Des

[PpfSuxTube]

What is this nonsense going on about removing desflurane and nitrous to save the environment. Are you all doing this?

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[agammaglobulin]

I've heard about this. I'm waiting for the comic strip showing an OR with people removing des/nitrous for environmental reasons while in the background there's an overflowing amount of garbage and single use medical devices being taken to the landfill.

My take - There's not enough topics to publish/do QI projects on. So the academic new 'area of interest' is environmental impact. Lots of space to research, do QI projects, present, etc.

 

[Maz777]

Started by loser academicians that want to pad their meaningless CVs. ASA has fully embraced it.

Meanwhile, 99% of what we use is single-use (including bronchoscopes and laryngoscopes). It's only a matter of time before someone makes a single-use anesthesia machine. Idiocy.

 

[coffeebythelake]

What is this nonsense going on about removing desflurane and nitrous to save the environment. Are you all doing this?

Honestly do u think des and nitrous really make your anesthetic that much better?

 

[Dr. Anonymouss]

Honestly do u think des and nitrous really make your anesthetic that much better?

I guess for academics nitrous doesn’t really matter cause things move slower, but for private practice those quicker wake times = more $$$. Turn and burn baby.

 

[PpfSuxTube]

Honestly do u think des and nitrous really make your anesthetic that much better?

Do you think removing them has any meaningful affect on the environment?

I never use them, but I'm about to start

 

[DocMcCoy]

Do you think removing them has any meaningful affect on the environment?

I never use them, but I'm about to start

I mean if you consider how much is used worldwide ya it probably would have a meaningful impact. That being said I love my nitrous. Take the Des, never understood the appeal. I don’t think there is anything wrong with trying to reduce waste. But, it is laughable to focus on the gas without addressing the sickening amount of hospital waste we produce everyday.

 

[Pharmado]

The amount of waste that Joint Commision forces on us is unconscionable. Their number one priority seems to be destroying the environment as quickly as possible. Nothing we do with our gases will make much of a dent in our overall waste as long as they continue to force waste upon the entire system.

That said, I don’t think Des offers any benefit that we can’t accomplish easily with other agents. Maybe the impact of getting rid of it is small, but it’s something we can do. Nitrous does have benefits in practice, but minimizing waste is also a benefit. Apparently, at my institution at least, leakage from nitrous lines results in a considerable loss and limiting leaking gas is something more of us can do.

 

[pgg]

Honestly do u think des and nitrous really make your anesthetic that much better?

I miss having desflurane available, but I got over it.

For fast wakeups now, I just do a rocuronium + esmolol TIVA, and when the dressing goes on I give sugammadex and wow are those patients motivated to GTFO of the hospital. You have to hold them down so they won't leave the OR under their own power.

 

[Arantius]

It’s actually that if you buy the vaporizer you are committed to buying a certain number of bottles a month no matter what you use- at least that’s what a pharmacist said at my place and DES is insane expensive. I said sure I’ll use the KING ISO all day

 

[rowsdower88]

Ceteris paribus, if you can do an anesthetic safely and quickly; why not also do it by reducing your environmental impact?

Talk about other types of waste aren't relevant to this question.

 

[IMGASMD]

I miss having desflurane available, but I got over it.

For fast wakeups now, I just do a rocuronium + esmolol TIVA, and when the dressing goes on I give sugammadex and wow are those patients motivated to GTFO of the hospital. You have to hold them down so they won't leave the OR under their own power.

Will try tomorrow.

 

[GassYous]

I miss having desflurane available, but I got over it.

For fast wakeups now, I just do a rocuronium + esmolol TIVA, and when the dressing goes on I give sugammadex and wow are those patients motivated to GTFO of the hospital. You have to hold them down so they won't leave the OR under their own power.

Opioid free anesthesia is so 2015 now its all about driving power

 

[T-burglar]

Lol if you think we aren’t going to dig up and emit every atom of sequestered carbon from all of earths previous mass extinctions and end up exterminating nearly all life on earth…

Then buddy…maybe you better sit down for this

 

[Blockit]

Honestly do u think des and nitrous really make your anesthetic that much better?

