E   The Open Mind
Desflurane Should Des-appear: Global and
Financial Rationale
Matthew J. Meyer, MD
GLOSSARY
CDE 20 = carbon dioxide equivalents over 20 years; CI = confidence interval; COVID-19 = coronavi-
rus disease 2019; FGF = fresh gas flow; GHG = greenhouse gas; GWP20 = 20-year global warming
potential; MAC-hour = minimum alveolar content per hour; NHS = National Health System; OR =
operating room; PPE = personal protective equipment
Downloaded from http://journals.lww.com/anesthesia-analgesia by BhDMf5ePHKbH4TTImqenVL3xadaqxR5nEribqix/90dgN999BG9PdPt/w5yh8DY1 on 09/16/2020
D
esflurane is a volatile anesthetic agent used
throughout the world. Since 2001, global
emissions of desflurane have increased from
150 tons per year to 960 tons per year in 20141 and
this trend is expected to continue. The global mar-
ket for desflurane was $244 million in 2018 and pro-
jected to increase by 5.1% each year through 2026.2
Anesthesiologists and anesthetists have an oppor-
tunity to improve our environmental impact on our
world and our financial cost on our health systems.
One singular choice, that can be made today, can
do both.
We need to stop using desflurane as a routine option
for general anesthesia. There is no good reason to use
desflurane in most patients, and there are a few great
reasons to avoid desflurane altogether. Foremost, des-
flurane is a potent greenhouse gas and this contrib-
utes to climate change.3 Second, desflurane is more
expensive than other volatile anesthetics.4
DESFLURANE’S HISTORY
Desflurane became commercially available in the
early 1990s. Desflurane’s low blood–gas parti-
tion coefficient offered hope for rapid inhalational
inductions and quicker recoveries. An introductory
Anesthesiology editorial,5 written by the then editor-in-
chief Dr Lawrence Saidman, tempered expectations
for desflurane with the statement “...it is too soon
From the Department of Anesthesiology, University of Virginia (UVA), UVA
Health, Charlottesville, Virginia.
Accepted for publication July 1, 2020.
Funding: Institutional and/or departmental.
The author declares no conflicts of interest.
Reprints will not be available from the authors.
Address correspondence to Matthew J. Meyer, MD, Department of Anesthe-
siology, University of Virginia, UVA Health, 1215 Lee St, Charlottesville, VA
22903. Address e-mail to mmeyer@virginia.edu.
Copyright © 2020 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000005102
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Copyright © 2020 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
either to embrace desflurane enthusiastically or to
suggest that its differences are insufficient enough to
preclude wide spread [sic] use.”
In pediatric anesthesiology, the potential for
a rapid inhalational induction was meaningful.
Unfortunately, desflurane was found to be a major air-
way irritant in the pediatric population with an early
study documenting high incidences of breath-holding
(50%), coughing (36%), and laryngospasm (30%).6
Over the last few decades, desflurane has been
examined repeatedly in different patient populations
and with different comparators to assess its impact
on recovery from anesthesia. The results have been
unconvincing.
One recent meta-analysis collated randomized
controlled trials in bariatric surgery—a population
that should be ideal to demonstrate the theorectical
benefits of desflurane’s pharmacokinetics and phar-
macodynamics. This study documented that bariat-
ric patients exposed to desflurane open their eyes to
command faster (3.80 minutes; 95% confidence inter-
val [CI], 1.83–5.76), extubate faster (4.97 minutes; 95%
CI, 1.34–8.59), and have a slightly better initial post-
anesthesia care unit Aldrete score (+0.52 points; 95%
CI, 0.19–0.84) when compared to patients exposed to
sevoflurane.7 While these findings are statistically sig-
nificant, with the exception of operating rooms (ORs)
with workloads exceeding the typically allocated
OR schedule,8 these findings may not be financially
compelling.
An attempt has also been made to link desflurane
with improved postoperative cognition with the theo-
retically sound hypothesis that less soluble volatile
anesthetics may have less impact on neurocognition.
