Des

[GassYous]

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)

That's why I got the new iphone 15. Enjoy it while you have it!

---

Members don't see this ad.

 

[medicine2wallstreet]

Syringes and desflurane literally matter zero in the scheme of China and Russias coal output. This entire forum is full of clowns who don't understand reality. I mean we got a guy who thinks opening less syringes per case is gonna save polar bears and prevent global warming. Who in the absolute Sam hell granted people like this medical degrees??? Such a disaster these people are in my specialty.

 

[pgg]

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)

Well, some of it matters. We could mitigate and limit the extent of the damage, and we might even do that. But it'd take building a couple thousand fission power plants and widespread decreases in digging up black stuff to burn, not changes in syringe habits and volatile anesthetic choices.

 

[pgg]

Syringes and desflurane literally matter zero in the scheme of China and Russias coal output. This entire forum is full of clowns who don't understand reality. I mean we got a guy who thinks opening less syringes per case is gonna save polar bears and prevent global warming. Who in the absolute Sam hell granted people like this medical degrees??? Such a disaster these people are in my specialty.

Oh **** I'm agreeing with medicine2wallstreet, minus the ad hominems and contempt.

I'm going to go reflect on some of my life choices for a while and think about what I've done.

 

[medicine2wallstreet]

I'm not all bad pgg.

 

[nimbus]

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.

We do that. The tanks always run out so I’ve stopped using nitrous.

 

[GassYous]

What's so bad about running low flows and not wasting plastic?

I also try to maximize my mpg and kwh. I plug out stuff I'm not using. Does that qualify as another disaster? Just because others are wasteful and polluting doesn't mean that I can't try to improve.

 

[coffeebythelake]

Syringes and desflurane literally matter zero in the scheme of China and Russias coal output. This entire forum is full of clowns who don't understand reality. I mean we got a guy who thinks opening less syringes per case is gonna save polar bears and prevent global warming. Who in the absolute Sam hell granted people like this medical degrees??? Such a disaster these people are in my specialty.

You talk as if you've been asked to do something so onerous and so unthinkable. Is it really that hard to do low flow? Is it really that hard to use sevo instead of des?

You seem to disguise apathy and laziness for a big picture / realist view of the world. Why bother doing anything? Perhaps your solution to the climate problem is a mass culling of the human population. But I'd rather start with small simple steps.

 

[Status Sciaticus]

I mean, if were looking at this from a private practice lens, and not an environmental one, the outcome is the same. Des and nitrous are expensive.

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

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 ...

www.ncbi.nlm.nih.gov

 

[T-burglar]

Well, some of it matters. We could mitigate and limit the extent of the damage, and we might even do that. But it'd take building a couple thousand fission power plants and widespread decreases in digging up black stuff to burn, not changes in syringe habits and volatile anesthetic choices.

the time for nuclear has passed unfortunately. Would have been great 50-60 years ago as a way to limit global temperature increases but it is too late.

The effects we are seeing now on global average temperature ALONE (saying nothing of the utter annihilation of the biosphere from all our other activities) are a result of emissions from the dawn of the Industrial Revolution. We have no idea what uncharted territory we have sentenced ourselves to now as a result of business as usual and unfettered growth since then. The closest climate regime in earths ancient past that we can point to as an example of where we are likely headed is the late Eocene. In other words, a climate that humans cannot survive.

Again, this is only the effects of temperature change, which although devastating are not the whole story. There is also the complete and irrevocable loss of arable soil, habitat and water source depletion and pollution, acidification of the oceans, the list goes on.

Ours is not the only story of a runaway invasive species decimating all life on earth. There is good evidence that it’s happened before on multiple occasions. Although the chixulub meteor impact that caused the end Cretaceous mass extinction is what most people think of, even more insane apocalypses have occurred simply by new life not finding balance with the planet.

Back to your original point. I’ve seen it written before that the discovery of clean cheap abundant energy (ie well regulated and sophisticated nuclear) would be the worst thing that could possibly happen, and I tend to agree. It would mean our current rape of the biosphere would experience an explosion in power and kick all of our destruction into the highest gear.

In the end it doesn’t matter, to fix the problem would require a coordinated global effort of nations to deglobalize and throttle the economy back to before the Industrial Revolution. which will never happen, nobody would accept a lower standard of living even if it meant we all got to live and not go extinct because humans are stupid and lazy.

 

[Radetzky]

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.

Lol I ain’t a climate denier. Quite the contrary. This is just something i was told by a phd in the field who gave a presentation on it at a conference.

