Download PDF
CC BY 4.0 · J Neuroanaesth Crit Care
DOI: 10.1055/s-0044-1795148
Review Article

In Defense of Desflurane: Is There a Specific Role for Desflurane in Neuroanesthesia?

Shailendra Joshi
1   Department of Anesthesiology, Columbia University, New York, New York, United States
,
Vidur Joshi
2   Department of Biomedical Engineering, Stevens Institute of Technology, Hoboken, New Jersey, United States
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Abstract

It is challenging to counter the widespread criticism of desflurane as the volatile anesthetic agent with the most significant greenhouse gas effect, one which is likely to exacerbate global warming. In 2022, the journal “Anaesthesia” published guidelines for minimizing the impact of anesthetic gases on global warming, which the anesthetic community has largely embraced. One of its recommendations was the removal of desflurane from drug formularies. However, this review underlines the likely benefits of desflurane in the context of actual and potential neurological injuries. With an estimated 13.8 million neurosurgical operations performed annually, desflurane could offer advantages to some of these patients. Therefore, it is imperative to develop an environmentally safe approach for its use rather than remove it from formularies. We discuss desflurane's environmental impact, its unique anesthetic and chemical properties, and its specific application in neuroanesthesia practice. Based on existing evidence, we argue that desflurane could hasten the wake-up of neurosurgical patients. We propose switching to desflurane toward the end of surgery for patients at risk of, or with, neurological injuries. Predictable, early, and monitorable wake-up in these cases could prevent surgical delays, avoid additional investigations, or enable early detection of new deficits. Instead of a blanket ban, desflurane's use should be investigated—systematically and carefully. With education, well-defined indications, limited use, intelligent vaporizers, scavenging, and recycling systems, the use of desflurane could be justified under specific circumstances. Moreover, the problem of environmental damage from inhaled anesthetics must be comprehensively evaluated. Minimizing the use of desflurane is a positive step to protect the environment, but anesthesiologists should enforce other measures to protect the environment with equal urgency.

Keywords

desflurane - inhaled anesthetic gases - greenhouse gases - medical - pollution - climate change


Publication History

Article published online:
24 December 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

 

  • References

  • 1 Young G. Pollution threat to man's only home. Natl Geogr Mag 1970; 138 (06) 738-780
    PubMedSearch in Google Scholar
  • 2 Campbell M, Pierce JT. Atmospheric science, anaesthesia, and the environment. BJA Educ 2015; 15 (04) 173-179
    CrossrefPubMedSearch in Google Scholar
  • 3 Sulbaek Andersen MP, Nielsen OJ, Karpichev B, Wallington TJ, Sander SP. Atmospheric chemistry of isoflurane, desflurane, and sevoflurane: kinetics and mechanisms of reactions with chlorine atoms and OH radicals and global warming potentials. J Phys Chem A 2012; 116 (24) 5806-5820
    CrossrefPubMedSearch in Google Scholar
  • 4 Rasool SI, De Bergh C. The runaway greenhouse and the accumulation of CO2 in the Venus atmosphere. Nature 1970; 226 (5250): 1037-1039
    CrossrefPubMedSearch in Google Scholar
  • 5 Alexander R, Poznikoff A, Malherbe S. Greenhouse gases: the choice of volatile anesthetic does matter. Can J Anaesth 2018; 65 (02) 221-222
