and action necessary for sea level rise.
Bloetscher et al. (2010) also provided a toolbox of general recommendations, largely in a coastal context, for protecting various water resources from climate change effects, as shown in Table 4.
Impact criteria and ratings can be defined, and weighting assigned to show the correlation the severity of climate change impacts and the importance of needed adaptation activities for infrastructure.This may be accomplished in a manner similar to the method presented by EPA (Johnston, 2010) for identifying the vulnerability of EPA Region 8 areas to climate change impacts. These impact rankings will help to create a ranking that can be used to prioritize adaptation activities.
For instance, a ranking of “1” would be the most severe or most threatening climate change impact to infrastructure.This would be the highest priority vulnerability to address, and its adaptation solution the highest priority adaptation activity to pursue.In many cases, this ranking would be determined as the climate change risk ranking of the product of likelihood and consequence.This can be rolled into the asset management risk scoring as an additional weight on the overall risk score.
Considering non-climatic drivers applicable to each of the applicable climate impacts and adaptation activities of concern is also important.Non-climatic drivers are, “external dynamics that have the potential to exacerbate climate change impacts”.In this sense,
Implementation program of adaptation alternatives (Source:Bloetscher et al., 2010)
Water Resource Issue | Tool |
Water Conservation | Reduce requirements for additional treatment capacity and for development of alternative water supplies |
Protect Existing Water Sources Against Saltwater Intrusion | Create hydrodynamic barriers:aquifer injection/infiltration trenches to counteract saltwater intrusion using treated wastewater |
Drill horizontal wells | |
Build salinity structures and locks to control advance of saltwater intrusion | |
Relocate well fields when saltwater intrusion or other threats render operations impractical | |
Develop Alternative Water Resources | Desalinate brackish waters |
Acquire regional alternative water supplies | |
Capture and store stormwater in reservoirs and impoundments | |
Wastewater Reclamation & Reuse | Irrigate to conserve water and recharge the aquifer |
Apply to industrial uses and cooling water | |
Implement indirect aquifer recharge for potable water | |
Stormwater management | Re-engineer canal systems, control structures, and pumping strategies |
Tools for protecting water resources from climate change (Adapted from: Bloetscher et al., 2010).
climate change activities should be developed and implemented using a holistic approach, rather than considered in isolation.Non-climatic drivers include:
Land use change
Population change
Failing infrastructure
Increased demand
Demographic shifts (rural to urban migrations)
CO2 effects on vegetation (Johnston, 2010)
As mentioned earlier, infrastructure asset systems can be inter-related and should be coordinated.The climate change risks and adaptation approaches should be considered in conjunction with climate water change risk as well, perhaps considering the risk and adaptation findings of approaches for other infrastructure systems.
One such approach is for transportation.The U.S. Federal Highway Administration has identified a useful approach for evaluating the vulnerability of the national highways to climate change, largely subsequent water change and risks (ICF, 2009).Such analysis and possible integration of climate change assessments on other such infrastructure will ultimately be useful in a more complete, efficient, and likely effective adaptation of infrastructure to climate change.Well-designed asset management approaches can help to coordinate and execute the coordinated climate adaptation of multiple infrastructure systems.
As may be concluded from the discussion within this chapter,a variety of considerations, drivers, constraints, stakeholders, and other issues will be considered in actionable adaptation decisions, strategies, and actions.Ideally, and hopefully with purposeful intent, the infrastructure adaptations should be made in as resilient, dynamic, intelligent, and sustainable manners as possible:
Resilient in the sense that the water infrastructure is modified, protected, or managed in a way that helps to serve its business drivers and levels of service commitments, while protecting and serving the health and welfare of society and the environment.Emergency management plans and contingency plans should be in place.
Dynamic as being enabled to adapt to changing climate, and subsequently, water conditions to the extent possible, and, otherwise, strategically managed in a regular, ongoing manner to incorporate new knowledge, new risks, and new actions.
Intelligent as in short-term steps are taken in the best interest of critical present vulnerabilities and in the best interest of the long term by not limiting the paths ahead that can be taken.Also, the management of the infrastructure includes new technologies and approaches to operating, maintaining, managing, and sustaining the infrastructure.Tools include strategic metrics and key performance indicators, real time monitoring technology, reporting performance dashboards, and other “smart” technology.The organization(s) managing the infrastructure must also have a solid foundation to enable this intelligence including a well-defined strategic direction, communication, and alignment; strong organizational capabilities and processes; and quality, applicable, accessible and well-managed data.This also includes regional collaboration and knowledge sharing.
Sustainable in the sense of balancing the triple bottom line across the interests of society, the environment, and financial enablers and feasibilities.This includes sustainable infrastructure design, life cycle assessment, life cycle management planning to maintain asset value while operating it to meet service levels, mitigating negative impacts of the infrastructure on society, natural resources and surroundings, and closing the loop of resource use to reduce waste streams and unneeded resource consumption (Conner et al., 2009).
As mentioned earlier, much of the infrastructure in developed countries has reached the end of its designed life.The time has come to significantly refurbish, or often, replace this infrastructure (ASCE, 2009).This presents an enormous opportunity to green significant amounts of infrastructure that will serve society for decades to come, often 50 years or more.Examples of some general green infrastructure opportunities and strategies are included from Conner et al. (2009) in the previous section of this chapter.Additional approaches may be found at the Institute for Sustainable Infrastructure (ISI, 2011) and WERF (2011).
