Predicting cost of inhalational anesthesia at low fresh gas flows: impact of a new generation carbon dioxide absorbent

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Abstract

It is well known that low fresh gas flows result in lower cost of inhalational agents. A new generation of carbon dioxide absorbents allows low flow anesthesia with all anesthetics but these new compounds are more expensive. This study examines the cost of inhalational anesthesia at different fresh gas flows combined with the cost of absorbent. The cost of sevoflurane and desflurane is lower at low fresh gas flows. Paradoxically the cost of isoflurane is cheaper at 2 L/min than at lower fresh gas flows due to increased cost of carbon dioxide absorbent. Therefore low fresh gas flows should be used when feasible with sevoflurane and desflurane, but higher fresh gas flows up to 2 L/min may be more economical with isoflurane during maintenance phase of anesthesia.

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Most cited references 20

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Life cycle greenhouse gas emissions of anesthetic drugs.

Jodi Sherman, Cathy Le, Vanessa Lamers … (2012)

Anesthesiologists must consider the entire life cycle of drugs in order to include environmental impacts into clinical decisions. In the present study we used life cycle assessment to examine the climate change impacts of 5 anesthetic drugs: sevoflurane, desflurane, isoflurane, nitrous oxide, and propofol. A full cradle-to-grave approach was used, encompassing resource extraction, drug manufacturing, transport to health care facilities, drug delivery to the patient, and disposal or emission to the environment. At each stage of the life cycle, energy, material inputs, and emissions were considered, as well as use-specific impacts of each drug. The 4 inhalation anesthetics are greenhouse gases (GHGs), and so life cycle GHG emissions include waste anesthetic gases vented to the atmosphere and emissions (largely carbon dioxide) that arise from other life cycle stages. Desflurane accounts for the largest life cycle GHG impact among the anesthetic drugs considered here: 15 times that of isoflurane and 20 times that of sevoflurane on a per MAC-hour basis when administered in an O(2)/air admixture. GHG emissions increase significantly for all drugs when administered in an N(2)O/O(2) admixture. For all of the inhalation anesthetics, GHG impacts are dominated by uncontrolled emissions of waste anesthetic gases. GHG impacts of propofol are comparatively quite small, nearly 4 orders of magnitude lower than those of desflurane or nitrous oxide. Unlike the inhaled drugs, the GHG impacts of propofol primarily stem from the electricity required for the syringe pump and not from drug production or direct release to the environment. Our results reiterate previous published data on the GHG effects of these inhaled drugs, while providing a life cycle context. There are several practical environmental impact mitigation strategies. Desflurane and nitrous oxide should be restricted to cases where they may reduce morbidity and mortality over alternative drugs. Clinicians should avoid unnecessarily high fresh gas flow rates for all inhaled drugs. There are waste anesthetic gas capturing systems, and even in advance of reprocessed gas applications, strong consideration should be given to their use. From our results it appears likely that techniques other than inhalation anesthetics, such as total i.v. anesthesia, neuraxial, or peripheral nerve blocks, would be least harmful to the environment.

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Age-related iso-MAC charts for isoflurane, sevoflurane and desflurane in man.

R Nickalls, W Mapleson (2003)

The motivation for this study was the current difficulty in estimating the total age-related MAC for a patient in a clinical setting. Age-related iso-MAC charts for isoflurane, sevoflurane and desflurane were developed for the clinically useful MAC range (0.6-1.6), age range 5-95 yr, and put in a convenient form for use by practising anaesthetists. The charts are based on Mapleson's meta-analysis (1996) of the available MAC data and can be used to allow for the contribution of nitrous oxide to the total MAC. The charts indicate the influence of age on anaesthetic requirements, showing, for example, that a total MAC of 1.2 using isoflurane and nitrous oxide 67% in oxygen requires an end-expired isoflurane concentration of only 0.25% in a patient of 95 yr vs 1% in a 5-yr-old patient. Colleagues found the charts to be helpful and simple to use clinically. The iso-MAC charts show clearly how patient age can be used to guide the choice of end-expired agent concentration. They also allow a consistent total MAC to be maintained when changing the inspired nitrous oxide concentration, thereby reducing the chance of inadvertent awareness, particularly at the extremes of age.