    CrossrefPubMedSearch in Google Scholar
  • 6 Andersen MPS, Nielsen OJ, Sherman JD. The global warming potentials for anesthetic gas sevoflurane need significant corrections. Environ Sci Technol 2021; 55 (15) 10189-10191
    CrossrefPubMedSearch in Google Scholar
  • 7 Shine KP. Climate effect of inhaled anaesthetics. Br J Anaesth 2010; 105 (06) 731-733
    CrossrefPubMedSearch in Google Scholar
  • 8 Özelsel TJ-P, Sondekoppam RV, Buro K. The future is now-it's time to rethink the application of the Global Warming Potential to anesthesia. Can J Anaesth 2019; 66 (11) 1291-1295
    CrossrefPubMedSearch in Google Scholar
  • 9 Ryan SM, Nielsen CJ. Global warming potential of inhaled anesthetics: application to clinical use. Anesth Analg 2010; 111 (01) 92-98
    CrossrefPubMedSearch in Google Scholar
  • 10 Sherman J, Le C, Lamers V, Eckelman M. Life cycle greenhouse gas emissions of anesthetic drugs. Anesth Analg 2012; 114 (05) 1086-1090
    CrossrefPubMedSearch in Google Scholar
  • 11 Devlin-Hegedus JA, McGain F, Harris RD, Sherman JD. Action guidance for addressing pollution from inhalational anaesthetics. Anaesthesia 2022; 77 (09) 1023-1029
    CrossrefPubMedSearch in Google Scholar
  • 12 Reduce Carbon Footprint from Inhaled Anesthesia with New Guidance Published. Accessed July 31, 2024 at: https://www.asahq.org/about-asa/newsroom/news-releases/2022/06/reduce-carbon-footprint-from-inhaled-anesthesia-with-new-guidance-published
    PubMed
  • 13 Joshi S. Appendix 18: Approach to Fast Track Wakeup After Craniotomy and Its Assessment. In: Neuroanesthesiology Case Companion. Jaypee Publisher; Delhi: 2023: 620-622
    Search in Google Scholar
  • 14 Eger EI, Westhorpe RN, Saidman LJ. 1910–1950: Anesthesia Before, During, and After Two World Wars. In: Eger Ii EI, Saidman LJ, Westhorpe RN. , editors. The Wondrous Story of Anesthesia. New York, NY: Springer New York; 2014: 51-70
    Search in Google Scholar
  • 15 Whalen FX, Bacon DR, Smith HM. Inhaled anesthetics: an historical overview. Best Pract Res Clin Anaesthesiol 2005; 19 (03) 323-330
    CrossrefPubMedSearch in Google Scholar
  • 16 Terrell RC, Speers L, Szur AJ, Treadwell J, Ucciardi TR. General anesthetics. 1. Halogenated methyl ethyl ethers as anesthetic agents. J Med Chem 1971; 14 (06) 517-519
    CrossrefPubMedSearch in Google Scholar
  • 17 Andersen MPS, Nielsen OJ, Sherman JD. Assessing the potential climate impact of anaesthetic gases. Lancet Planet Health 2023; 7 (07) e622-e629
    CrossrefPubMedSearch in Google Scholar
  • 18 Purohit P, Höglund-Isaksson L. Global emissions of fluorinated greenhouse gases 2005–2050 with abatement potentials and costs. Atmos Chem Phys 2017; 17 (04) 27952816
    CrossrefPubMedSearch in Google Scholar
  • 19 NASA. Are Ozone Hole and Global Warming Related. National Aeronautics and Space Administration. Accessed July 31, 2024, at: https://earthobservatory.nasa.gov/blogs/climateqa/category/global-warming/
    PubMed
  • 20 Son S-W, Tandon NF, Polvani LM, Waugh DW. Ozone hole and Southern Hemisphere climate change. Geophys Res Lett 2009; 36 (15) 1-5
    PubMedSearch in Google Scholar
  • 21 Kelleher D, Fouts-Palmer E, Yu S, Malhotra V. Greening the operating room and your budget by reducing desflurane use. ASRA Pain Medicine News. 2022
    PubMedSearch in Google Scholar
  • 22 Hu EP, Yap A, Davies JF, Goyagi T, McGain F. Global practices in desflurane use. . Br J Anaesth 2023; •••:S0007-0912(23)00471-3
    PubMed