Standards provide a framework for greening infrastructure in a sustainable manner.For instance, ASCE, the American Council of Engineering Companies (ACEC), and the American Public Works Association launched a new standards organization and rating system for sustainable infrastructure (ASCE, 2011).ISI’s (2011) rating system for sustainable infrastructure aims to be:
Performance-based (outcomes) rather than prescriptive
Scalable for size and complexity of projects
Adaptable for specific needs and circumstances
Conducive to self-assessment, as well as independent verification
Voluntary
The demand for water resources will also have to be managed.Two main channels exist to accomplish this (Miller et al., 2005):
Improve water efficiency – for instance, through price incentives, water transfers, technology improvements, regulations, and reduction of system water loss.
Effective reallocation of saved water – this could often require regional collaboration and infrastructure and management mechanisms in place for the future.
As discussed in this chapter, water is a significant enabler of economic prosperity and well-being. Water infrastructure is the medium that enables this.This infrastructure faces numerous threats and uncertainty from climate change, which directly leads to water change and subsequent needs to adapt this infrastructure in the face of a myriad of existing drivers, constraints, and expectations of water infrastructure.
A framework is needed to identify, assess, strategize, plan, and act on the risks that this infrastructure faces due to climate change.This chapter has shown how climate adaptation planning and prioritization may be incorporated as a component of risk in what has been identified as a sound, successful, and actionable risk-based asset management program.The chapter has aimed to connect the dots among related best practices in infrastructure climate adaptation assessment, planning, and implementation in a robust, yet flexible manner for the long term.
Additional efforts and knowledge need to be pursued to better define specific climate change impacts on local water and its infrastructure to reduce the level of uncertainty.This information should be shared and leveraged in a collaborative manner through Integrated Water Resources Management, and on a watershed, rather than political, basis when considering water supplies.
Also, ripple effects will be felt throughout associated sectors that are important to infrastructure.These include the banking, insurance, business policy (i.e., U.S. Securities and Exchange climate change disclosure risk requirements, corporate social responsibility, etc.), and industrial sectors.
Very importantly, to successfully enable and implement this adaptation, organizations that manage water and its infrastructure must develop the readiness to address climate change vulnerability and provide strategy for ongoing monitoring with needed adjustments.The organization must develop both the capacity and the capability to adapt its infrastructure, for which sound leadership, knowledge management and transfer, tools, internal and external communication, and possible change management will be needed.
Although endoscopy can be traced back to ancient Greece, the Lichtleiter invented by Bozzini in 1805, is one of the earliest descriptions of endoscopy and established the basis of current endoscopy [1]. Further developments include the development of flexible endoscopes. However, endoscopy did not become widespread until the invention of the fiber optic endoscope in the 1960s [2]. Endoscopic ultrasound (EUS) was developed in 1980 and constituted another innovatory development of endoscopy [3].
Initially a purely diagnostic procedure, gastrointestinal (GI) endoscopy has evolved to become a therapeutic resource for multiple pathologic conditions, utilizing many of the techniques, tools and materials successfully employed in conventional surgery. A current advancement is natural orifice transluminal endoscopic surgery (NOTES) or incisionless surgery. First described in 2004, it uses endoscopic equipment to perform surgical procedures using natural orifices to access the peritoneal cavity, also known as “second space”. However, safe closure of the point of entry has been a concern. More recently, another concept developed in 2007 and known as “third space” or submucosal endoscopy, has allowed access to the submucosal or intramural space, creating a mucosal safety valve, addressing one of the concerns of NOTES [2, 4].
Endoscopic surgery demands knowledge, skills and judgment that spans both surgery and gastroenterology training. It requires good knowledge of the pathophysiology of the diseases, exceptional endoscopic skills, an in-depth understanding of the anatomy, as well as the ability to manage the potential adverse events associated with the procedure. The standardization of technique has allowed to reduce the complexity associated with these procedures, currently being performed mostly in endoscopy suites, usually with less cost and less hospital stay [4].
With the widespread use of anticoagulation and antiplatelet medication, GI bleeding has become a common condition seen among gastroenterologists, and achieving effective hemostasis is paramount to successful treatment. In GI bleeding, the combination of two hemostatic modalities has demonstrated superiority over single therapy. Furthermore, failed control of bleeding during the index endoscopic procedure or re-bleeding after successful hemostasis, significantly increases the risk of mortality, emphasizing the importance in strategies to decrease this risk [5, 6].
Endoscopy has completely changed the approach to GI bleeding and has replaced surgery as the main modality of treatment. Hemostasis also constitutes one of the Halstedian principles of surgery and these principles can be extrapolated to endoscopic surgery [7].
Under normal circumstances the hemostatic process is always active and happens naturally as an interrelation between vessel contraction, platelets and coagulation factors. Hemostasis can be divided into four stages: initiation, amplification, clot formation, consolidation and dissolution, and each stage is a prospective site for a therapeutic intervention to facilitate hemostasis. Hemostasis is initiated by vessel damage, triggered by tissue factor and collagen exposure at the site of injury. The amplification process is oriented to generate thrombin through various steps. Thrombin plays a central role in the clot formation stage by promoting the conversion of fibrinogen to fibrin, which then creates a polymer that recruits platelets to form a stable clot and seal the site of vessel injury. Once the clot is formed, additional fibrin cross-linking is stimulated by factor XIIIa in order to consolidate the clot. Simultaneous to consolidation, the process of dissolution is started by a separate but interconnected system, with the conversion of plasminogen to plasmin, causing the degradation of fibrin into smaller fragments (Figure 1) [8, 9].