Professor Julia Slingo if you want to know who; she’s quite a big deal

 

[IlDestriero]

I happily gave up des, grudgingly gave up nitrous, though it’s still available, all in the name of the environment while simultaneously embracing our single use blades, VLs and fibers, and then blast away with a smile in my 8 cylinder 11mpg luxobarge every afternoon knowing I’m doing my part.

 

[coffeebythelake]

Lol I ain’t a climate denier. Quite the contrary. This is just something i was told by a phd in the field who gave a presentation on it at a conference.

Professor Julia Slingo if you want to know who; she’s quite a big deal

I have no doubt she is an expert in her field. But I question the interpretation of her statements, clear as they may seem. After all her statements were made in rebuttal of NHS top down decision to severely limit desflurane use, and perhaps balancing the climate data with the clinical benefit of its use.. which most of us would agree is minimal compared to alternative agents such as sevoflurane

So.. is she denying that desflurane has an atmospheric half life of 10 to 15 years? And that 1 MAC hour of desflurane at standard flows contribute to 75 kg of CO2 equivalent and has more than 30 times the GHG potential compared to an equipotent dose of sevoflurane? Hint: she hasn't. She also have not advocated for an unfettered use of desflurane.

https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(23)00084-0/fulltext

Here is some data with actual numbers. From a climate scientist who actually studies anesthetics. The greenhouse warming potential of sevoflurane has actually been recalculated and is lower than initially believed. The difference in effect for equipotent dose of des vs sevo is wider than ever

Note that this column in the Lancet is written as a "personal view" by this expert even though it contains a great deal of solid data. Just as Prof Slingo's thoughts should be seen as her personal view, and not carry the weight of her previois position as head of the Met office.

 

[ProPropofol]

Our academic institution got rid of Des a few years ago and some of the Ivory Tower folks frown upon those using nitrous. One guy was adamantly against getting rid of Des so now carries the vaporizer in a personal suitcase around the hospital so he can use it as he pleases. Hospital looks the other way after the temper tantrum he threw about it. Do enjoy less emergence delirium with Des but haven't terribly missed it.

Personally, I use low flow very regularly (<1LPM flows) so i consider the environmental impact to be minimal in my case. Nitrous, I like to use it just in the last 20-30min of the case as I find I can wake them up and have them responsive and speaking sentences in the OR or on the way to the PACU since our PACU has less than qualified people in it... Imagine a PACU where no one knows what an oral airway or nasal trumpet is while also not having them stocked anywhere within a 5min walk round trip. And a patient who requires an oral airway in the PACU is written up by the nurse prompting an apology letter needing to be written to the patient by the anesthesiologist. "Sorry for saving your life after an elective surgery!" Surprisingly, the surgeons don't have to write an apology letter after ligating a popliteal artery or severing a nerve...

What erks me the most about it is that no other specialty will they take away tools from the physician in the name of altruism. They don't tell surgeons how to operate based on how expensive/environmentally unfriendly their tools are (i.e. use traditional laparoscopy instead of robotic, do the spine surgery without neuromonitoring, gonna have to do that surgery without the O arm, gotta use non-disposable surgical gown now, etc). Combating other things like ridiculously long operative times, stronger acceptance of spinal anesthesia for cases that can be done with them, utilizing regional anesthesia as the primary anesthetic when able is much more effective imo to reduce cost, produce safer anesthetics for patients, and minimize environmental impact.

 

[PpfSuxTube]

Oh **** I'm agreeing with medicine2wallstreet, minus the ad hominems and contempt.

I'm going to go reflect on some of my life choices for a while and think about what I've done.

Me too ha ha ha... wtf is going on!!

 

[PpfSuxTube]

I happily gave up des, grudgingly gave up nitrous, though it’s still available, all in the name of the environment while simultaneously embracing our single use blades, VLs and fibers, and then blast away with a smile in my 8 cylinder 11mpg luxobarge every afternoon knowing I’m doing my part.

You are my hero anyway...

I drive my truck to the pizza shop 200metres away some nights... and I take all their single use cutlery and straws...

 

[Bertelman]

How many people reading this thread......

You just reminded me of the energy use from all the servers hosting SDN.

I better quit checking SDN 10 times a day so I can be the first reply with a sassy response.

 

[coffeebythelake]

You just reminded me of the energy use from all the servers hosting SDN.

I better quit checking SDN 10 times a day so I can be the first reply with a sassy response.

