No more desflurane

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pgg

pgg

Laugh at me, will they?
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I just got an email from one of the hospitals where I work stating that desflurane is being removed from the ORs in order to "avoid approximately 1,671 metric tons of CO2 from being released into the atmosphere."

Anyone else hearing this from your hospitals?
 
The place where I did residency got rid of des in 2013. The place I'm at now has a couple vaporizers floating around but use is rare even though anyone is free to use them. Des is superfluous, and I say this as someone who does 2 gastric sleeves a day with surgeons who take 3 hrs+.
 
Des was removed from our university hospital (where the inventor of Des is a Professor Emeritus), but we still have some vaporizers at the VA. The rationale was the GWP20 (global warming potential over 20 yrs, per mol) being so much higher than sevo. I have wondered, and I'd love some other opinions, whether sevo, run at the usual 2 l/min, ultimately puts more sevo molecules into the atmosphere compared to Des run at low-flow/closed-ish circuit, and whether this would offset the difference in GWP20. I mean, it's not like sevo's is zero, and if you're scavenging all that sevo out to the sky at higher flows, wouldn't this ultimately be worse than des?
 
cchoukal said:
Des was removed from our university hospital (where the inventor of Des is a Professor Emeritus), but we still have some vaporizers at the VA. The rationale was the GWP20 (global warming potential over 20 yrs, per mol) being so much higher than sevo. I have wondered, and I'd love some other opinions, whether sevo, run at the usual 2 l/min, ultimately puts more sevo molecules into the atmosphere compared to Des run at low-flow/closed-ish circuit, and whether this would offset the difference in GWP20. I mean, it's not like sevo's is zero, and if you're scavenging all that sevo out to the sky at higher flows, wouldn't this ultimately be worse than des?
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Who still does 2L/min with Sevo?
I've been doing <0.5L/min for 10 years...

1 ETH kickback from Nephro per dialysis patient is a sweet deal.
 
cchoukal said:
Des was removed from our university hospital (where the inventor of Des is a Professor Emeritus), but we still have some vaporizers at the VA. The rationale was the GWP20 (global warming potential over 20 yrs, per mol) being so much higher than sevo. I have wondered, and I'd love some other opinions, whether sevo, run at the usual 2 l/min, ultimately puts more sevo molecules into the atmosphere compared to Des run at low-flow/closed-ish circuit, and whether this would offset the difference in GWP20. I mean, it's not like sevo's is zero, and if you're scavenging all that sevo out to the sky at higher flows, wouldn't this ultimately be worse than des?
Click to expand...

I always low flow my sevo
 
🤦‍♂️. My reaction when I go into a case and see the crna has done Sevo for the four hour case, switch to Des for last 45 minutes and then nitrous at the very end. Wtf. If you know the theory behind low flow techniques you can wake people up when the drapes drop.
 
PainDrain said:
🤦‍♂️. My reaction when I go into a case and see the crna has done Sevo for the four hour case, switch to Des for last 45 minutes and then nitrous at the very end. Wtf. If you know the theory behind low flow techniques you can wake people up when the drapes drop.
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Or just keep them 0.7 MAC of gas and ETCO2 of 40 with muscle relaxant instead of 1.2 MAC and ETCO2 of 30 that I always see these CRNAs do.
 
The amount of trash we generate is just shocking. I've got to think this is a bigger issue than the impact of volatile anesthetics. We have these single use, disposable plastic laryngoscopes that drive me insane. They're poor quality and generate so much plastic waste.

I'd be curious to see some sort of environmental impact comparison of volatile anesthetics vs TIVA. Less greenhouse gas vs more plastic waste.
 
STLINI said:
The amount of trash we generate is just shocking. I've got to think this is a bigger issue than the impact of volatile anesthetics. We have these single use, disposable plastic laryngoscopes that drive me insane. They're poor quality and generate so much plastic waste.

I'd be curious to see some sort of environmental impact comparison of volatile anesthetics vs TIVA. Less greenhouse gas vs more plastic waste.
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The whole laryngoscope is disposable??? I've seen some of those and they were just horrible. I feel bad about throwing away the cover on the mcgrath. I feel like just washing and reusing them.