Biomaterials and their effects on hemostasis.
Wound healing is regulated by the interplay of cellular, humoral and molecular processes and begins after tissue damage, at the same time that the coagulation cascade is initiated. There are three phases of wound healing:
Inflammatory phase in which cytokines recruit pro-inflammatory cells.
Proliferative phase whereby fibroblasts create bands of connective tissue rich in collagen.
Remodeling phase, which can last for many years, and consists of the granulation tissue transforming into vigorous scar tissue [10].
Additional methods are used to expedite the process of hemostasis and achieve a stable coagulum. In a broad sense, these methods fall into three categories: thermal, mechanical or chemical [6]. Thermocoagulation coupled with irrigation and aspiration has been adapted successfully to endoscopic devices. Mechanical hemostasis in endoscopy is usually performed by using through the scope or over the scope clips, as well as detachable loops. Chemical hemostasis can be obtained from biomaterial, which are synthetic or natural substances that interact with the body, to replace tissues or augment its functions such as hemostasis and wound healing [6, 11, 12]. Biologically active materials such as thrombin and fibrin or absorbable products such as gelatins, collagen and oxidized cellulose have been used. Synthetic products and inorganic powder have also been employed in endoscopy. Besides the effects on the hemostatic process, many of these substances can have a positive or negative effect in the wound healing process [10].
Although the options for biomaterials have expanded over the last decades, the use of biomaterials to achieve chemical hemostasis has not been as widespread in endoscopy as in conventional surgery. One of the reasons is the restriction of delivering the biomaterial through the endoscope, and although most of the available options can be administered using through-the-scope injection or spraying catheters, other materials require to be grasped with endoscopic forceps and carried along the endoscope, to be delivered into the gut lumen [13, 14, 15, 16, 17]. The endoscopes are expensive medical equipment and endoscope damage is a genuine concern, especially with the use of acrylate polymers. It is recommended to flush the catheter immediately after acrylate use to prevent crystallization of the glue in the delivery needle. Dilution of the acrylate with lipiodol is also recommended to prevent potential clogging of the endoscopic channel [11, 18].
Thrombin is an enzyme with significant roles in hemostasis, inflammation and cell signaling. It has been used since the 1940s and can be obtained from bovine, pooled human plasma and recombinant sources. It has been used routinely since the 1980s for hemostasis due to its effectiveness and ease of use [19].
Thrombin is commercially available alone and in combination with other substances, usually delivered through endoscopic needles. The injection of any agent will likely have a mechanical effect during hemostasis by compressing the bleeding vessel, also known as tamponade effect. The main effect, however, is through a complex process that releases peptides from the alpha and beta chains from fibrinogen, which in turn polymerize by hydrogen bonding in a lateral and end-to-end fashion into an unstable fibrin clot. Further stabilization occurs by covalent cross-links promoted by factor XIIIa which promotes platelet aggregation and seals the bleeding [20, 21]. Thrombin can also induce vasoconstriction and chemotaxis of neutrophils and fibroblasts as well as the production of vascular endothelial growth factor [22]. Typically, thrombin is used in combination with other drugs such as epinephrine for vasoconstriction which has demonstrated to be superior to epinephrine alone. A study was performed in 140 patients presenting with severe GI bleeding from peptic ulcers to compare epinephrine to epinephrine plus thrombin. The combination of epinephrine plus thrombin obtained permanent hemostasis more often than epinephrine alone with decreased blood transfusion requirements and significant reduction in mortality [23]. However, a similar study was performed in 64 patients which did not show any benefits from thrombin, although the dose of thrombin in this study was significantly less than the first study (150–300 IU vs. 600–1000 IU) [24]. Other studies have used a mixture of epinephrine and thrombin sprayed into the ulcer bed; however, this approach did not show any benefits [23]. The use of thrombin has also been reported in the treatment of gastric varices since 1947 [25]. Although variceal band ligation treatment is effective for bleeding from esophageal varices, the use of banding for gastric varices is limited. Gastric varices are present in 15 to 100% of patients with esophageal varices, and although less prone to bleeding, when bleeding does occur, it is often more severe with high rebleeding rates and is more challenging to achieve effective hemostasis. Currently the main modality of treatment for gastric varices is acrylate injection, however its use it typically limited to highly specialized centers given its increased risk of systemic embolization and difficulty in administration and the potential to cause damage to the endoscope. Direct injection of thrombin is another method that has been explored for the treatment of varices. This agent is most commonly delivered through endoscopic needles. Multiple series have documented its safety and efficacy achieving hemostasis in almost all patients, although no randomized trials have compared it to the other treatment modalities available [25, 26, 27]. Advances in EUS have allowed successful EUS guided thrombin injection, with theoretical less risk of systemic embolization since the feeding vessel can be identified under visualization, requiring less amounts of thrombin than direct injection with regular endoscopy [28].
Due to its biologic nature, thrombin can be highly immunogenic and allergic reactions and autoimmune phenomena have been reported, especially with the bovine derived thrombin. Recombinant thrombin is less immunogenic than bovine and human, but there is still a possibility of cross-reaction if a patient has had previous exposure to the other types of thrombin with resultant antibody formation [20, 22]. In regards to human thrombin, it is isolated from pooled plasma donors and there is always concern for transmission of blood-borne pathogens such as HIV and viral hepatitis as well as the theoretical risk of prion disease [29]. The use of thrombin has been associated with coagulopathy and abnormal laboratory results such as prothrombin time and partial thromboplastin time [19, 27]. The development of autoantibodies against factor V may precipitate paradoxical bleeding after thrombin injection [30, 31]. With the injection of thrombin directly into a vessel, it clots the fibrinogen of blood immediately and there is concern for distant embolization, however its use appears to be safe based on small studies [29].