Think about the energy use from bitcoin and that nonsense.

 

[Bertelman]

Think about the energy use from bitcoin and that nonsense.

So since you pointed out something far more wasteful than me, can I just ignore all personal responsibility and do what I want? Since it doesn't matter?

 

[BlueRug]

Our academic institution got rid of Des a few years ago and some of the Ivory Tower folks frown upon those using nitrous. One guy was adamantly against getting rid of Des so now carries the vaporizer in a personal suitcase around the hospital so he can use it as he pleases. Hospital looks the other way after the temper tantrum he threw about it. Do enjoy less emergence delirium with Des but haven't terribly missed it.

Personally, I use low flow very regularly (<1LPM flows) so i consider the environmental impact to be minimal in my case. Nitrous, I like to use it just in the last 20-30min of the case as I find I can wake them up and have them responsive and speaking sentences in the OR or on the way to the PACU since our PACU has less than qualified people in it... Imagine a PACU where no one knows what an oral airway or nasal trumpet is while also not having them stocked anywhere within a 5min walk round trip. And a patient who requires an oral airway in the PACU is written up by the nurse prompting an apology letter needing to be written to the patient by the anesthesiologist. "Sorry for saving your life after an elective surgery!" Surprisingly, the surgeons don't have to write an apology letter after ligating a popliteal artery or severing a nerve...

What erks me the most about it is that no other specialty will they take away tools from the physician in the name of altruism. They don't tell surgeons how to operate based on how expensive/environmentally unfriendly their tools are (i.e. use traditional laparoscopy instead of robotic, do the spine surgery without neuromonitoring, gonna have to do that surgery without the O arm, gotta use non-disposable surgical gown now, etc). Combating other things like ridiculously long operative times, stronger acceptance of spinal anesthesia for cases that can be done with them, utilizing regional anesthesia as the primary anesthetic when able is much more effective imo to reduce cost, produce safer anesthetics for patients, and minimize environmental impact.

Wat

He carries a des vaporizer in a personal suitcase?

 

[ProPropofol]

Wat

He carries a des vaporizer in a personal suitcase?

Yep, been practicing anesthesia for almost 50 years and not giving it up. Also turns off the waste gas scavenging systems because it inhibits the gas flows. Thus he has been accused of causing CRNA miscarriages. Nice guy though.

 

[<(^_^)>]

Just for reference a 10cc syringe (21 grams plastic, or ~63g co2) pollutes roughly 1/141th a gallon of gas (8887g co2). A round trip flight from Los Angeles to Sydney Australia for two people is approximately 300 gallons of fuel, or 42,300 syringes worth.

For nitrous/desflurane going off this infographic: Rethinking Desflurane - California Society of Anesthesiologists nitrous at 0.5 mac, 1 liter/min for 20 min is equivalent to driving 10 miles. Conversely 1 mac of DES at 1 liter/min for 2 hours is 400 miles of driving. Up to the reader to determine what they think is significant, but my takeaway was plastic syringes are way less wasteful than I initially thought, nitrous for wakeups have a pretty minimal impact, and DES really is quite harmful.

 

[Radetzky]

I have no doubt she is an expert in her field. But I question the interpretation of her statements, clear as they may seem. After all her statements were made in rebuttal of NHS top down decision to severely limit desflurane use, and perhaps balancing the climate data with the clinical benefit of its use.. which most of us would agree is minimal compared to alternative agents such as sevoflurane

So.. is she denying that desflurane has an atmospheric half life of 10 to 15 years? And that 1 MAC hour of desflurane at standard flows contribute to 75 kg of CO2 equivalent and has more than 30 times the GHG potential compared to an equipotent dose of sevoflurane? Hint: she hasn't. She also have not advocated for an unfettered use of desflurane.

https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(23)00084-0/fulltext

Here is some data with actual numbers. From a climate scientist who actually studies anesthetics. The greenhouse warming potential of sevoflurane has actually been recalculated and is lower than initially believed. The difference in effect for equipotent dose of des vs sevo is wider than ever

Note that this column in the Lancet is written as a "personal view" by this expert even though it contains a great deal of solid data. Just as Prof Slingo's thoughts should be seen as her personal view, and not carry the weight of her previois position as head of the Met office.

I really have no axe to grind here nor pretend to be an expert, I’m just sharing something that was told to me by an expert in the issue that I found surprising. Her key slide I’ve attached.

 

[jwk]

You are my hero anyway...