I definitely mac as many of my patients as possible and minimize my syringe and needle use. I see people going nuts giving precedex boluses, new syringes for every medication, have 3 different tubes open and ready to go, 2 prop sticks drawn up for a 90 year old 30 kg lady, running 2+L a min for no reason etc. The amount of waste that academics teaches you to generate is just crazy.
 
GassYous said:
The whole laryngoscope is disposable??? I've seen some of those and they were just horrible. I feel bad about throwing away the cover on the mcgrath. I feel like just washing and reusing them.

I definitely mac as many of my patients as possible and minimize my syringe and needle use. I see people going nuts giving precedex boluses, new syringes for every medication, have 3 different tubes open and ready to go, 2 prop sticks drawn up for a 90 year old 30 kg lady, running 2+L a min for no reason etc. The amount of waste that academics teaches you to generate is just crazy.
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The whole thing is disposable. The handle is all plastic plus batteries and the blade is some ****ty malleable metal-probably aluminum I guess. All goes in the trash. The saddest thing is they're really crappy too, the light is always quite dim. It's obviously a minority of our trash but it drives me crazy. Our hospital has gone like 90% Glidescope though since COVID started. So thats a plastic cover in the garbage every time as well.
 
STLINI said:
The whole thing is disposable. The handle is all plastic plus batteries and the blade is some ****ty malleable metal-probably aluminum I guess. All goes in the trash. The saddest thing is they're really crappy too, the light is always quite dim. It's obviously a minority of our trash but it drives me crazy. Our hospital has gone like 90% Glidescope though since COVID started. So thats a plastic cover in the garbage every time as well.
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Oh yes we used those in residency. I don't get why you can't just wipe down the handle. So many batteries used for 15 seconds and then will rot in a landfill forever. I'm assuming it is related to those *****s at jcaho who should be charged for crimes against the environment. I still remember that post where someone said they use 70 masks a day after getting cited by those useless idiots.

PainDrain said:
🤦‍♂️. My reaction when I go into a case and see the crna has done Sevo for the four hour case, switch to Des for last 45 minutes and then nitrous at the very end. Wtf. If you know the theory behind low flow techniques you can wake people up when the drapes drop.
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wtf is the point of that? Horrible for the environment

I run flows at 0.5 whenever I can. I used to use nitrous for the last 10 mins of every case and realized that it was not necessary. No one has recall.
 
GassYous said:
The whole laryngoscope is disposable??? I've seen some of those and they were just horrible. I feel bad about throwing away the cover on the mcgrath. I feel like just washing and reusing them.

I definitely mac as many of my patients as possible and minimize my syringe and needle use. I see people going nuts giving precedex boluses, new syringes for every medication, have 3 different tubes open and ready to go, 2 prop sticks drawn up for a 90 year old 30 kg lady, running 2+L a min for no reason etc. The amount of waste that academics teaches you to generate is just crazy.
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Not for nothing, the ASA (and the AANA, for that matter) has a “one syringe, one med, one patient” guideline, discouraging the re-use of syringes…

Here’s the CDC policy to which the ASA refers:

One and Only Campaign | Injection Safety | CDC

The One & Only Campaign is a public health educational effort to raise awareness among patients and healthcare providers about safe injection practices.
www.cdc.gov www.cdc.gov
 
I'm not telling you to reuse syringes for other patients...

But you can induce with one syringe, put the prop lido roc fent decadron zofran all in there. Draw up the ancef in that syringe and push. Then use it again for the toradol, sugammadex at the end. For lma cases I only draw up meds once and use one syringe.
 
I like desflurane. Obviously I can live without it. And I figure eventually we'll look back at all volatile anesthetics the way we look at halothane and cyclopropane.

Of course anyone can wake up anyone with any gas at any time. There is a benefit to desflurane though, and that is that it continues to off-gas much more quickly than iso or sevo after the patient is awake, and the time between MAC-just-woke-up and MAC-totally-awake is much less. Whether that matters or is even desirable in some cases is debatable, but des absolutely does have unique properties that can be exploited.