For most of what I do, no. However I use Des maybe 5-10% of the time in specific situations, but ALWAYS with low fresh gas flows. It is a fact that it’s “global warming” potential is MUCH higher than that of sevo.
As long as we continue to just blow this crap out of the smokestack on top of the hospital we should at least TRY. Every bit helps.

 

[cchoukal]

If the energy and motivation to take on projects designed to eliminate waste or pollution were infinite, sure focus on reducing a 1-ish-percent GHG contributor. But since they're not, effort to make large reductions in a small contributor are extraordinarily less efficient than making smaller reductions in large contributors. This is an academic QI project in search of a problem. But no, I never use Des, and, yes, the pharmacy costs are high, so whatever.

 

[UscGhost]

I guess for academics nitrous doesn’t really matter cause things move slower, but for private practice those quicker wake times = more $$$. Turn and burn baby.

Propofol works just as well and less nausea.

If LMA, you just leave it in and pull out in pacu. No real need to do a complex wean from sevo to nitrous

If intubated, keep them paralyzed and breath off most of the gas and then reverse with sugammadex and extubated 15 seconds later. No real need for nitrous or des.

Maybe only need for nitrous is the old, unstable patients?

 

[GravelRider]

It’s cost-cutting under the guise of being environmentally friendly. Desflurane is expensive.

 

[GravelRider]

I miss having desflurane available, but I got over it.

For fast wakeups now, I just do a rocuronium + esmolol TIVA, and when the dressing goes on I give sugammadex and wow are those patients motivated to GTFO of the hospital. You have to hold them down so they won't leave the OR under their own power.

 

[PainDrain]

I guess for academics nitrous doesn’t really matter cause things move slower, but for private practice those quicker wake times = more $$$. Turn and burn baby.

If you need Des and/or nitrous for a “fast wake up” then you are doing it wrong. If using a volatile such as sevo/iso, simply turn your flows down to aalmost nothing and pay F-ing attention, you can get a smooth wake up. Last sutures going in then crank the flows up to 11. Reverse muscle relaxant with suggamadex and boom. Alternatively, use a propofol TIVA, turn it down at the appropriate time and get them breathing, pull LMA or tube. Also, the idea that the vast majority of our patients need to be awake and doing higher level math prior to removing a tube is garbage.

 

[agammaglobulin]

If you need Des and/or nitrous for a “fast wake up” then you are doing it wrong. If using a volatile such as sevo/iso, simply turn your flows down to aalmost nothing and pay F-ing attention, you can get a smooth wake up. Last sutures going in then crank the flows up to 11. Reverse muscle relaxant with suggamadex and boom. Alternatively, use a propofol TIVA, turn it down at the appropriate time and get them breathing, pull LMA or tube. Also, the idea that the vast majority of our patients need to be awake and doing higher level math prior to removing a tube is garbage.

I’d rather not pay attention to the resident/PA closing and just use nitrous.

 

[Radetzky]

If you talk to an actual climate scientist they will tell you Des doesn’t stick around in the atmosphere and therefore has no contribution to climate change

 

[coffeebythelake]

If you talk to an actual climate scientist they will tell you Des doesn’t stick around in the atmosphere and therefore has no contribution to climate change

are u an actual climate scientist?

I might not have a PhD in this field but I majored in it and was going to do graduate studies in this field.

It's interesting for all the leftist leanings on this forum we also have a bunch of climate deniers.

 

[coffeebythelake]

I guess for academics nitrous doesn’t really matter cause things move slower, but for private practice those quicker wake times = more $$$. Turn and burn baby.

Like others have said, u can achieve fast wakeups without des and nitrous if u pay attention. But whatever. You want the autopilot of anesthesia. I'd rather pay attention and drive the car myself.

 

[coffeebythelake]

Propofol works just as well and less nausea.

