Today is Earth Day: A repost of Ditching Desflurane for the good of Planetary Health

Elizabeth E Hansen, MD PhD and Diane W Gordon, MD

Today, April 22nd is Earth Day and to celebrate I’m reposting a previous PAAD by Dr. Diane Gordon, the chair of SPA’s Sustainability Special Interest Group and Dr. Liz Hansen of Seattle Children’s Hospital and a primary investigator and team leader in Project Spruce Forest, a multi-institutional quality improvement and implementation science project.

From SPA’s website: “The Special Interest Group for Sustainability brings together pediatric anesthesiologists with a passion for learning, teaching, and practicing ways to reduce the environmental impact of anesthesia and the wider operating room environment. The SIG will facilitate education on sustainability topics at meetings, foster collaboration across institutions, promote sharing of ideas for projects and publications, and maintain the creative energy of pediatric anesthesiologists working for changes in their hospitals.  Further, the Sustainability SIG is helping to recruit pediatric anesthesia groups to a multi-institutional quality improvement and implementation science project to reduce GHG emissions! Visit the website to learn more!  Project Spruce Forest”

All of SPA’s committees and special interest groups are open to all of the members to join and participate. Don’t put this off and join the Sustainability SIG today.  Simply contact Diane and/or Liz. Myron Yaster MD

The climate emergency is a health crisis that disproportionately impacts children and other vulnerable populations. The planet is warming due to human activity and healthcare delivery contributes 5-10% of global emissions. Inhaled anesthetics are greenhouse gases (GHGs), and desflurane has nearly 50 times the greenhouse gas emissions of sevoflurane when used clinically [1]. With safe and effective alternatives to desflurane, continuing its use is difficult to defend. Many hospitals have decreased its use, and others have removed it from formulary.

Last week, it was announced that NHS Scotland removed desflurane from its supply chain, effective this month. This decision supports NHS Scotland’s goal of reducing the environmental impact of healthcare overall, and anesthetic care specifically. By 2027, NHS Scotland will aim to achieve net-zero anesthetic gas use as part of the “National Green Theatres Programme,” an initiative that aims to take NHS Scotland to net-zero health care delivery by 2040. In 2020/21, anesthetic gases were responsible for 27,000 metric tons of CO₂ equivalents in Scotland’s NHS. This is the equivalent to 149 railcars’ worth of coal burned, over 67 million miles driven in an average US gasoline powered car, or over 5,000 US homes’ electricity use for one year. To sequester this volume of emissions would require 32,000 acres of forest for a year, or planting nearly 450,000 seedlings and growing them for 10 years[2].

Using desflurane, even at lower fresh gas flows, emits far more greenhouse gas than alternatives like sevoflurane or total IV anesthesia. A MAC-hour with desflurane at 1lpm FGF is equivalent to driving a US car 189 miles (304km) while the same MAC-hour with sevoflurane at 1lpm FGF is equivalent to driving the car 4 miles (6km) [1]. Moreover, the clinical relevance of desflurane’s low lipid solubility in providing an expeditious wake-up has been called into question by multiple studies in obese adults [3,4,5], and should not be used to justify its continued use.

If your hospital still uses desflurane we encourage you to approach your anesthesia group, pharmacy representatives, and the purchasing department about removing it from formulary. In addition to a large reduction in GHG emissions, there will be cost savings as well, since desflurane is far more expensive than the other volatile agents. Prior to removing it from formulary, Seattle Children’s Hospital’s costs for desflurane were over $46,000 per year. At Children’s Hospital Colorado desflurane was only used in 10% of cases but accounted for 40% of the budget for volatile anesthetics. Since removing it from formulary, that hospital is saving $120,000 per year even accounting for the increased purchase of sevoflurane.

Carbon dioxide equivalents of inhaled anesthetics can be quantified using published calculations. We can help you track emissions at your hospital by surgical type, patient age, case length, and anesthesia clinician in our quality improvement initiative Project SPRUCE (Saving our Planet by Reducing Carbon Emissions) Forest. This international collaboration combines socialization and education, practice constraints (like desflurane removal and lower default fresh gas flows), plus direct clinician feedback using AdaptX software. Seattle Children’s has used this paradigm to reduce measured emissions from inhaled anesthetics by 87% [6]. We are currently recruiting institutions for Phase 2 of Project SPRUCE Forest and we hope you’ll join us.

Removing desflurane is the single biggest change you can make– the lowest-hanging fruit there is– to reduce the environmental impact of your anesthesia practice. Scotland has figured this out and has implemented on a wide scale; NHS England will be removing desflurane in early 2024 and many countries in Europe will likely follow suit. Without a national health system to bring about large-scale change we’ll have to do it piecemeal in the US– we hope the change starts with you!

References

1. Sherman J, Feldman J, Berry JM. Reducing inhaled anesthetic waste and pollution. Anaesthesiology News. April 13, 2017. https://www.anesthesiologynews.com/Commentary/Article/04-17/Reducing-Inhaled-Anesthetic-Waste-and-Pollution/40910

2. US Environmental Protection Agency. 2015. “Greenhouse Gas Equivalencies Calculator.” August 28, 2015. https://www.epa.gov/energy/greenhouse-gas-equivalencies-calculator.

3. Arain SR, Barth CD, Shankar H, et al. Choice of Volatile Anesthetic for the Morbidly Obese Patient: Sevoflurane or Desflurane. Journal of Clinical Anesthesia. 2005;17(6):413–19.

4. Vallejo M, Sah N, Phelps AL, et al. Desflurane versus Sevoflurane for Laparoscopic Gastroplasty in Morbidly Obese Patients. Journal of Clinical Anesthesia. 2007;19(1):3–8.

5. Torri G, Casati A, Albertin A, et al. Randomized Comparison of Isoflurane and Sevoflurane for Laparoscopic Gastric Banding in Morbidly Obese Patients. Journal of Clinical Anesthesia 2001;13:565–570.

6. Hansen EE, Chiem JL, Righter-Foss K, Zha Y, Cockrell HC, Greenberg SLM, Low DK, Martin LD. Project SPRUCE: Saving our Planet by Reducing Carbon Emissions, a Pediatric Anesthesia Sustainability Quality Improvement Initiative. Anesthesia & Analgesia, in press.