Currently US and European guidelines recommend acrylate injection as the initial modality of treatment for bleeding gastric varices and do not include thrombin [32, 33]. However, thrombin alone as well as in combination with gelatin matrices, has demonstrated to be effective, safe and easy to administer, contrary to sclerosing agents and acrylate. With thrombin, there is no risk of secondary bleeding from post injection ulceration, and constitutes a true alternative to acrylate [26, 28].
Fibrin sealant has been widely used as a tissue adhesive for non-suture closure of lesions, mimicking the last steps of the coagulation cascade where fibrinogen is converted to fibrin.
Fibrinogen is the main component in fibrin sealants and is a dimer with identical units formed by three polypeptide chains (α, β and γ) [34]. Thrombin is the only coagulation factor that can cleave fibrinogen into fibrin which then assemble into fibrils that will form a three-dimensional network. This network is further stabilized by factor XIIIa by initiating new peptide unions known as gamma-gamma dimmers to form the alpha-polymers, a process assisted by the presence of calcium. Factor XIIIa also induces crosslinking of plasmin inhibitors to protect the clot from fibrinolysis by plasmin. Once the fibrin net is formed, it attracts cells and functions as a scaffold to stimulate granulation tissue and facilitate wound healing. Fibrin also has high affinity to collagen and cell surface receptors such as integrins, which facilitate adherence to wound surfaces [21, 30, 34, 35].
The composition of multiple presentations of fibrin available in the market is variable and neither the concentration or purity of the components is uniform. Usually the product is available as a two-component kit consisting of separate fibrinogen and thrombin which acts as an activator of fibrin. Calcium is always combined with one of the components. Factor XIII, a clot stabilizer, and aprotinin or tranexamic acid acting as fibrinolysis inhibitors, are also included in the fibrinogen containing mixture. The significant variation in components of these available products affects their qualities such as viscosity, adherence force of the clot, mechanical strength, speed of clotting and resistance to proteolysis [21, 34, 36, 37].
Fibrin has been used extensively across an extensive range of surgical procedures, providing bleeding control, suture support and sealing. It has been available in Europe and Japan since the 1970s, but did not receive regulatory approval in the United States until 1998, still however, its use is not widespread in endoscopic procedures [37, 38, 39]. Most of the initial reports of the use of fibrin sealant were in the treatment of upper GI bleeding from peptic ulcer disease, delivered using injection needles in a similar fashion as thrombin. Although the studies showed conflicting data in terms of benefits, fibrin was not shown to be superior to epinephrine injection alone [38, 40, 41]. Intravariceal injection of fibrin has also been reported for bleeding gastric varices showing efficacy to control bleeding with low risk of rebleeding [42].
Postoperative fistulas are secondary to a broad range of factors and are relatively common complications after surgery. While most fistulas respond to conservative management, healing is unlikely after 6 weeks and persistent fistulas are associated with increased morbidity and mortality from malnourishment and septic complications. Endoscopy has been used in the treatment of persistent enterocutaneous fistulas as an alternative to surgery. Fibrin application coupled with debridement of the epithelized fistulous tract and ablation of the mucosa at the internal opening has been used successfully for endoscopic sealing of the fistulous tract. Fistula occlusion intends to halt further passage of secretions, but also fibrin may have a role in stimulating wound healing by promoting fibroblast proliferation and formation of new blood vessels. Nonetheless, the studied populations are quite heterogeneous and the reported success has wide variability from 36–100% [39, 43, 44, 45, 46, 47, 48]. The same technique has been used for the closure of gastrocutaneous fistulas that failed to close after gastrostomy tube removal [49].
With third space endoscopy, large amounts of tissue can be resected en-bloc using electrosurgical knives. However, bleeding and/or perforation are serious adverse event, especially in patients with resection size larger than 4 cm or taking antiplatelet or anticoagulants [16, 50]. When perforation results after ESD, the endoscopic options include endoscopic clips or suturing. The utility of clips is of limited use when dealing with large tissue defects. While suturing can close large defects, its use may be disadvantageous when the tissue is friable or the layers are thin such as in the duodenum. A new method of “tissue shielding” has been described to treat large ulcers or perforations induced by endoscopic submucosal dissection (ESD), with this technique sheets of polyglycolic acid are applied to the ESD area and then the sheet is coated with fibrin sealant. This method has demonstrated in retrospective studies, to be effective as well as simple and safe, even in patients under continued use of antiplatelets or anticoagulants, avoiding the morbidity of an emergency surgery [51, 52, 53, 54, 55, 56]. The use of this technique has also demonstrated decreased risk for delayed complications such as stricture, since the defect is covered rather than closed, with results comparable or even better than with the use of systemic or intralesional injection of steroids, without the side effects associated to the use of steroids [13, 57, 58]. On the other hand, a prospective randomized study, did not show any benefit in the prevention of bleeding from the use of polyglycolic acid sheet and fibrin sealant after ESD in the stomach, in patients with high risk for bleeding [50].
A fibrin sealant spray alone has also been used during ESD for early gastric cancer, this modality of treatment was compared to standard thermal and mechanical hemostasis and showed less bleeding and earlier wound healing in the fibrin group, since micro vessels were less affected in the fibrin sealant group due to limited use of thermal coagulation [59, 60].