However, a meta-analysis published in 2015 noted,
while desflurane does result in a faster time to fol-
lowing commands (3.27 minutes; 95% CI, 1.59–4.95)
than sevoflurane, there is no difference in the incidence
of postoperative cognitive dysfunction.9 Interestingly, a
 Desflurane Should Des-appear
recently published retrospective study analyzing vola-
tile anesthetics found a higher incidence of postopera-
tive delirium in patients who received desflurane than
those who received isoflurane.10 While it is far from cer-
tain that desflurane is associated with worse postop-
erative cognition, it is equally uncertain that desflurane
is associated with improved postoperative cognition.
When some scientists were searching for the
advantages of desflurane, others were documenting
its deficits: (1) desflurane is expensive, this was5 and
continues to be4 true; and (2) desflurane is the most
potent greenhouse gas of the modern volatile anes-
thetics by an order of magnitude.3,11
HEALTH CARE AND THE GLOBAL CLIMATE
The World Health Organization has declared climate
change “the greatest threat to global health.”12 Globally,
health care is responsible for 4.6% of greenhouse gas
emissions.13 In the United States, health care is respon-
sible for 10% of US greenhouse gas emissions.14
Each year health care pollutants result in the loss
of >400,000 disability-adjusted life years in the United
States alone.14 This staggering number is similar in
magnitude to the harm caused by medical errors
reported in the groundbreaking Institute of Medicine
article on patient safety15 that meaningfully changed
the practice of medicine. It is time we acknowledge
the harmful effects of health care on the environment
and global health and act similarly. We must mitigate
the impact of health care on the environment and con-
sequently improve the health of everyone.
As anesthesiologists we use volatile anesthetics
every day, and, once the patient exhales, the gases are
vented into the atmosphere. All volatile anesthetics
are greenhouse gases, but some are worse greenhouse
gases than others. The “20-year global warming
potential (GWP20)” is a standardized unit used to
compare the impact various molecules may have on
the climate: a higher number means more potential
to capture energy and thus greater impact on the
climate. Carbon dioxide is the benchmark and has a
GWP20 value of 1. Sevoflurane has a GWP20 of 349,
isoflurane has a GWP20 of 1401, and desflurane has a
GWP20 of 3714. When comparing minimum alveolar
content per hour (MAC-hour) of anesthesia, desflu-
rane at 1 L of fresh gas flow is 13 times worse than
sevoflurane at 2 L of fresh gas flow.3
As anesthesiologists, we can begin with eliminat-
ing (or drastically reducing) desflurane venting into
the air and have an impact on health care’s contribu-
tion to climate change immediately.
DESFLURANE’S OUTSIZED POLLUTION PROFILE
Large hospitals are approximately 2% of US com-
mercial floor space but consume 4.3% of all energy
delivered to the commercial sector.16 Operating suites
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with multiple cycles of conditioned air per hour,
bright lighting, and complex electrical machinery
are high consumers of energy. A recent study exam-
ined the impact of ORs on greenhouse gas emissions.
Interestingly, in hospitals that used a disproportion-
ate amount of desflurane (1 in Canada and 1 in the
United States), anesthetic gases were responsible for
over 50% of the greenhouse gas equivalents created in
the OR; in the institution that did not use desflurane,
anesthetic gas contributed only 4% (nitrous oxide use
was negligible at all 3 of these institutions).17
For clarification, while the desflurane vaporizer is
unique among volatile anesthesia vaporizers in requir-
ing electricity, the amount of electrical energy is mini-
mal.18 The actual desflurane molecules released into the
atmosphere are responsible for the vast majority of green-
house gas emissions attributable to desflurane usage.
The overall contribution of anesthetic gases to total
health care greenhouse gas burden has been estimated
at 2% in England’s National Health Service  (NHS).