I drive my truck to the pizza shop 200metres away some nights... and I take all their single use cutlery and straws...

Don't ya just love the paper straws in plastic wrappers?

 

[GravelRider]

You are my hero anyway...

I drive my truck to the pizza shop 200metres away some nights... and I take all their single use cutlery and straws...

Are you fat? That’s a bizarre thing to (?) brag about.

 

[GassYous]

Just for reference a 10cc syringe (21 grams plastic, or ~63g co2) pollutes roughly 1/141th a gallon of gas (8887g co2). A round trip flight from Los Angeles to Sydney Australia for two people is approximately 300 gallons of fuel, or 42,300 syringes worth.

For nitrous/desflurane going off this infographic: Rethinking Desflurane - California Society of Anesthesiologists nitrous at 0.5 mac, 1 liter/min for 20 min is equivalent to driving 10 miles. Conversely 1 mac of DES at 1 liter/min for 2 hours is 400 miles of driving. Up to the reader to determine what they think is significant, but my takeaway was plastic syringes are way less wasteful than I initially thought, nitrous for wakeups have a pretty minimal impact, and DES really is quite harmful.

I had an attending who ran nitrous/des at 6 liters for every case at a slow hospital

 

[anbuitachi]

i never really like des. havent used much des since residency year a many many years ago, and thats bc i was learning.
never used it as an attending. the hospital i work at currently has no DES. it got removed.
nitrous ive used sometimes, we havent removed the pipes yet but my residency hospital stopped wall nitrous. if you want to use it it'll be from cylinder


this whole thing started because the first thing on their blame list is anesthesia

 

[coffeebythelake]

I had an attending who ran nitrous/des at 6 liters for every case at a slow hospital

Terrible

 

[GassYous]

Terrible

Yeah but compared to China and Russia it is nothing so nbd

 

[zizzer]

I'm a private practice anesthesiologist who manages routinely timely wakeups without N2O or desflurane. The only use I can think of for either is N2O on obstetrics and I'm sure there are ways around that.

 

[Maz777]

You talk as if you've been asked to do something so onerous and so unthinkable. Is it really that hard to do low flow? Is it really that hard to use sevo instead of des?

You seem to disguise apathy and laziness for a big picture / realist view of the world. Why bother doing anything? Perhaps your solution to the climate problem is a mass culling of the human population. But I'd rather start with small simple steps.

Thanos was right. It's now academic dogma.

What percentage of emissions is related to volatile anesthetics/nitrous? If someone can answer me that (and it's greater than 1/1,000,000,000 of a percent, then I will shut my mouth about nitrous being taken away.

 

[pgg]

I'm a private practice anesthesiologist who manages routinely timely wakeups without N2O or desflurane. The only use I can think of for either is N2O on obstetrics and I'm sure there are ways around that.

Propofol TIVA is the way to go for general anesthetic c-sections. No uterine atony, no nausea. I quit using volatile+nitrous on these cases a while ago and I'll never go back.

I very rarely do peds, but every once in a while I do inhalation inductions in cooperative kids that starts with nitrous, then I add sevo and turn the nitrous off. It's a little less jarring than the sudden stink of sevo.


I don't use nitrous, not because I'm worried about climate effects, but because there are genuinely better techniques that don't rely on it.


Anyway, the anti-des argument of "I don't use des and my patients wake up so you just suck if you want to use des and you should learn to be a better anesthesiologist" is a tired and dumb strawman.

For years all we had was neostigmine to reverse NMBDs. Now we have sugammadex. Yes, yes, of course you can reverse someone whenever you want with neostigmine if you plan ahead. It even costs less. But it's an inferior drug that's harder to use well than sugammadex. No sane person tries to flex about how good they are because they use neostigmine today.

But for some reason people are inordinately proud of using isoflurane when sevoflurane is objectively better in every regard (except a negligible difference in cost). And the anti-desflurane argument is just a shadow of that nonsense.

 

[zizzer]

Propofol TIVA is the way to go for general anesthetic c-sections. No uterine atony, no nausea. I quit using volatile+nitrous on these cases a while ago and I'll never go back.

I very rarely do peds, but every once in a while I do inhalation inductions in cooperative kids that starts with nitrous, then I add sevo and turn the nitrous off. It's a little less jarring than the sudden stink of sevo.


I don't use nitrous, not because I'm worried about climate effects, but because there are genuinely better techniques that don't rely on it.


Anyway, the anti-des argument of "I don't use des and my patients wake up so you just suck if you want to use des and you should learn to be a better anesthesiologist" is a tired and dumb strawman.