Coagulopathy secondary to thrombin, which is included in the fibrin sealant has been widely documented. Aprotinin may also be present in some versions of fibrin sealants and since it is obtained from a bovine source, it includes the risk of anaphylaxis. Although aprotinin may be valuable when fibrinolysis is high, it is not considered an absolute requirement for the success of the sealant and aprotinin free versions eliminate that risk [37]. Commercially available fibrin is obtained from multidonor blood products and HIV transmission after the use of fibrin has been reported in the past and the risk for other blood borne infections is also a theoretical risk. Presently, the available sealants in the market are virally inactivated and this risk is practically inexistent [21].
Fibrin sealant is a versatile product that has multiple properties useful not only for hemostasis but also to promote wound healing, and currently is probably being underused and oftentimes misused. The ability to recreate the last stage of the coagulation mechanism allows its use as a lifesaving treatment in patients with coagulopathies. However, its use should not be limited to those patients and its use has been described more frequently during endoscopic procedures [21]. Heterologous fibrin sealants which will decrease costs and risk of blood related infections are currently under development [36].
Gelatin is a hemostatic agent made from hydrolyzed and purified animal collagen (swine, sheep or equine dermis or tendon). Its use in hemostasis was first reported by Correll in 1945 [61]. Capable of absorbing up to 45 times its weight of whole blood, it has become commonplace in surgery for hemostatic intervention [62]. Since its introduction, few advances in its composition have been made and is available in sponge, powder and solution forms. It has also been used in conjunction with other products that aid in hemostasis such as thrombin and tranexamic acid. Although its mechanism of action is not fully known, it is believed to act more physically than chemically, however it has been theorized that the clotting effect of gelatin sponge may be due to the release of thromboplastin from damaged platelets while coming into contact with the walls of the sponge upon entering, which then interacts with prothrombin and calcium, producing thrombin and initiating the clotting cascade [63].
It is currently indicated as a hemostatic device in surgical interventions, when control of capillary, venous, and arteriolar bleeding is not possible by conventional procedures. It has also been a basic embolic material particularly used in interventional radiology (IR) for various disease entities such as hypervascular tumors, bleeding, and preoperative embolization, showing to be quite effective. However, experience in the field of GI endoscopy is limited. In fact, most experience comes in the form of case reports. One case series describes successful EUS-guided coil injection in combination with hemostatic absorbable gelatin sponge for treatment of bleeding gastric varices [64]. In another case, IR embolization failed to achieve hemostasis in a patient with hemorrhagic shock due to an arterial hemorrhage at an oversewn bile duct stump after liver transplantation, and a gelatin slurry was applied into the bile duct stump during endoscopic retrograde cholangiopancreatography, achieving control of the bleeding [65].
Hemostatic gel matrices have been used as hemostatic agents during surgery that requires atraumatic hemostasis due to its safety and ease of use. They are composed of a flowable gelatin matrix of either bovine or swine origin and thrombin. The fluidity of the matrix offers the benefit of adapting to the shape of the wound site allowing full tissue contact. While the matrix promotes passive hemostasis from mechanical compression and platelet aggregation, the addition of thrombin will promote the coagulation process by the mechanism discussed previously, and these agents combined may also facilitate the healing process [66, 67, 68]. Since these hemostatic agents require platelet aggregation, their use is not recommended in patients with thrombocytopenia. However, they have demonstrated efficacy even in patients with recent use of antiplatelet agents or anticoagulation. Matrices provide hemostasis in about 5 minutes and are usually absorbed from 4 to 8 weeks [68].
Like gelatins, the use of hemostatic matrices in endoscopy has been limited. Its use was extrapolated from IR procedures for varices such as coil-assisted retrograde transvenous obliteration. The reported use of matrices is mainly as adjuvant therapy with coiling during EUS guided embolization of gastric varices. The potential benefits of this absorbable material are the lack of post injection ulceration that has been associated with acrylate injection as well as the ease of administration [69, 70]. Small series have compared both modalities of treatment showing high technical and clinical success with no rebleeding after 9 months with the use of coils/hemostatic matrix, compared to rebleeding in 38% of patients in the acrylate group. There was also a decrease in the transfusion requirements and adverse events after the use of the coils/hemostatic matrix [64, 69, 70]. No intraprocedural complications were reported with the coils/hemostatic matrix, and the only minor adverse events of abdominal pain were likely related to the procedure itself [70].
One of the constraints of the fluidity of the hemostatic matrices is the need to keep the matrix in direct contact with the bleeding surface until hemostasis is achieved. Recently another concept of hemostatic matrix delivery has been reported in animals, accomplished with the use of a special applicator consisting of a nitinol mesh coated with plastic. The applicator has angular variation up to 45 degrees that allows to keep the matrix in the desired place until achieving clot formation [71].
Although uncommon, allergic reaction to gelatins has been reported [72].
The reported adverse effects are dependent on the location and purpose of its use and include: infection, abscess formation, granuloma and compression of adjacent structures when used in a closed space [73]. Organ infarction has been reported when used for embolization [74].
While the use of gelatin in hemostasis goes back to the mid 20th century, its application has certainly evolved and gained attention in the different fields of medicine, particularly surgery and intervention radiology. While there are promising case reports in the GI endoscopic literature, further studies are needed to see if this is an effective and viable option for endoscopic hemostasis.