To contextualize this number, the NHS Sustainable
Development Unit estimates a single hour of anes-
thesia; using the most carbon-intensive volatile anes-
thetic (eg, desflurane) is similar to the emissions from
driving 370 km in a gas-powered automobile.19 By
abstaining from (or dramatically reducing) desflu-
rane, anesthesiologists can make a large reduction in
these emissions with likely no clinical implications.
DESFLURANE’S EXPENSE TO A HEALTH CARE
SYSTEM
A MAC-hour of desflurane has been calculated to cost
$12.96 when used at 1 L of fresh gas flow; this is 2
times more expensive than sevoflurane (at 1 L of fresh
gas flow) and 25 times more expensive than isoflu-
rane (at 1 L of fresh gas flow).4 A recent study from
Hungary calculated an hour of sevoflurane anesthe-
sia to be (including all disposables and other pharma-
ceuticals) to be €12.15 ± 5.32 and an hour of propofol
anesthesia (including all disposables and other phar-
maceuticals) to be €13.23 ± 4.23.20 Extrapolating the
cost per MAC-hour ratio of the different anesthesia
choices, it is likely a MAC-hour of desflurane is gen-
erally more expensive than a MAC-hour of propofol
(disposables included).
Reducing or eliminating desflurane brings a finan-
cial benefit to institutions. Wake Forest Baptist Health
(Winston-Salem, NC) educated its anesthesiologists,
anesthetists, and trainees about volatile anesthetics
and emphasized the appropriateness of isoflurane in
many scenarios. By shifting away from more expen-
sive agents (eg, desflurane), they have calculated over
$1.8 million in savings, or approximately $1000 per
day.21 Similar results were found at the University of
Wisconsin (Madison, WI) where they estimate saving
$25,000 per month.22
ANESTHESIA & ANALGESIA
 EE The Open Mind

Figure 1. Global social cost of volatile anesthesia choice. The global social cost (expected economic damage) of carbon dioxide has recently
been estimated at a median of $417 per ton. A, The social cost of anesthetic emissions is calculated for different volatile agents and different
FGF. B, The social cost of anesthetic emissions is normalized to the option with the lowest social cost per MAC-hour (isoflurane at half a liter
of FGF). Notably, data for sevoflurane were only available for 2 L of FGF and not for lower flows. CDE 20 indicates carbon dioxide equivalents
over 20 y; FGF, fresh gas flow; MAC-hour, minimum alveolar content per hour (measure of anesthesia that 50% of patients will not respond
to surgical stimulus).

ARE THERE APPLICATIONS FOR DESFLURANE IN
OPERATING ROOM ANESTHESIA?
The coronavirus disease 2019 (COVID-19) pandemic
may provide a setting for desflurane to be used. In
hospitals where conservation of personal protec-
tive equipment (PPE) is paramount, patients may go
through phase 1 of anesthesia recovery in the OR to
reduce consumption of PPE by recovery room staff
and risk of contamination of recovery room staff and
the physical plant.23 In this situation, the potential
OR efficiency gained using desflurane over other
inhaled anesthetics24 may result in more cases per-
formed during scheduled OR hours while reducing
PPE consumption and risk of transmission to staff
and other patients. The novelty and complexity of
this situation warrants additional analysis especially
considering the relationship between desflurane and
coughing25 and thus the aerosolization of respiratory
secretions.
There are many different systems of OR anes-
thesia throughout the world.  Undeniably, there are
instances where the pharmacodynamics of desflurane
could improve the focused definition of OR efficiency
(surgery per unit time). In general, these situations
involve individual ORs where the final procedure (or
procedures) could be performed inside of a scheduled
workday8 if the occurrence of prolonged extubation
time (>15 minutes) could be reduced.26 Meta-analyses
comparing desflurane to isoflurane24 and sevoflu-
rane27 found that desflurane was associated with
markedly fewer prolonged extubations. Desflurane
may also be of unique value in hospitals without
recovery rooms, such as in many hospitals in Japan.28
However, while all of these instances may improve
OR efficiency, we must balance the importance of OR
efficiency against broader societal goals. The social
cost (expected economic damage) of greenhouse gas
emissions29 associated with anesthetic choice3 may
be 12 times more (or greater depending on fresh gas
flow) for desflurane than for isoflurane (see Figure 1).