  • 23 Anonymous. Guidance: Desflurane decommissioning and clinical use. NHS England. Updated 27 March 2024. Accessed August 27, 2024, at: https://www.england.nhs.uk/longread/guidance-desflurane-decommissioning-and-clinical-use
    PubMed
  • 24 Kamal FA, Fernet LY, Da Silva NK. et al. Comparing perioperative outcomes of total intravenous anesthesia (TIVA) with volatile anesthesia in patients with obesity: a systematic review. Cureus 2024; 16 (02) e54094
    PubMedSearch in Google Scholar
  • 25 Dewan MC, Rattani A, Fieggen G. et al; Executive Summary of the Global Neurosurgery Initiative at the Program in Global Surgery and Social Change. Global neurosurgery: the current capacity and deficit in the provision of essential neurosurgical care. J Neurosurg 2018; 130 (04) 1055-1064
    CrossrefPubMedSearch in Google Scholar
  • 26 Falcó-Roget J, Cacciola A, Sambataro F, Crimi A. Functional and structural reorganization in brain tumors: a machine learning approach using desynchronized functional oscillations. Commun Biol 2024; 7 (01) 419
    CrossrefPubMedSearch in Google Scholar
  • 27 Zotey V, Andhale A, Shegekar T, Juganavar A. Adaptive neuroplasticity in brain injury recovery: strategies and insights. Cureus 2023; 15 (09) e45873
    PubMedSearch in Google Scholar
  • 28 Yuan B, Xie H, Gong F. et al. Dynamic network reorganization underlying neuroplasticity: the deficits-severity-related language network dynamics in patients with left hemispheric gliomas involving language network. Cereb Cortex 2023; 33 (13) 8273-8285
    CrossrefPubMedSearch in Google Scholar
  • 29 Lv K, Cao X, Wang R. et al. Neuroplasticity of glioma patients: brain structure and topological network. Front Neurol 2022; 13: 871613
    CrossrefPubMedSearch in Google Scholar
  • 30 Guidotti R, Del Gratta C, Perrucci MG, Romani GL, Raffone A. Neuroplasticity within and between functional brain networks in mental training based on long-term meditation. Brain Sci 2021; 11 (08) 1086
    CrossrefPubMedSearch in Google Scholar
  • 31 Lin N, Han R, Zhou J, Gelb AW. Mild sedation exacerbates or unmasks focal neurologic dysfunction in neurosurgical patients with supratentorial brain mass lesions in a drug-specific manner. Anesthesiology 2016; 124 (03) 598-607
    CrossrefPubMedSearch in Google Scholar
  • 32 Vlisides PE, Mashour GA. Pharmacologic unmasking of neurologic deficits: a stress test for the brain. Anesthesiology 2019; 131 (01) 5-6
    CrossrefPubMedSearch in Google Scholar
  • 33 Thal GD, Szabo MD, Lopez-Bresnahan M, Crosby G. Exacerbation or unmasking of focal neurologic deficits by sedatives. Anesthesiology 1996; 85 (01) 21-25 , discussion 29A–30A
    CrossrefPubMedSearch in Google Scholar
  • 34 Anonymous. Inhaled Anesthetics. NYSORA. Accessed July 30, 2024, at: https://www.nysora.com/anesthesia/inhaled-anesthetics/
    PubMed
  • 35 Lockwood G. Theoretical context-sensitive elimination times for inhalation anaesthetics. Br J Anaesth 2010; 104 (05) 648-655
    CrossrefPubMedSearch in Google Scholar
  • 36 Black S, Enneking FK, Cucchiara RF. Failure to awaken after general anesthesia due to cerebrovascular events. J Neurosurg Anesthesiol 1998; 10 (01) 10-15
    CrossrefPubMedSearch in Google Scholar
  • 37 Kim JH, Jin Y, Hong SW. Failure to awaken from general anesthesia due to infratentorial hemorrhage after cervical spine surgery: a case report. Medicine (Baltimore) 2019; 98 (44) e17678
    CrossrefPubMedSearch in Google Scholar
  • 38 Bennetts FE. Thiopentone anaesthesia at Pearl Harbor. Br J Anaesth 1995; 75 (03) 366-368
    CrossrefPubMedSearch in Google Scholar