Oxidized cellulose (OC) has been used clinically as a hemostatic agent since the 1940s [75, 76]. Cellulose is a polysaccharide of glucopyranose united by β-glucosidic bonds. It can be produced by two methods: using a regenerated process that forms organized fibers; and a non-regenerated process where fibers remain unorganized. Its synthesis involves multiple steps and the final product is oxidized to make it absorbable by the tissues, this process also gives its low pH to cellulose and is responsible for its hemostatic and bactericidal properties. The low pH of the physical matrix promotes platelet aggregation to form a blood clot, and the acid milieu generated by the carboxylic group cannot be survived by many gram-positive and gram-negative bacteria, including antibiotic resistant strains [76, 77]. However, this feature may be disadvantageous since the acidity makes OC cytotoxic, with detrimental effects on erythrocytes causing some hemolysis and affecting wound healing, since acidity prevents the proliferation of fibroblast and halts the contraction of the extracellular matrix. OC also has the ability to absorb fluids and can have a tamponade effect during hemostasis [75, 76, 77, 78]. Although non-regenerated OC may have superior hemostatic performance, the main difference between regenerated and non-regenerated OC lies in the way they are absorbed. Regenerated OC degradation starts within 18 hours of implantation via β-elimination by glycosidases and is fully absorbed in 7–14 days, while non-regenerated OC requires phagocytosis and then hydrolysis by macrophages through a longer process [10, 76, 78].
OC is used when conventional hemostasis is not effective or practical and is the chemical hemostatic agent most commonly used worldwide because it is cost-effective, easy to use, atraumatic, biocompatible, absorbable and bactericidal [10, 75, 76].
Simultaneous administration of organic hemostatics such as thrombin and/or fibrin to enhance the hemostatic properties of cellulose is purposeless since the low pH denatures the proteins and they become ineffective [76].
The use of OC in the treatment of active GI bleeding from ulcers and angiodysplasia has been reported in the literature [79, 80].
The concept of “tissue shielding” reported with the use of thrombin and a sheet of polyglycolic acid has been used with OC in animal models and recently in humans. With this technique, a fragment of hemostatic is placed over the mucosal defect to prevent bleeding after ESD has been carried out [81, 82].
Cellulose requires dry application, although a new modality of delivery has been described recently during bleeding prevention following ESD, where OC is delivered via endoscopic spraying after being mixed with saline in a syringe [15, 83].
Although the acidity associated with the oxidized cellulose has antibacterial properties, it should be used with caution in an infected wound since the presence of a foreign body may increase the predisposition to infection or formation of granulomas [36, 73]. However, infection is probably less of a concern in the GI tract since it is not a sterile space. Due to its low pH, oxidized cellulose can either provoke a strong inflammatory reaction or delay wound healing by decreasing the number of fibroblasts, and it is recommended to remove any excess product once hemostasis is achieved [73]. There are documented reports of migration of oxidized cellulose through suture lines provoking fistulation [84].
Although many of the properties of oxidized cellulose make it an attractive hemostatic product. Its use in GI endoscopy is limited to few case reports, mainly because of the constraint of delivering the product through the endoscope. And although the hemostatic effect of OC is better when applied dry, the reported use of OC by spraying has demonstrated good results and may increase its use during GI procedures.
Collagen is a three-polypeptide chain (α-chains) characterized by the presence of one or more triple-helical domains and serves as a structural scaffold in tissue because of its stiff structure which is essential for tissue integrity. It plays an important role in hemostasis during injury, via interaction with Von Willebrand factor, integrins and clotting factors. Collagen is in the matrix underlying vascular endothelial cells. An injury will result in exposure of blood flow to subendothelial structures that contain a high percentage of collagen which results in activation of platelets and the intrinsic coagulation pathway. Platelets bind to collagen via glycoprotein receptors, inducing a negative charged lipid to become exposed to the platelet membrane, exposing procoagulant phospholipids, leading to the change of shape reaction, triggering irreversible platelet aggregation and thrombosis. Various studies have also demonstrated administration of collagen could aid in wound healing by activation of inflammatory cells and increased vascularization of injured tissue [35, 85].
In the US, collagen-based products are being used in surgical hemostasis since the 1970s [86]. Hydrolyzed collagen is available as a viscous, amber aqueous solution or most commonly used as white hygroscopic powder. It is commercially prepared from many sources but mainly from bovine or porcine sources. Sponges incorporating collagen are manufactured by several companies to achieve hemostasis for surgical procedures, however, there is limited literature regarding the use of collagen for hemostasis during endoscopic procedures. Several case reports and small case series have demonstrated successful management of GI bleeding with use of collagen spray. A prospective study of 18 patients demonstrated collagen spray is safe and an effective hemostatic agent in treating peptic ulcers with Forrest classification category 1a and 1b. The collagen spray was used for patients that failed conventional therapy due to poor visualization or persistent bleeding after application of therapy. The collagen spray kit consists of an air pump, probe, a 7.5 Fr spray catheter, and a pre-loaded collagen cartridge containing five grams of powder. The spray catheter was passed through the working channel of the endoscope. One gram of collagen powder was delivered at a time over 10s, with the distal end of the catheter 2 to 3 cm from the lesion with maximum of 2 gram for the bleeding site. Endoscopy in this study was repeated after 24 to 48 hours, confirming treatment success [14].
Collagen injection has also been used in the treatment of a radiation induced broncho-esophageal fistula, injection in the submucosa around the fistula was performed using a standard endoscopic needle achieving closure of the fistula [87].