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The pharmacology of sevoflurane in infants and children.

S Kleinman, Bruce Lerman, N Sikich … (1994)

Sevoflurane is a new volatile anesthetic with physical properties that should make it suitable for anesthesia (MAC of sevoflurane on oxygen alone and in 60% nitrous oxide, (MAC) of sevoflurane in oxygen alone and in 60% nitrous oxide, the hemodynamic, induction and emergence responses to sevoflurane and the metabolism to inorganic fluoride were studied in 90 ASA physical status 1 or 2 neonates, infants, and children. MAC of sevoflurane in oxygen was determined in six groups of subjects stratified according to age: full-term neonates, infants 1-6 and > 6-12 months and children > 1-3, > 3-5 and > 5-12 yr. MAC in 60% nitrous oxide was determined in a separate group of children 1-3 yr of age. After an inhalational induction, the trachea was intubated (except for neonates in whom an awake intubation was performed). MAC for each age group was determined using the Up-and-Down technique of Dixon. MAC of sevoflurane in neonates, 3.3 +/- 0.2% and in infants 1-6 months of age, 3.2 +/- 0.1%, were similar; MAC in older infants 6-12 months and children 1-12 yr was constant at approximately 2.5%; MAC of sevoflurane in 60% nitrous oxide in children 1-3 yr of age was 2.0 +/- 0.2%. Systolic arterial pressure decreased significantly at 1 MAC before skin incision compared with awake values in all subjects except children 1-3 yr with 60% nitrous oxide and children 5-12 yr in oxygen, and then returned toward awake values after skin incision. Heart rate was unchanged at approximately 1 MAC sevoflurane before incision compared with awake values in all subjects except children > 3-5 and > 5-12 yr in whom heart rate increased before incision. Induction of anesthesia, particularly with respect to airway irritability, and emergence from sevoflurane anesthesia were not remarkable. The plasma concentration of inorganic fluoride reached maximum values (8.8-16.7 microM) 30 min after discontinuation of anesthesia. We conclude that sevoflurane appears to be a suitable anesthetic agent for use in neonates, infants and children undergoing < or = 1 h of anesthesia.

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Journal

Journal ID (nlm-ta): Med Gas Res

Journal ID (iso-abbrev): Med Gas Res

Journal ID (publisher-id): MGR

Title: Medical Gas Research

Publisher: Wolters Kluwer - Medknow (India )

ISSN (Electronic): 2045-9912

Publication date Collection: Apr-Jun 2020

Publication date (Electronic): 05 June 2020

Volume: 10

Issue: 2

Pages: 64-66

Affiliations

[1 ]Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA

[2 ]Department of Internal Medicine, University of Nevada Reno, Reno, NV, USA

Author notes

[* ] Correspondence to: Alastair E. Moody, Alastair.moody@ 123456hsc.utah.edu .

Author contributions

Study design, implementation, and manuscript writing: AEM, BDB, CEM; data analysis: AEM, BDB. All authors approved the final version of the manuscript.

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Alastair E. Moody http://orcid.org/0000-0002-5232-7705

Article

Publisher ID: MGR-10-64

DOI: 10.4103/2045-9912.285558

PMC ID: 7885709

PubMed ID: 32541130

SO-VID: e1a2e4f7-84e3-407f-8f86-f67517843162

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Predicting cost of inhalational anesthesia at low fresh gas flows: impact of a new generation carbon dioxide absorbent

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Most cited references 20

Life cycle greenhouse gas emissions of anesthetic drugs.

Age-related iso-MAC charts for isoflurane, sevoflurane and desflurane in man.

The pharmacology of sevoflurane in infants and children.

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