  • 39 Schubert A, Mascha EJ, Bloomfield EL, DeBoer GE, Gupta MK, Ebrahim ZY. Effect of cranial surgery and brain tumor size on emergence from anesthesia. Anesthesiology 1996; 85 (03) 513-521
    CrossrefPubMedSearch in Google Scholar
  • 40 Dedrick RL. Arterial drug infusion: pharmacokinetic problems and pitfalls. J Natl Cancer Inst 1988; 80 (02) 84-89
    CrossrefPubMedSearch in Google Scholar
  • 41 Gkantinas G, Tataki EΙ, Lykoudis PM, Lelekaki E, Kouki P. Clinical effects and adverse events associated with desflurane use in adult patients undergoing supratentorial craniotomy: a systematic review. J Neurosurg Anesthesiol 2024; 36 (01) 20-28
    CrossrefPubMedSearch in Google Scholar
  • 42 Haldar R, Kannaujia AK, Verma R. et al. Randomized trial to compare plasma glucose trends in patients undergoing surgery for supratentorial gliomas under maintenance of sevoflurane, desflurane, and propofol. Asian J Neurosurg 2020; 15 (03) 579-586
    Thieme ConnectPubMedSearch in Google Scholar
  • 43 Paul AP, Vedantam A, Korula G, Chacko AG. A comparison of the recovery profiles of desflurane and isoflurane anesthesia in patients undergoing elective supratentorial craniotomy: a randomized controlled trial. Neurol India 2017; 65 (05) 1053-1058
    CrossrefPubMedSearch in Google Scholar
  • 44 Gökçek E, Kaydu A, Akdemir MS, Akil F, Akıncı IO. Early postoperative recovery after intracranial surgical procedures. Comparison of the effects of sevoflurane and desflurane. Acta Cir Bras 2016; 31 (09) 638-644
    CrossrefPubMedSearch in Google Scholar
  • 45 Bastola P, Bhagat H, Wig J. Comparative evaluation of propofol, sevoflurane and desflurane for neuroanaesthesia: a prospective randomised study in patients undergoing elective supratentorial craniotomy. Indian J Anaesth 2015; 59 (05) 287-294
    CrossrefPubMedSearch in Google Scholar
  • 46 Dube SK, Pandia MP, Chaturvedi A, Bithal P, Dash HH. Comparison of intraoperative brain condition, hemodynamics and postoperative recovery between desflurane and sevoflurane in patients undergoing supratentorial craniotomy. Saudi J Anaesth 2015; 9 (02) 167-173
    CrossrefPubMedSearch in Google Scholar
  • 47 Mikuni I, Harada S, Yakushiji R, Iwasaki H. Effects of changing from sevoflurane to desflurane on the recovery profile after sevoflurane induction: a randomized controlled study. Can J Anaesth 2016; 63 (03) 290-297
    CrossrefPubMedSearch in Google Scholar
  • 48 Kim JW, Lee JY, Hwang SW. et al. The effects of switching from sevoflurane to short-term desflurane prior to the end of general anesthesia on patient emergence and recovery: a randomized controlled trial. BioMed Res Int 2022; 2022: 1812728
    PubMedSearch in Google Scholar
  • 49 Kang H, Cha SM, Park SG. et al. The effects of changing from isoflurane to desflurane on the recovery profile during the latter part of anesthesia. Acta Med Okayama 2010; 64 (05) 307-316
    PubMedSearch in Google Scholar
  • 50 Neumann MA, Weiskopf RB, Gong DH, Eger II EI, Ionescu P. Changing from isoflurane to desflurane toward the end of anesthesia does not accelerate recovery in humans. Anesthesiology 1998; 88 (04) 914-921
    CrossrefPubMedSearch in Google Scholar
  • 51 Leijonhufvud F, Jöneby F, Jakobsson JG. The impact of fresh gas flow on wash-in, wash-out time and gas consumption for sevoflurane and desflurane, comparing two anaesthesia machines, a test-lung study. F1000 Res 2017; 6: 1997
    CrossrefPubMedSearch in Google Scholar
  • 52 Kampman JM, Hermanides J, Hollmann MW. et al. Mortality and morbidity after total intravenous anaesthesia versus inhalational anaesthesia: a systematic review and meta-analysis. EClinicalMedicine 2024; 72: 102636