Cost is a non issue. Seriously does anyone really care about a case costing $11 for low flow des vs $9 for package-insert-flow sevo vs $3 for low flow sevo vs $.17 for any-flow iso? I saw an orthopod drop a hip prosthetic on the floor when I was a resident, and we've all seen five figures of factor 7 given to a dying bleeding patient so they die with clots instead, and there's a shopping bag full of expired prosthetic heart valves on my desk right now because someone forgot to exchange stock with the manufacturer in time. I've got enough anesthesia cost-of-care credit karma banked for a dozen lifetimes. I couldn't possibly care less about the cost of des vs sevo.

It irritates me that someone who's never set foot in an OR is making formulary decisions though - and for a explicitly NON-MEDICAL reason. I'm still salty about losing droperidol all these years later, but at least that was superficially grounded in some pseudo-medical concerns.

Getting rid of desflurane because of its CO2 burden is ... weird.
 
I used to work at a place where some people would run high flows on des an entire case… Then leave flows on over night as well… So it made me wonder about how much carbon monoxide poisoning occurred due to desiccated absobant. Also makes me wonder how many hundreds of thousands of dollars were wasted over the years.
 
Guillemot said:
I used to work at a place where some people would run high flows on des an entire case… Then leave flows on over night as well… So it made me wonder about how much carbon monoxide poisoning occurred due to desiccated absobant. Also makes me wonder how many hundreds of thousands of dollars were wasted over the years.
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I interviewed at a PP recently, and the interview process was basically to chat with a few of the partners, which meant hanging out in their cases and talking during a case. One of the partners was in the middle of a lap whatever and had the des pegged at 8% on 4L/min the whole time. I guess they don't pay for their supplies.
 
GassYous said:
i only use iso and my patients wake up on a dime. don't know what the point of des is, seems unnecessarily expensive and wasteful
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Des is more insoluble than nitrous... It's metabolism in the body is 10 x less than iso and at least 1000x less than sevo if that's your bag.
 
Nice thought. 40 years late. The last time there was this much CO2 in the atmosphere in the geologic record the earth was 8 degrees Celsius warmer than it is now (at a MINIMUM, may have been as much as 12). The Arctic circle was an alien boiling swamp of endless twilight .
we are emitting CO2 and methane at a rate never before seen in earths history, including the PT extinction event. It’s actually mind boggling how not even massive primordial volcanism even comes close.

Earth will return to a hothouse Eocene Pliocene climate, or probably worse, with permanent wet bulb conditions that will exterminate humanity. Sorry
 
T-burglar said:
Nice thought. 40 years late. The last time there was this much CO2 in the atmosphere in the geologic record the earth was 8 degrees Celsius warmer than it is now (at a MINIMUM, may have been as much as 12). The Arctic circle was an alien boiling swamp of endless twilight .
we are emitting CO2 and methane at a rate never before seen in earths history, including the PT extinction event. It’s actually mind boggling how not even massive primordial volcanism even comes close.

Earth will return to a hothouse Eocene Pliocene climate, or probably worse, with permanent wet bulb conditions that will exterminate humanity. Sorry
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You are as optimistic as I 👍
 
T-burglar said:
Nice thought. 40 years late. The last time there was this much CO2 in the atmosphere in the geologic record the earth was 8 degrees Celsius warmer than it is now (at a MINIMUM, may have been as much as 12). The Arctic circle was an alien boiling swamp of endless twilight .
we are emitting CO2 and methane at a rate never before seen in earths history, including the PT extinction event. It’s actually mind boggling how not even massive primordial volcanism even comes close.

Earth will return to a hothouse Eocene Pliocene climate, or probably worse, with permanent wet bulb conditions that will exterminate humanity. Sorry
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But, how will it affect my stocks?
 
dr doze said:
But, how will it affect my stocks?
Click to expand...
pgg said:
I just got an email from one of the hospitals where I work stating that desflurane is being removed from the ORs in order to "avoid approximately 1,671 metric tons of CO2 from being released into the atmosphere."