Considering this negative externality alongside of the
calculation of OR efficiency may make desflurane less
economical in many of these situations.
ELIMINATING DESFLURANE
Remove It
One way to ensure desflurane usage is reduced is to
eliminate the vaporizers. This can be accomplished by
leadership or grassroots support from a majority of a
department or practice. Simply removing vaporizers
streamlines the OR because it will be an entire set of
vaporizers that no longer need to be maintained and an
entire drug that no longer needs to be purchased and
stocked. However, this approach may not be popular
because individual clinicians may recoil if they believe
financial policy is limiting their clinical practice.
Educate on It
Wake Forest demonstrated the efficacy of focused
education encouraging usage of a volatile anes-
thetic besides desflurane. While they published
data related to the financial impact,21 it is likely that
the impact on greenhouse gases is as impressive.
Education should be directed toward the values of
the audience. Depending on your colleagues, educa-
tion can focus on environmental stewardship, clinical

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Copyright © 2020 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
 Desflurane Should Des-appear
appropriateness, or financial savings—because all 3 of
these approaches are valid and can motivate different
clinicians.
Meaningful Change
The elimination of desflurane is a large step toward
improving the greenhouse gas footprint of an OR.
However, there are a few other behaviors that must be
discussed to ensure the change is not counterproduc-
tive (Figure  2). First, nitrous oxide must not be sub-
stituted for a quick-acting anesthetic gas. Along with
desflurane, nitrous oxide is a bad greenhouse gas—its
GWP20 is 289 and this underestimates its impact sig-
nificantly because it will exist in the atmosphere for
114 years.3 A single hour’s application of 50% nitrous
oxide with 50% air at only 1 L of fresh gas flow may
create equivalent greenhouse gas emissions as driv-
ing an automobile 120 km—there are some who argue
nitrous oxide has a larger impact on anesthetic-related
greenhouse gas creation than desflurane.30 From the
perspective of climate change, nitrous oxide should
be avoided unless clinically imperative.
Second, low-flow anesthesia should be practiced; all
volatile anesthetics should be delivered with the mini-
mum, clinically appropriate fresh gas flow. Historically,
the US Food and Drug Administration’s recommenda-
tion of at least 2 L of fresh gas flow for sevoflurane
anesthesia (concern related to compound A) has been
a barrier to the adoption of low-flow anesthesia tech-
niques in the United States. However, the Chair of the
Committee on Technology at the Anesthesia Patient
Safety Foundation published “Based upon the lit-
erature, we believe that our recommendation to use
absorbents without KOH and low concentrations of
NaOH is sound, and supports the safe use of low-flow
or closed-circuit anesthesia in the presence of sevo-
flurane.”31 Hopefully, adoption of this carbon dioxide
absorbent technology along with said guidance from
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Figure 2. Reducing the global/
financial costs of general anes-
thesia. Here are a few simple
maneuvers an anesthesiologist
can do to reduce the cost of
his/her work on departmental
finances and global environ-
mental health. GHG indicates
greenhouse gas; GWP20, global
warming potential over 20 y;
MAC-hour, minimum alveolar
content per hour (measure of
anesthesia that 50% of patients
will not respond to surgical
stimulus).
the Anesthesia Patient Safety Foundation will accel-
erate the adoption of this important practice in the
United States. Extrapolating from earlier research,3
low-flow sevoflurane anesthesia has the least green-
house gas impact of any volatile anesthetic. For partic-
ularly attentive anesthesia practitioners, closed-circuit
technique can be performed that absolutely minimizes
the amount of volatile anesthetic used and released
into the environment by supplying only enough fresh
gas to fulfill metabolic requirements.32
Dr Sherman’s group from Yale Health (New Haven,
CT) took many of the aforementioned principles
and developed a smart phone application called Yale
Gassing Greener (https://publichealth.yale.edu/cli-
mate/research/conferences/challenge/) to assist in
anesthesia planning. Clinicians enter the medications
they plan on using, and the application calculates cost
and greenhouse gas emissions. This is a phenomenal
tool for anesthetists throughout the world interested in
environmental and financial stewardship.