    CrossrefPubMedSearch in Google Scholar
  • 53 Rudolff AS, Moens YP, Driessen B, Ambrisko TD. Comparison of an infrared anaesthetic agent analyser (Datex-Ohmeda) with refractometry for measurement of isoflurane, sevoflurane and desflurane concentrations. Vet Anaesth Analg 2014; 41 (04) 386-392
    CrossrefPubMedSearch in Google Scholar
  • 54 Boztuğ N, Bigat Z, Akyuz M, Demir S, Ertok E. Does using the bispectral index (BIS) during craniotomy affect the quality of recovery?. J Neurosurg Anesthesiol 2006; 18 (01) 1-4
    CrossrefPubMedSearch in Google Scholar
  • 55 Hirata N. Efficacy of desflurane for early recovery and early detection of neurological abnormality in spinal surgery. J Jpn Soc Clin Anesth 2015; 35 (03) 393-398
    PubMedSearch in Google Scholar
  • 56 Ting CK, Hu JS, Teng YH, Chang YY, Tsou MY, Tsai SK. Desflurane accelerates patient response during the wake-up test for scoliosis surgery. Can J Anaesth 2004; 51 (04) 393-397
    CrossrefPubMedSearch in Google Scholar
  • 57 Alnemri A, Sussman S, Estephan L. et al. Cost of total intravenous anesthesia versus inhalation anesthesia in obstructive sleep apnea surgery. Laryngoscope 2022; 132 (07) 1487-1494
    CrossrefPubMedSearch in Google Scholar
  • 58 Cleland J, Bill V, Williams E, Shelton C. Retained desflurane in decommissioned vaporisers: a national problem?. Anaesthesia 2023; 78 (05) 651-652
    CrossrefPubMedSearch in Google Scholar
  • 59 O'Brien O, Conlon N. Anaesthetic gases and the environment: is it time for a rethink?. Surgeon 2024; 22 (04) 200-202
    CrossrefPubMedSearch in Google Scholar
  • 60 Jänchen J, Brückner JB, Stach H. Adsorption of desflurane from the scavenging system during high-flow and minimal-flow anaesthesia by zeolites. Eur J Anaesthesiol 1998; 15 (03) 324-329
    CrossrefPubMedSearch in Google Scholar
  • 61 Yadav VK, Choudhary N, Inwati GK. et al. Recent trends in the nanozeolites-based oxygen concentrators and their application in respiratory disorders. Front Med (Lausanne) 2023; 10: 1147373
    CrossrefPubMedSearch in Google Scholar
  • 62 El Sherif D, Knox JC. International Space Station Carbon Dioxide Removal Assembly (ISS CDRA) Concepts and Advancements. SAE Technical Paper 2005-01-2892, 2005
    PubMedSearch in Google Scholar
  • 63 Doyle DJ, Byrick R, Filipovic D, Cashin F. Silica zeolite scavenging of exhaled isoflurane: a preliminary report. Can J Anaesth 2002; 49 (08) 799-804
    CrossrefPubMedSearch in Google Scholar
  • 64 Fulton B. Combating the Negative Impacts of Volatile Anesthetic on the Environment by Embracing New Technology. The Sensor 2023 (04) 9-15
    PubMed
  • 65 Gandhi J, Barker K, Cross S, Goddard A, Vaghela M, Cooper A. Volatile capture technology in sustainable anaesthetic practice: a narrative review. Anaesthesia 2024; 79 (03) 261-269
    CrossrefPubMedSearch in Google Scholar
  • 66 Cubanski J, Neuman T. A Small Number of Drugs Account for a Large Share of Medicare Part D Spending. Updated August 27, 2024, at: https://www.kff.org/medicare/issue-brief/a-small-numberof-drugs-account-for-a-large-share-of-medicare-part-d-spending/
    PubMed
  • 67 Pasternak JJ, Lanier WL. Is nitrous oxide use appropriate in neurosurgical and neurologically at-risk patients?. Curr Opin Anaesthesiol 2010; 23 (05) 544-550
    CrossrefPubMedSearch in Google Scholar
  • 68 Culley DJ, Crosby G. Nitrous oxide in neuroanesthesia: tried and true or toxin?. Anesthesiology 2008; 108 (04) 553-554
