Desflurane, once hailed as a revolutionary volatile anesthetic for its rapid onset and recovery times, is increasingly falling out of favor in modern anesthetic practice. The movement away from desflurane is driven by a combination of environmental concerns, the availability of more efficient alternatives, and a reevaluation of its overall clinical benefits.
One of the primary reasons for the movement away from desflurane is its significant environmental impact. Desflurane is a potent greenhouse gas with a global warming potential that is significantly higher than that of other inhaled anesthetics. Specifically, desflurane’s global warming potential is over 2,500 times that of carbon dioxide, making it one of the most environmentally harmful anesthetic gases 1. In recent years, the healthcare industry has become increasingly aware of its carbon footprint and the role that anesthetic gases play in contributing to climate change. Anesthesia providers and institutions are being urged to adopt more sustainable practices, which include reducing or eliminating the use of high global warming potential substances like desflurane. This environmental consciousness is driving a shift toward anesthetic agents with a lower environmental impact, such as sevoflurane and isoflurane 2,3.
The development and refinement of other inhaled anesthetics have also facilitated the movement away from desflurane. Sevoflurane, for example, offers many of the same advantages as desflurane, including rapid induction and emergence from anesthesia, but with fewer environmental drawbacks. Sevoflurane is well-tolerated by patients, has a relatively low blood-gas partition coefficient (which contributes to its fast onset and recovery), and is associated with less airway irritation compared to desflurane 4,5.
In addition, isoflurane, while slower in onset and recovery compared to both desflurane and sevoflurane, remains a reliable and cost-effective alternative, particularly in settings where rapid turnover is less critical. Moreover, isoflurane’s global warming potential is much lower than that of desflurane, making it a more environmentally friendly choice 4.
The increased availability and use of total intravenous anesthesia have also played a role in reducing reliance on volatile anesthetics like desflurane. Total intravenous anesthesia, which involves the administration of anesthetic drugs intravenously, offers several benefits, including reduced postoperative nausea and vomiting, stable hemodynamics, and the elimination of anesthetic gas emissions 6.
While desflurane was initially favored for its rapid onset and recovery characteristics, subsequent experience and research have led to a reevaluation of its clinical advantages. The rapid emergence from anesthesia provided by desflurane, while beneficial in certain situations, is not always necessary, particularly when other agents can achieve similar outcomes without the associated environmental costs.
Furthermore, desflurane is known to cause airway irritation, which can lead to coughing, laryngospasm, and increased sympathetic stimulation during induction and emergence. These side effects can be particularly problematic in patients with reactive airways or those at risk of cardiovascular complications. The availability of other agents that provide comparable benefits with fewer side effects has made desflurane less appealing in routine clinical practice 7–9.
The movement away from desflurane reflects a broader trend in anesthetic practice toward sustainability, patient safety, and cost-effectiveness. As environmental concerns become increasingly important to healthcare decision-making, and as alternative anesthetics continue to improve, desflurane’s role in clinical practice is likely to diminish further.
References
1. Ryan, S. M. & Nielsen, C. J. Global warming potential of inhaled anesthetics: Application to clinical use. Anesth. Analg. 111, 92–98 (2010). DOI: 10.1213/ANE.0b013e3181e058d7
2. Sulbaek Andersen, M. P., Nielsen, O. J. & Sherman, J. D. Assessing the potential climate impact of anaesthetic gases. Lancet Planet. Heal. 7, e622–e629 (2023).doi: 10.1016/S2542-5196(23)00084-0
3. Patel, S. D. & Smith-Steinert, R. Greening the operating room, one procedure at a time. J. Clim. Chang. Heal. (2021). doi:10.1016/j.joclim.2021.100014
4. Varughese, S. & Ahmed, R. Environmental and Occupational Considerations of Anesthesia: A Narrative Review and Update. Anesth. Analg. (2021). doi:10.1213/ANE.0000000000005504
5. Reducing the Environmental Impact of Anesthesia | Clinical View. Available at: https://clinicalview.gehealthcare.com/article/practical-ways-reduce-environmental-impact-anesthesia.
6. Bajwa, S. J. S. et al. Recent advancements in total intravenous anaesthesia and anaesthetic pharmacology. Indian J. Anaesth. (2023). doi:10.4103/ija.ija_1022_22
7. Shelton, C. L., Sutton, R. & White, S. M. Desflurane in modern anaesthetic practice: walking on thin ice(caps)? British Journal of Anaesthesia (2020). doi:10.1016/j.bja.2020.09.013
8. Kapoor, M. C. & Vakamudi, M. Desflurane-Revisited. J. Anaesthesiol. Clin. Pharmacol. (2012). doi:10.4103/0970-9185.92455
9. Moonesinghe, S. R. Desflurane decommissioning: more than meets the eye. Anaesthesia (2024). doi:10.1111/anae.16219