Limited studies exist for GI bleeding, but extensive experience and literature is available in the field of surgery. There are no major side effects reported and potential allergic reaction is possible since most formulations are derived from bovine or porcine source.
There is extensive surgical literature to support use of collagen-based products for hemostasis. Collagen spray has been successful in treating GI bleeding secondary to peptic ulcer disease, but larger studies are required to investigate this further, and also to see if its application would be beneficial in other sources of GI bleeding.
Acrylate is a liquid monomer that can rapidly polymerize when in contact with an ionic medium like water, blood or tissue proteins. The polymer forms a strong adhesive bond to tissues with sealing properties, satisfying the definition of biomaterial. Because of the rapid polymerization, it can be combined with an ethiodized oil like Lipiodol. This combination has the advantage of prolonging the polymerization time, controlling the speed of solidification, reducing the risk of embolization and opacifying the liquid, which allows it to be radio-opaque under fluoroscopy. However, injection of undiluted cyanoacrylate is also performed [11, 88].
Acrylate has been widely used for bleeding gastric varices and is the first line treatment for bleeding fundal varices, achieving hemostasis in more than 90% of the cases.
Studies have also demonstrated the efficacy of acrylate achieving hemostasis in refractory non-variceal GI bleed, usually after trying epinephrine injection, cauterization and/or endoscopic clips, prior to IR or surgical interventions [89, 90, 91]. Its usefulness has been demonstrated in peptic ulcer bleeding refractory to conventional hemostatic measures and also in the treatment of rectal ulcers. It has also been able to achieve hemostasis for Dieulafoy’s lesion that failed hemostasis with epinephrine and bipolar cautery. Acrylate is an effective mode of treatment for bleeding ectopic varices, especially those located in the antrum as well as the duodenum, and has also demonstrated efficacy in controlling bleeding from oozing gastric vascular ectasia after argon plasma coagulation and endoscopic clips have failed. Furthermore, it has shown favorable outcomes in bleeding from tumor invasion into the intestinal wall.
Injections of acrylate are delivered endoscopically using a standard forward viewing video-endoscope via injection catheters. A 1:1 ratio of acrylate is mixed with Lipiodol and this is injected as a bolus. The tip of the endoscope and the accessory channel can be treated with silicone oil to prevent endoscopic damage, other studies have used Teflon catheters. Some studies also suggest that spraying acrylate directly over the bleeding point might be better than injection [11, 18]. A standardized injection technique was developed for the use of acrylate, performed using a Luer lock injection needle catheter. To minimize the risk of systemic embolization, it is recommended that not more than 1 mL of the acrylate/Lipiodol solution be injected into the tissue each time, multiple injections can be used but the maximum volume of each injection should be 1 mL. The dead space volume of the needle catheter should be measured and the needle should not be primed with glue before injection. A ‘sandwich’ technique has been described where the injecting catheter is primed with Lipiodol and Lipiodol-acrylate-Lipiodol solution is injected [92]. After injecting the glue, a second injection of distilled water is recommended, the volume of which should be the dead space volume of the needle catheter. This is done to deliver the entire glue from the catheter. When used for varices, the varix must then be probed to ensure obliteration. If the varix remains soft, another injection of 1 mL must be given [93]. Coils delivered with EUS assistance can also be used along with acrylate to provide a structure for localized acrylate polymerization [70].
After injection, the vessel plug formed by the polymer of acrylate will be expelled from the varix as early as one week and up to a year after the procedure and rebleeding may occur [11]. Although rarely reported, the needle can get trapped in the varix due to rapid polymerization of the acrylate with inability to withdrawn the needle from the varix and/or unroofing of the varix [70]. One of the major complications of acrylate polymers is systemic embolization. Although rare, this can be potentially lethal. It is most commonly seen when acrylate is used for the treatment of isolated gastric varices type 1 [94].
Systemic embolization can lead to portal and splenic vein thrombosis, pulmonary embolism and splenic infarction. Transient bacteremia was noted in clinical studies especially in patients with advanced liver disease. Recurrent sepsis is rare but has been reported. In patients with a patent foramen ovale, systemic embolization can lead to stroke. This can be prevented by injecting no more than 1 mL of the acrylate/Lipiodol solution. Duodenal ulcer perforation has also been described after using acrylate to control bleeding duodenal ulcers [36, 41]. Necrosis of the vessel wall with perivascular inflammation has also been described and is supposed to be related to a foreign body reaction [11].
Acrylate has multiple properties that make it an efficient hemostatic agent. It is a relatively safe and easy to use agent, already established as first line treatment for gastric varices and has also demonstrated efficacy in non-variceal bleeds that are refractory to conventional methods. It can be considered prior to IR or surgical intervention for refractory GI bleeding using the above technique, especially in patients who would be poor surgical candidates. Given its inexpensive cost and ease of use, it can be considered as a second line hemostatic agent for non-variceal GI bleeding that is refractory to conventional methods.
For years, inert mineral powders have been used by military medical personnel for achieving hemostasis in the field [95]. A proprietary mineral powder based on Bentonite clay has been developed and works in two different ways: as a mechanical barrier and by absorption. When in contact with the bleeding site, the powder forms a barrier over the vessel wall, quickly stopping the bleeding, and secondly, the absorbent powder increases the local concentration of clotting factors and enhances clot formation [96]. Last, it has also been postulated that the mineral powder may activate the clotting cascade along with aggregating platelets, forming a fibrin plug [97]. Given the lack of systemic absorption, the coagulum then falls off after 24–72 hours and is eliminated through the GI tract [98].