    CrossrefPubMedSearch in Google Scholar
  • 69 Moody AE, Beutler BD, Moody CE. Predicting cost of inhalational anesthesia at low fresh gas flows: impact of a new generation carbon dioxide absorbent. Med Gas Res 2020; 10 (02) 64-66
    CrossrefPubMedSearch in Google Scholar
  • 70 Smith M, Singh H, Sherman JD. Infection prevention, planetary health, and single-use plastics. JAMA 2023; 330 (20) 1947-1948
    CrossrefPubMedSearch in Google Scholar
  • 71 Özelsel TJ-P, Sondekoppam RV, Ip VHY, Tsui BCH. Re-defining the 3R's (reduce, refine, and replace) of sustainability to minimize the environmental impact of inhalational anesthetic agents. Can J Anaesth 2019; 66 (03) 249-254
    CrossrefPubMedSearch in Google Scholar
  • 72 Gonzalez-Pizarro P, Brazzi L, Koch S. et al; Sustainability National Representatives. European Society of Anaesthesiology and Intensive Care consensus document on sustainability: 4 scopes to achieve a more sustainable practice. Eur J Anaesthesiol 2024; 41 (04) 260-277
    CrossrefPubMedSearch in Google Scholar
  • 73 Anonymous. Anesthesia Disposable Global Market Report 2024 by The Business Research Company, Accessed August 27, 2024 at: https://www.thebusinessresearchcompany.com/report/anesthesia-disposables-globalmarket-report
    PubMed
  • 74 Jain N, LaBeaud D. How should US health care lead global change in plastic waste disposal?. AMA J Ethics 2022; 24 (10) E986-E993
    CrossrefPubMedSearch in Google Scholar
  • 75 Papadopoulou A, Kumar NS, Vanhoestenberghe A, Francis NK. Environmental sustainability in robotic and laparoscopic surgery: systematic review. Br J Surg 2022; 109 (10) 921-932
    CrossrefPubMedSearch in Google Scholar
  • 76 Fairbridge RW. Climatology of a glacial cycle. Quat Res 1972; 2 (03) 283-302
    CrossrefPubMedSearch in Google Scholar
  • 77 Yue X-L, Gao Q-X. Contributions of natural systems and human activity to greenhouse gas emissions. Adv Clim Chang Res 2018; 9 (04) 243-252
    CrossrefPubMedSearch in Google Scholar
  • 78 Voosen P. ‘Hot’ climate models exaggerate Earth impacts. Science 2022; 376 (6594): 685
    CrossrefPubMedSearch in Google Scholar
  • 79 Anonymous. How does war contribute to climate change? Conflict and Environment Observatory. 2024, Accessed August 27, 2024 at: https://ceobs.org/how-does-war-contribute-to-climate-change/
    PubMed
  • 80 Hall S. The New Space Race Is Causing New Pollution Problems. New York Times. 2024, Accessed August 27, 2024 at: https://www.nytimes.com/2024/01/09/science/rocket-pollution-spacexsatellites.html?smid=url-share
    PubMed
  • 81 Anonymous. Ukraine war responsible for 150 million tons of CO2 emissions. Japan Times. 2023, Accessed August 27, 2024 at: https://www.japantimes.co.jp/environment/2023/12/05/climatechange/ukraine-war-co2emissions/#:∼:text=The%20experts%20also%20took%20into,in%20ruins%20by%20the%20war
    PubMed
  • 82 Bun R, Marland G, Oda T. et al. Tracking unaccounted greenhouse gas emissions due to the war in Ukraine since 2022. Sci Total Environ 2024; 914: 169879
    CrossrefPubMedSearch in Google Scholar
  • 83 Weller M. A general review of the environmental impact of health care, hospitals, operating rooms, and anesthetic care. Int Anesthesiol Clin 2020; 58 (04) 64-69
    CrossrefPubMedSearch in Google Scholar
  • 84 Tomson C. Reducing the carbon footprint of hospital-based care. Future Hosp J 2015; 2 (01) 57-62
    CrossrefPubMedSearch in Google Scholar
  • 85 Editorial. The question of intravenous anesthesia in war surgery. Anesthesiology 1943; 4 (01) 74-77
    CrossrefPubMedSearch in Google Scholar