If LMA, you just leave it in and pull out in pacu. No real need to do a complex wean from sevo to nitrous

If intubated, keep them paralyzed and breath off most of the gas and then reverse with sugammadex and extubated 15 seconds later. No real need for nitrous or des.

Maybe only need for nitrous is the old, unstable patients?

I used nitrous and des during residency, and I'm not sad to see it gone where I work now. Bunch of clown cars here talking like they've never even heard of isoflurane before. What an easy life.

 

[coffeebythelake]

If the energy and motivation to take on projects designed to eliminate waste or pollution were infinite, sure focus on reducing a 1-ish-percent GHG contributor. But since they're not, effort to make large reductions in a small contributor are extraordinarily less efficient than making smaller reductions in large contributors. This is an academic QI project in search of a problem. But no, I never use Des, and, yes, the pharmacy costs are high, so whatever.

I dont use des or nitrous. I also think we should do low flow anesthesia. I'm not exactly why you seem to think changing simple practices require so much energy and motivation. This is something you have direct control over.

 

[Simba1711]

Yeah I don’t really use nitrous or des either. Can get a fast wake up using propofol. Some of my older colleagues run nitrous the entire case which makes me cringe. I do get your point of the amount of plastic waste we generate every case. It’s ridiculous.

 

[pgg]

Speaking of waste - what would y'all say if I told you that a desflurane-free hospital put one too many bloody sponges in the regular trash, one too many times, and now they have to truck all of their trash to another state because the local landfill won't take their garbage any more?

 

[jwk]

leakage from nitrous lines results in a considerable loss and limiting leaking gas is something more of us can do.

This was a hot topic on the ASA Community a month or two ago. Supposedly the major cause of nitrous pollution is actually leaks in the system itself, not it's actual use. Several contributors noted that they have switched to tank N2O only (the ones on the back of the anesthesia machine) and stopped using the piped-in N2O altogether.

 

[coffeebythelake]

Speaking of waste - what would y'all say if I told you that a desflurane-free hospital put one too many bloody sponges in the regular trash, one too many times, and now they have to truck all of their trash to another state because the local landfill won't take their garbage any more?

This whataboutism is quite a way to distract from the topic. I don't label and truck away the garbage (And you are correct that someone screwed up with that). But I can control the use of my anesthetics.

 

[sevo00]

Honestly do u think des and nitrous really make your anesthetic that much better?

Do you really think using sea and nitrous is what’s going to kill the planet?

 

[GassYous]

I use low flow iso. I like the predictability. Nitrous sticks around in the atmosphere for 100 years and there's really no need for it. You can have quick predictable wakeups with anything if you know how to use it. Our wanton use of chemicals, particularly fossil fuels, is greatly detrimental to the environment. I try to limit my unnecessary overuse of materials. I only use one syringe for a case, I reuse syringes for the cuff, I try not to open twenty vials of stuff I don't need. I mean really how long does it take to draw up and dilute down some ephedrine?

The real question is why we are doing so many unnecessary procedures for people who have low or zero quality of life?

 

[IMGASMD]

I haven’t use sevo for years until very recently. Forgot how fast the patients can wake up….

It’s like driving an EV. It won’t make a huge difference, but some people like the technology and the idea of helping the planet.

 

[NumTacos]

Do you really think using sea and nitrous is what’s going to kill the planet?

Responses like that are exactly why we are doomed.

 

[rowsdower88]

Do you really think using sea and nitrous is what’s going to kill the planet?

It's all about marginal benefit. What improves cost, efficacy, safety, environment etc... on the margin.

If you can reliably get a similar safety and efficacy profile by using an anesthetic other than des, why would you want to use it? Just get good.

 

[GassYous]

I haven’t use sevo for years until very recently. Forgot how fast the patients can wake up….

It’s like driving an EV. It won’t make a huge difference, but some people like the technology and the idea of helping the planet.

I like EVs because the acceleration is fun and there's no cloud of gas when you pull out of the driveway. Maintenance is better. The major issue is that the price tends to be high and if you're not on the tesla supercharger network, it's way harder to find a charger in a timely fashion than it is to pump gas. Less relevant if you have a home charger.