Anesthesiology as a profession reaches into many
aspects of the health care system beyond the OR.
While outside the scope of this article, it is important
to note that anesthesiologists can and should improve
health care efficiency beyond anesthetic gases and
fresh gas flows. Anesthesiologists can modify technol-
ogy, consumable, and pharmacy choices by consider-
ing life cycle analyses; they can improve recycling and
waste reduction efforts inside and outside the OR;
and they can influence system-wide decisions related
to energy—the limitation is creativity and motivation.
Organizations throughout the world engaged with
broader perioperative efficiency and environmental
initiatives are listed in Figure 3.
Why It Matters
A counter argument to eliminating desflurane usage
is that anesthetic gases are not a major greenhouse gas
ANESTHESIA & ANALGESIA
 EE The Open Mind
contributor and therefore not worth modifying. One
estimate of the total greenhouse gas impact of anes-
thetic gases calculates anesthetic gases to have 0.01%
that of fossil fuel consumption.33 While that is likely
an underestimation of volatile anesthesia greenhouse
gas impact, because the calculations come from an
institution with limited desflurane usage,34 even
if anesthetic gases are only the first of 10,000 steps
needed to arrive at the solution, we will never reach
our destination without taking that step.
Stop Using Desflurane
Many institutions have already decreased their
usage of desflurane—for both financial reasons as at
Wake Forest,21 and climate change concerns as at the
University of Wisconsin.22 With limited desflurane
usage, these institutions continue to provide anes-
thesia services for a wide range of patient acuity and
surgical complexity. Almost all patients can undergo
anesthesia without desflurane.
There is multinational interest in decreasing the
usage of desflurane.35,36 The NHS in the United
Kingdom explicitly states “The NHS Long Term
Plan aims for a 51% reduction in the NHS carbon
footprint by 2025, with 2% of this to come through
‘transforming anaesthetic practices’ such as using
alternatives to desflurane.”37 And the American Society
of Anesthesiologists has a specific Inhaled Anesthetic
Challenge 2020 with a focus on reducing desflurane
usage.38 With health care’s emphasis on value-based
care, considering what we know about desflurane’s
financial and environmental costs, the onus is on the
clinician39 to have evidence for improved outcomes for
their patient when choosing desflurane.
It is rare when a single clinical behavior can reduce
either OR cost or environmental harm. Avoiding
desflurane will do both. While eliminating desflu-
rane will not alone solve the climate crisis, it is a step
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Figure 3. Organizations through-
out the world engaged with OR
efficiency and environmental
sustainability. OR indicates
operating room.
toward solving the climate crisis. Most importantly,
it can be done today and does not need any advance
in technology or implementation of government pol-
icy. Collectively as anesthesiologists, we can make
an instantaneous reduction in greenhouse gases and
have a positive impact on global health, by simply
turning off the desflurane canister. E
ACKNOWLEDGMENTS
I thank Dr Aaron Bernstein for planting the seed for
this manuscript. I thank Drs Marcel Durieux and Jodi
Sherman for reviewing initial manuscripts. I thank Dr
Martin Vollmer for his atmospheric research on volatile
anesthetics and his rapid response to my inquiry. I thank
the clinician anesthesiologists (many cited in this article)
who have led the way researching the global health
implications of the practice of anesthesia. I thank my col-
leagues at the Department of Anesthesiology, University
of Virginia, for their support in our effort to make our
anesthesia practice more sustainable while maintaining
excellent quality of care.
‍DISCLOSURES
Name: Matthew J. Meyer, MD.
Contributions: This author helped design, research, write, and
revise the manuscript.
This manuscript was handled by: Ken B. Johnson, MD.
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