Anyone else hearing this from your hospitals?
Click to expand...
Given that line of reasoning they should also get rid of nitrous oxide. Since nitrous is cheap I doubt that will happen. 😏🙈
 
PainDrain said:
🤦‍♂️. My reaction when I go into a case and see the crna has done Sevo for the four hour case, switch to Des for last 45 minutes and then nitrous at the very end. Wtf. If you know the theory behind low flow techniques you can wake people up when the drapes drop.
Click to expand...
I compare people that call this their art of anesthesia to Jackson Pollock.🤪
 
The amazing thing is that people are just pumping methane into the air all over the country but especially in Texas. Unburned, unused just letting it vent out and acting like there's nothing we can do to stop it. I could let my car idle for the rest of my life and it wouldn't even come close to the damage that one of these smokestacks are doing in a month.
 
narcusprince said:
I disagree. Des/nitrous wakeups are fast. What do you know about precedex reversal with narcan? Thats faster…..
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They are fast, but switching to des/nitrous at the end screams amateur. And using precedex screams amateur also in my opinion.. The less you use the more of a pro you are.... Sorta like surgeons... some surgeons need only 2-3 instruments to do a surgery but same surgery and some surgeons need 3 trays......... Freakin Amateurs..
 
pgg said:
I like desflurane. Obviously I can live without it. And I figure eventually we'll look back at all volatile anesthetics the way we look at halothane and cyclopropane.

Of course anyone can wake up anyone with any gas at any time. There is a benefit to desflurane though, and that is that it continues to off-gas much more quickly than iso or sevo after the patient is awake, and the time between MAC-just-woke-up and MAC-totally-awake is much less. Whether that matters or is even desirable in some cases is debatable, but des absolutely does have unique properties that can be exploited.

Cost is a non issue. Seriously does anyone really care about a case costing $11 for low flow des vs $9 for package-insert-flow sevo vs $3 for low flow sevo vs $.17 for any-flow iso? I saw an orthopod drop a hip prosthetic on the floor when I was a resident, and we've all seen five figures of factor 7 given to a dying bleeding patient so they die with clots instead, and there's a shopping bag full of expired prosthetic heart valves on my desk right now because someone forgot to exchange stock with the manufacturer in time. I've got enough anesthesia cost-of-care credit karma banked for a dozen lifetimes. I couldn't possibly care less about the cost of des vs sevo.

It irritates me that someone who's never set foot in an OR is making formulary decisions though - and for a explicitly NON-MEDICAL reason. I'm still salty about losing droperidol all these years later, but at least that was superficially grounded in some pseudo-medical concerns.

Getting rid of desflurane because of its CO2 burden is ... weird.
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Doesn’t mean we shouldn’t strive to use the least expensive and environmentally friendly gas, so long as there is no clinical difference. I think you can wake people up from sevo just as fast, it’s the only gas you need, it does it all.

I think iso works great too, it can replace all gases for everything but mask inductions. The wake ups take a little longer, but only in the order of minutes, and there is definitely less emergence combative delirium with iso.
 
Took a look into this and came away surprised by the data:

Running desflurane at 6% with flows of 2l/min is 134 kg co2 per hour.

Sevo 2.2% at 2l is 2.8 kg co2 per hour.

Iso is 5.2 kg co2 per hour

nitrous is about 30 kg per hour for 50%.

conversely plastic tubing etc is on the order of 4x the weight of plastic as co2 (assuming it’s all combusted as medical waste - no recycling here). So for 134 kg co2 = 33.5 kg plastic tubing/syringes/glide scopes or 74lb…every hour.

A 20ml syringe is 15 grams or 0.015kg, 0.060 kg co2. So per hour of des that’s 558 20 ml syringes. Or per hour of sevo that’s still 46 20 ml syringes worth per hour.


So take home message for me was:

Plastic waste in anesthesia is small potatoes unless you’re already doing TIVA.

Desflurane really is that bad.

Nitrous is probably best used judiciously, but also not that bad if used just at the end of the case.
 
