Reader response/short takes

Myron Yaster MD

From Steve Shafer MD

In today’s Pediatric Article of the Day (5/12/2025), Graffe and colleagues compare the environmental effects of propofol vs. sevoflurane. They conclude that sevoflurane poses substantially greater environmental effects than propofol. This agrees with substantial previous literature.

As the authors point out, the environmental effects of propofol relate to groundwater contamination and entry into the ecosystem. A point frequently missed is that patients are never the source of this propofol. Propofol is completely (>99%) metabolized by the liver to propofol glucuronide, which is then eliminated by the kidney. Propofol glucuronide has little to no pharmacological activity. Any 2,6-diisopropylphenol (i.e., propofol) in the environment got there by way of disposing unused propofol from operating rooms and procedural suites into landfill. Propofol degrades completely upon incineration (see, for example, https://www.bjanaesthesia.org/article/S0007-0912(20)30165-3/fulltext). AstraZeneca even recommends incineration in the propofol data safety sheet: https://www.astrazeneca.com.au/content/dam/az-au/Material%20Safety%20Data/Diprivanltsupgt174ltsupgt.pdf.

Propofol in the environment comes entirely from improper disposal by healthcare providers, hospitals, and clinics. It does not come from our patients. By taking the simple step of squirting unused propofol into sharps containers, which get incinerated anyway, we should be able to completely eliminate 2,6-diisopropylphenol contamination of the environment.

From Myron Yaster MD short take on new therapies for epidermolysis bullosa

We’ve discussed the anesthetic management of patients with epidermolysis bullosa in 2 previous PAADs (01/25/2022 https://ronlitman.substack.com/p/epidermolysis-bullosa-experience ) and ( 02/07/2022 https://ronlitman.substack.com/p/anesthetic-management-of-adults-with )

Patients with this debilitating dermatologic condition are born with COL7A1 mutations in both gene copies, affecting the ability to produce functional type VII collagen and resulting in extremely fragile skin that is subject to chronic wounds that can remain open for years. A simply terrible disease but with some exciting, game changing news: The United States Food and Drug Administration approved prademagene zamikeracel (Zevaskyn) for treating adults and children with the blistering wounds caused by recessive dystrophic epidermolysis bullosa (RDEB), Abeona Therapeutics . An autologous cell-based gene therapy, prademagene zamikeracel uses patients' genetically modified keratinocytes, altered to produce functional type VII collagen. Sheets of the therapy are surgically applied to the painful wounds, which often can cover over 30% of a patient's body -- sometimes as much as 80%.

The FDA also recently granted approval to a topical herpes-simplex virus type 1 vector-based gene therapy (Vyjuvek) for patients ages 6 months and older with either RDEB or the dominant inherited form, typically a milder form of the condition that affects the hands, feet, knees, and elbows.

If any of you have experience with either of these new therapies or know of articles published on their use drop me a note and we’ll post in a future PAAD.

From Karla Castro-Frenzel MD on Anesthesia and the Perioperative Care of the Cancer Patient

Thank you for bringing attention to this important subject. I very much enjoyed reading this article, but must add my own caveats. As both a cancer patient who is currently enrolled in a clinical trial and an anesthesiologist who serves on the clinical trial committee of cancer advocacy group, Alk Positive, I think it's important to draw attention to some significant details in the Cancer Biology and the Perioperative Period article.

While the authors elegantly elucidate mechanisms by which anesthetic agents and surgical factors might promote metastasis and enable bypass mechanisms, the fact remains that some patients actually demonstrate an increase in progression-free survival when they have had surgery or radiation along with the start of medical oncology therapy. Such has been the case for patients with ALK-driven lung cancer https://pubmed.ncbi.nlm.nih.gov/36895922/. It is important to emphasize that cancers demonstrate tremendous heterogeneity, even within the same kind. So it is important that we avoid stating that surgery or anesthesia is bad for all cancers all the time. Clearly, what is seen in the lab must be balanced by actual clinical outcomes seen in human patients.

I would have hoped that this article mentioned the growing field of immuno-oncology, which started with checkpoint inhibitors. Now it includes oncologic vaccines, oncolytic viruses, bispecifics, Tumor-Infiltrating-Lymphocytes, and many more biologics. The Society for Immunotherapy in Cancer (SITC) offers a great annual conference for those who wish to learn more.

Finally, I'd like to emphasize the need to highlight the wins, achievements, and the glimmers of impending victories in oncology. Patients with cancer have double the risk of suicide as the general population. Female anesthesiologists have a suicide risk 2.5 times that of the general population. It is imperative that we mitigate all language that could incite fear regarding cancer. As the emperor of all maladies, it does not need our help in rousing fear. What serves us far better than fear is hope. At this point in time, hope lies in immuno-oncology.

My hope is that we one day figure out a way to create an targeted therapy that can be coupled to a volatile anesthetic, so that a single anesthetic can both perform cancer surveillance at the cellular level and treatment of the whole body in a single exposure, eliminating the need for the repeated CTs we, as oncology patients, have to undergo.

From Alan Jay Schwartz MD MSEd on OR fires

Another great resource comes from the Anesthesia Patients Safety Foundation and I recommend, really urge all of you to view the accompanying videos.

https://www.apsf.org/videos/preventing-surgical-fires/