The mineral powder is available as a kit containing a hand-held device including a pressurized CO2 canister, a through-the-scope delivery catheter (10-Fr or 7-Fr), and a reservoir for the 21-g powder cartridge. The powder is delivered via push button in 1- to 2-second bursts until hemostasis is achieved. Up to three kits can be used in each patient. It has been evaluated for its safety and efficacy in numerous studies for the primary, adjunctive and rescue therapy of non-variceal gastrointestinal bleeding including: peptic ulcers, post-polypectomy bleeding, post endoscopic mucosal resection or dissection bleeding, gastric antral vascular ectasia, Dieulafoy’s lesions, Mallory-Weiss tears and tumor bleeding [99].
Rare adverse events associated to the use of the mineral powder may include embolism, intestinal obstruction, and allergic reaction to its components [100]. However, given the relatively low-pressure system used in the canister during deployment of the powder, the risk of embolism is minimal [96]. Reports of hemostatic powder dislodgement from the GI mucosa approximately 48 hours after its use may theoretically cause intestinal obstruction [98]. However, review of the literature did not reveal any of these potential adverse events. Because the mineral powder cannot be taken in by mucosal tissues, absorption and metabolism of the powder does not occur in the body, thereby nearly eliminating the risk of systemic toxicity. Since the mineral powder does not contain human or animal proteins or botanicals and has no known allergens, it has been shown to have minimal side effects [98, 99].
The advantages of the mineral powder are that, unlike traditional techniques, it is non-contact, non-thermal and does not require specific targeting making endoscopic application easier. In a summary of 19 studies comprising treatment of 234 patients with the hemostatic mineral powder, the combined rate of successful hemostasis was 88.5%. Rebleeding occurred within 72 hours in 16.2% after successful initial hemostasis [100]. Given the above, it is a welcomed addition to the endoscopic armamentarium to treat GI bleeding.
Head to head randomized controlled trials compared to more traditional hemostatic therapy (i.e. endoscopic clips, epinephrine injection, and thermal coagulation) would truly help discern the role of mineral powder in achieving endoscopic control of GI bleeding.
Another option for endoscopic hemostasis comes in the form of plant-based polysaccharide components and two such products are available currently. When the polysaccharide powder come into contact with blood it absorbs water, increasing the concentration of platelets and clotting factors, resulting in an accelerated clotting cascade. Additionally, it forms a gel-like matrix that adheres to the bleeding lesion, providing a mechanical barrier. Both available products have almost an instantaneous effect on hemostasis upon contact and since they are plant-starch derived, it is degraded and absorbed naturally by digestive enzymes within hours [101, 102].
Presently these products have been studied for endoscopic use in GI bleeding and there are case reports about successful use as salvage therapy in post-necrosectomy bleeding [17]. Current indications include upper and lower GI bleeding caused by ulcer, post polypectomy, tumor, post endoscopic mucosal dissection/ESD, in-stent, Mallory-Weiss tear, etc. [99]. It is deployed using compressed air through an endoscopic catheter. In 21 patients, the use of polysaccharide successfully achieved hemostasis in all patients when conventional therapy using dual or triple therapy had failed [101]. Another study looked at the use of polysaccharide powder in 22 patients and found to have success in 21/22 patients of which 16 patients underwent primary hemostasis with the polysaccharide [103].
Similar to mineral powder, the side effect profile of polysaccharide based topical agents include theoretical side effects of embolism, intestinal obstruction and allergic reaction, however there are no reported cases.
The use of hemostatic powders certainly has its advantages when compared to conventional modalities of endoscopic hemostasis. The hemostatic powders have been shown to be effective in upper and lower GI bleeding and as primary and salvage or bridge therapies. Polysaccharide and mineral powders have no differences when assessing short term and long-term hemostasis and rebleeding [99]. However, the majority of studies particularly looking at the polysaccharide based topical therapies have been small and focused on adjunctive therapy. Further randomized studies are needed to assess the role of this type of hemostatic intervention.
Biomaterials have demonstrated proven efficacy and improved clinical outcomes in conventional surgery. And although the cost of these materials is higher compared to traditional hemostatics, it may be offset by the possible benefits of decreased bleeding related complications, procedure time, hospital stay and blood transfusion.
Given the advances in endoscopy over the past few decades, and healthcare leaning towards more minimally invasive first line therapies, the migration of these concepts to GI endoscopy is well positioned and likely much welcomed by endoscopists around the world. While the use of these agents has certainly expanded exponentially over the past decade, the use and prior descriptions of biomaterials in endoscopy is particularly limited, considering the full array of potential applications of these substances. Most of the reported uses of biomaterials in endoscopy are actually “off label” and more studies are required to allow for better understanding and decision-making guidance to best aid in patient care.
The authors have no financial conflicts of interest to disclose.
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Non-native English speakers take help of various NLP tools such as E-Dictionary, MT applications and others to better understand the English language and thus learn it better and faster. Aviation English poses a challenge to MT systems and understanding it as a whole requires specialized handling as it has own phonetic pronunciations and terminologies and constituent Out-Of-Vocabulary words. Dealing with Aviation English calls for teaming up of experts from Applied Linguistics, NLP and AI. As a result it becomes a cross-research discipline that covers situations that demand real time use of proper language, e.g. ATC communications. This Paper aims to discuss most recent research methodologies that deals with the Aviation English and reviews the problems posed by it. Being a specialized and structured form of English, the problems are faced by both native and non-native speakers of English Language. 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