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I never use Desflurane, but a single nuclear power plant reduces CO2 emissions by millions of metric tons every year. Had we increased our Nuclear Capacity going back to just 1995 we could have reduced CO2 emissions by hundreds of BILLIONS of metric tons.

Just saying. Eliminating Desflurane from ORs does as much to help reduce the adverse effects of climate change as switching brands of toilet paper has on the budget of a hospital.
 
Used to use des/nitrous all the time in residency for the wakeups. I usually use sevo now because the des vaporizer is always empty. Haven’t noticed much of a difference.....
 
<(^_^)> said:
Took a look into this and came away surprised by the data:

Running desflurane at 6% with flows of 2l/min is 134 kg co2 per hour.

Sevo 2.2% at 2l is 2.8 kg co2 per hour.

Iso is 5.2 kg co2 per hour

nitrous is about 30 kg per hour for 50%.

conversely plastic tubing etc is on the order of 4x the weight of plastic as co2 (assuming it’s all combusted as medical waste - no recycling here). So for 134 kg co2 = 33.5 kg plastic tubing/syringes/glide scopes or 74lb…every hour.

A 20ml syringe is 15 grams or 0.015kg, 0.060 kg co2. So per hour of des that’s 558 20 ml syringes. Or per hour of sevo that’s still 46 20 ml syringes worth per hour.


So take home message for me was:

Plastic waste in anesthesia is small potatoes unless you’re already doing TIVA.

Desflurane really is that bad.

Nitrous is probably best used judiciously, but also not that bad if used just at the end of the case.
Click to expand...
I don’t really know the chemistry of this? Are these numbers kg equivalent of CO2 that contributes to global warming? Or do volatile anesthetics change somehow into CO2?
 
ProwlerturnGas said:
I don’t really know the chemistry of this? Are these numbers kg equivalent of CO2 that contributes to global warming? Or do volatile anesthetics change somehow into CO2?
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The “equivalent co2” is not the whole story, have to look at how long the gas stays before decomposing in the atmosphere, nitrous is a greenhouse gas that lasts a very long time, it should be eliminated from practice.
 
dipriMAN said:
I never understood why it’s still in the anesthesia machine. Maybe it used to be useful for wake ups or for mask inductions.
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Used it a bit in the children's hospital as a resident, it is less pungent than sevo so we start with nitrous in a scented mask then crank up the sevo after. For adults who are extreme needle phobic I've done mask inductions before but go straight to sevo.

I've never used nitrous as maintenance anesthetic and I've never used nitrous for speeding up emergence because sevo works just fine.

Maybe when they were using iso it made a difference?
 
coffeebythelake said:
Used it a bit in the children's hospital as a resident, it is less pungent than sevo so we start with nitrous in a scented mask then crank up the sevo after. For adults who are extreme needle phobic I've done mask inductions before but go straight to sevo.

I've never used nitrous as maintenance anesthetic and I've never used nitrous for speeding up emergence because sevo works just fine.

Maybe when they were using iso it made a difference?
Click to expand...

It did help a little with iso, but High concentration Nitrous/morphine with a whiff of agent is a beautiful anesthetic with a picture perfect emergence. Loved it, until it was shown to be suboptimal.
 
coffeebythelake said:
Used it a bit in the children's hospital as a resident, it is less pungent than sevo so we start with nitrous in a scented mask then crank up the sevo after. For adults who are extreme needle phobic I've done mask inductions before but go straight to sevo.

I've never used nitrous as maintenance anesthetic and I've never used nitrous for speeding up emergence because sevo works just fine.

Maybe when they were using iso it made a difference?
Click to expand...

Nitrous made a difference with halothane and enflurane. The newer agents made it obsolete IMO.
 
coffeebythelake said:
Can you explain what is it with this nitrous morphine technique that made things so smooth?
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Nitrous for the last 20 minutes of the case while the iso is coming off IS smooth as butter. It's a "tap them on the forehead and they open their eyes" kind of wake-up. Of course, i think this is also possible with iso alone, but much harder to time well.
 
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