I'm hoping that the batteries become as recyclable as lead and am looking forward to solid state batteries (estimated 2026 by toyota and bmw).

 

[PpfSuxTube]

I assume surgeons and medical device companies are reducing their carbon footprint in a similar fashion

 

[IMGASMD]

I use low flow iso. I like the predictability. Nitrous sticks around in the atmosphere for 100 years and there's really no need for it. You can have quick predictable wakeups with anything if you know how to use it. Our wanton use of chemicals, particularly fossil fuels, is greatly detrimental to the environment. I try to limit my unnecessary overuse of materials. I only use one syringe for a case, I reuse syringes for the cuff, I try not to open twenty vials of stuff I don't need. I mean really how long does it take to draw up and dilute down some ephedrine?

The real question is why we are doing so many unnecessary procedures for people who have low or zero quality of life?

So they can use up valuable resources for a few more days /s

I like EVs because the acceleration is fun and there's no cloud of gas when you pull out of the driveway. Maintenance is better. The major issue is that the price tends to be high and if you're not on the tesla supercharger network, it's way harder to find a charger in a timely fashion than it is to pump gas. Less relevant if you have a home charger.

I'm hoping that the batteries become as recyclable as lead and am looking forward to solid state batteries (estimated 2026 by toyota and bmw).

I was trying to get one earlier this year…. Both for the fun factor and tax deduction. Won’t qualify (which I imagining is true for most attending here….). Decided just keep on driving my SO’s hand me down…. Maybe I’ll wait until 2026.

 

[GassYous]

So they can use up valuable resources for a few more days /s





I was trying to get one earlier this year…. Both for the fun factor and tax deduction. Won’t qualify (which I imagining is true for most attending here….). Decided just keep on driving my SO’s hand me down…. Maybe I’ll wait until 2026.

If you buy a car you don't qualify. But a lot of companies are getting corporate tax deductions and passing them on to consumers through leases. EVs are not selling well these days, especially luxury cars and there are some serious discounts being passed on. BMW had one that just ended with the IX getting 9900 from bmw corporate (7500 from the government) and a suggested 4000$ dealer discount. Some people were getting cars priced at 99k msrp for 71. Mercedes is desperate to sell eqe, eqs sedans because no one's buying those ugly egg looking cars and I've seen these cars purportedly worth over $100k being leased for 500/month. Same deal throughout all the dealers, the mach e, audi etron, etc are not selling well and inventory is piling up. Dealers are still trying to sell at msrp and still putting on bs addons (crappy tint, "protection plans") but they want to move units, especially as the end of the year approaches.

 

[pgg]

This whataboutism is quite a way to distract from the topic. I don't label and truck away the garbage (And you are correct that someone screwed up with that). But I can control the use of my anesthetics.

I see where you're coming from - small efforts matter. Except for the most part they really don't.

Re: cost - It's hard for me to get anxious if pharmacy whines about how much my drugs cost, when I've seen orthopods drop hip prosthetics on the floor or when a CT surgeon opens a second valve because he thinks maybe it'll fit better than the first one he opened.

Re: environmental impact - Likewise, the mountain of plastic waste and single-use nonsense dwarfs the effect of the sevo vs des @ 0.5 lpm debate.

Sevo is a greenhouse gas too, so maybe we should be doing TIVAs for everyone? I mean, you can control that, too.

If you want to reduce your medical carbon footprint, start doing spinals for every outpatient case you do. Don't use a kit. Pour some alcohol from a 1 liter bottle on some gauze for your prep, open a needle and a syringe onto a towel, and deliver a $3 anesthetic. This is the standard for most of the developing world.

These conversations remind me of living in California during bad drought years. People would get hassled or ticketed for watering their plants at the wrong time of day, meanwhile it's 105 degrees in July and across the street there's an almond orchard getting flood irrigated twice per week.

We're not the problem.

 

[pgg]

I use low flow iso. I like the predictability. Nitrous sticks around in the atmosphere for 100 years and there's really no need for it. You can have quick predictable wakeups with anything if you know how to use it. Our wanton use of chemicals, particularly fossil fuels, is greatly detrimental to the environment. I try to limit my unnecessary overuse of materials. I only use one syringe for a case, I reuse syringes for the cuff, I try not to open twenty vials of stuff I don't need. I mean really how long does it take to draw up and dilute down some ephedrine?

The real question is why we are doing so many unnecessary procedures for people who have low or zero quality of life?

So you see the negligible effect a one-syringe anesthetic has in the shadow of an ICU's consumption for an end-of-life hospitalization ... but you still do it. Tthis perplexes me.

Have you ever taken an international flight for a vacation? How many syringes will you have to not use to offset that fossil fuel burn? Are you never going to take such a flight again?

How many people reading this thread and worrying about desflurane are going to fly to a warm island and stay in a luxury hotel for a tax-deductible CME conference this winter?

Just devil advocating here. I'm going to guess the great majority of us high-earnings American doctors have massive carbon footprints, and quibbling over syringes and desflurane is an exercise in cognitive dissonance.

 

[UscGhost]

I see where you're coming from - small efforts matter. Except for the most part they really don't.

Re: cost - It's hard for me to get anxious if pharmacy whines about how much my drugs cost, when I've seen orthopods drop hip prosthetics on the floor or when a CT surgeon opens a second valve because he thinks maybe it'll fit better than the first one he opened.

Re: environmental impact - Likewise, the mountain of plastic waste and single-use nonsense dwarfs the effect of the sevo vs des @ 0.5 lpm debate.

Sevo is a greenhouse gas too, so maybe we should be doing TIVAs for everyone? I mean, you can control that, too.

If you want to reduce your medical carbon footprint, start doing spinals for every outpatient case you do. Don't use a kit. Pour some alcohol from a 1 liter bottle on some gauze for your prep, open a needle and a syringe onto a towel, and deliver a $3 anesthetic. This is the standard for most of the developing world.

These conversations remind me of living in California during bad drought years. People would get hassled or ticketed for watering their plants at the wrong time of day, meanwhile it's 105 degrees in July and across the street there's an almond orchard getting flood irrigated twice per week.

We're not the problem.

All of those are poor examples and you know it

You can't do anything about surgical implants or their cost

Reusing syringes is a real infection risk, and not worth the benefit.

Sevo is a greenhouses gas, but less expensive and less problematic than Des and less environmentally damaging than nitrous. And tiva has it's own risks, spinals have their place.

More importantly, there is no legitimate need for Des that isn't provided by sevo. So there is no legitimate need for it and never really was.

So ask yourself why do we need to use an inhalation gas that's more expensive, more environmentally damaging and provides no additional benefit over available alternatives.

 

[GassYous]

So you see the negligible effect a one-syringe anesthetic has in the shadow of an ICU's consumption for an end-of-life hospitalization ... but you still do it. Tthis perplexes me.

Have you ever taken an international flight for a vacation? How many syringes will you have to not use to offset that fossil fuel burn? Are you never going to take such a flight again?

How many people reading this thread and worrying about desflurane are going to fly to a warm island and stay in a luxury hotel for a tax-deductible CME conference this winter?

Just devil advocating here. I'm going to guess the great majority of us high-earnings American doctors have massive carbon footprints, and quibbling over syringes and desflurane is an exercise in cognitive dissonance.

What are you talking about?

How is taking a flight related to wasting syringes and needles? If you do 1000 cases a year and open 20 syringes for each one you're using 20,000 syringes and needles vs my 1000. That's 600,000 unnecessary syringes and needles over a 30 year career. I'm not trying to offset anything, just not wasting all the packaging and materials under the guise of sterility.

 

[coffeebythelake]

I see where you're coming from - small efforts matter. Except for the most part they really don't.

Re: cost - It's hard for me to get anxious if pharmacy whines about how much my drugs cost, when I've seen orthopods drop hip prosthetics on the floor or when a CT surgeon opens a second valve because he thinks maybe it'll fit better than the first one he opened.

Re: environmental impact - Likewise, the mountain of plastic waste and single-use nonsense dwarfs the effect of the sevo vs des @ 0.5 lpm debate.

Sevo is a greenhouse gas too, so maybe we should be doing TIVAs for everyone? I mean, you can control that, too.

If you want to reduce your medical carbon footprint, start doing spinals for every outpatient case you do. Don't use a kit. Pour some alcohol from a 1 liter bottle on some gauze for your prep, open a needle and a syringe onto a towel, and deliver a $3 anesthetic. This is the standard for most of the developing world.

These conversations remind me of living in California during bad drought years. People would get hassled or ticketed for watering their plants at the wrong time of day, meanwhile it's 105 degrees in July and across the street there's an almond orchard getting flood irrigated twice per week.

We're not the problem.

I mean, the real problem is too many people using too many resources. It's easy to think small daily decisions don't matter. But they do when multiplied by all the people whose practices change just a little bit without any real burden.

 

[pgg]

I mean, the real problem is too many people using too many resources. It's easy to think small daily decisions don't matter

My whole point is that the bigger decisions matter orders of magnitude more, and the syringe skimpers and isoflurane users are still doing things like driving F250s and flying to Fiji and setting the AC to 65 in their 4000 sq ft homes and not carpooling ... and even within the narrow context of just medicine these decisions are lost in the noise and their quiet participation in futile or wasteful care.

I mean, good on you for caring, but I think your impact with these things is negligible.

Fort the record, I never use nitrous and I haven't even seen desflurane in years. But I did see all of the OR trash here get red bagged for weeks (longer?) because of a hospital error that put biohazardous waste in the local landfill.

 

[GassYous]

It adds up. Just because it doesn't make a huge difference doesn't mean it doesn't make a difference.

 

[pgg]

What are you talking about?

How is taking a flight related to wasting syringes and needles? If you do 1000 cases a year and open 20 syringes for each one you're using 20,000 syringes and needles vs my 1000. That's 600,000 unnecessary syringes and needles over a 30 year career. I'm not trying to offset anything, just not wasting all the packaging and materials under the guise of sterility.

I'm not telling you not to do that, I'm just pointing out that it doesn't really matter.

Also, nobody uses 20 syringes for a case. I just did an AVR and I didn't make any real effort to minimize syringes, and (not counting the syringes for blood gas analysis) I probably only used 8 or 9.

Most cases I'd guess I use about 4 or 5.

 

[Maverikk]

One place I was at had a guy who was a real QI guy..he got data for one year imported from the machines, the newer ones show you cost/hr for your flows. He did a educational presentation on using low flows, asked everyone to try it for a month, gathered more data. Showed the hospital we would save a little less than a million a year if everyone ran less than 0.5 (30 something sites, lots of late rooms). Everyone respected him, he asked everyone to try their best to try it out, did troubleshooting. Tracked the data, got a big stipend increase the year after. Wonder how many people would stop using des, use low flow if that was the incentive. Does it really alter your practice. Wonder what all the ‘oh but somebody else is doing something a lot worse’ would think.

 

[GassYous]

One place I was at had a guy who was a real QI guy..he got data for one year imported from the machines, the newer ones show you cost/hr for your flows. He did a educational presentation on using low flows, asked everyone to try it for a month, gathered more data. Showed the hospital we would save a little less than a million a year if everyone ran less than 0.5 (30 something sites, lots of late rooms). Everyone respected him, he asked everyone to try their best to try it out, did troubleshooting. Tracked the data, got a big stipend increase the year after. Wonder how many people would stop using des, use low flow if that was the incentive. Does it really alter your practice. Wonder what all the ‘oh but somebody else is doing something a lot worse’ would think.

Does he take international vacations though

 

[T-burglar]

None of this matters. The ecosystem is collapsing at a rate never before seen in the fossil record including all of earths previous major and minor mass extinctions. Which , by the way, killed off species that were around for millions of years (way more successful organisms than humans are or will ever prove to be)