For years all we had was neostigmine to reverse NMBDs. Now we have sugammadex. Yes, yes, of course you can reverse someone whenever you want with neostigmine if you plan ahead. It even costs less. But it's an inferior drug that's harder to use well than sugammadex. No sane person tries to flex about how good they are because they use neostigmine today.

But for some reason people are inordinately proud of using isoflurane when sevoflurane is objectively better in every regard (except a negligible difference in cost). And the anti-desflurane argument is just a shadow of that nonsense.

Good idea with the propofol TIVA. I actually have a co-worker that bragged about still using neostigmine over sugammadex last week. I think the difference between sevoflurane and desflurane or N2O in clinical utility is much less than the difference between sugammadex and neostigmine. Anyways, I'm not arguing against those gases as a flex, but just because you don't gain much from them and they're bad for the climate.

 

[PpfSuxTube]

I'm a private practice anesthesiologist who manages routinely timely wakeups without N2O or desflurane. The only use I can think of for either is N2O on obstetrics and I'm sure there are ways around that.

Good idea with the propofol TIVA


These are an unusual 2 posts to follow each other...

When someone starts a sentence by telling ppl what they are it's usually to outline their authority on a subject. And then following it up with a eureka moment on an age old technique possibly even standard... I'm not sure what to make of that

 

[zizzer]

Good idea with the propofol TIVA


These are an unusual 2 posts to follow each other...

When someone starts a sentence by telling ppl what they are it's usually to outline their authority on a subject. And then following it up with a eureka moment on an age old technique possibly even standard... I'm not sure what to make of that

Context. It's a response to the ones claiming that N2O is necessary in private practice for quicker wakeups.

 

[GravelRider]

Propofol TIVA is the way to go for general anesthetic c-sections. No uterine atony, no nausea. I quit using volatile+nitrous on these cases a while ago and I'll never go back.

I very rarely do peds, but every once in a while I do inhalation inductions in cooperative kids that starts with nitrous, then I add sevo and turn the nitrous off. It's a little less jarring than the sudden stink of sevo.


I don't use nitrous, not because I'm worried about climate effects, but because there are genuinely better techniques that don't rely on it.


Anyway, the anti-des argument of "I don't use des and my patients wake up so you just suck if you want to use des and you should learn to be a better anesthesiologist" is a tired and dumb strawman.

For years all we had was neostigmine to reverse NMBDs. Now we have sugammadex. Yes, yes, of course you can reverse someone whenever you want with neostigmine if you plan ahead. It even costs less. But it's an inferior drug that's harder to use well than sugammadex. No sane person tries to flex about how good they are because they use neostigmine today.

But for some reason people are inordinately proud of using isoflurane when sevoflurane is objectively better in every regard (except a negligible difference in cost). And the anti-desflurane argument is just a shadow of that nonsense.

Except des vs. sevo is nowhere the same comparison as neostigmine vs. sugammadex. Sevoflurane is still an excellent, safe, fast anesthetic that is cheaper than the marginally faster desflurane. Sevoflurane is the best and most well-rounded of our volatile anesthetics…still is, despite Desflurane marketing. If I ignore cost and greenhouse effects and had to pick one vaporizer to stock on my anesthesia machine, it would be Sevo, not Des.

 

[pgg]

Except des vs. sevo is nowhere the same comparison as neostigmine vs. sugammadex. Sevoflurane is still an excellent, safe, fast anesthetic that is cheaper than the marginally faster desflurane. Sevoflurane is the best and most well-rounded of our volatile anesthetics…still is, despite Desflurane marketing. If I ignore cost and greenhouse effects and had to pick one vaporizer to stock on my anesthesia machine, it would be Sevo, not Des.

Geez man, it's an analogy. The basic point was to mock the people who state, with faux bewilderment, that people who use desflurane must be bad at anesthesia because they can't wake people up quickly with sevoflurane. Or if they're in an especially flexy mood, isoflurane. I was pointing out that their argument made as much sense as someone being proud of using neostigmine over sugammadex.

No one ever suggested anyone has to give up sevoflurane -but people have stridently demanded everyone give up desflurane. It's hard to do inhalation inductions with desflurane, and it wouldn't be my first choice for someone with severe reactive airway disease, so obviously for those reasons alone it's not a good choice for a single vaporizer on a machine.

If I had to pick one drug to have in the drawer on my desert island, it'd be ketamine. But that doesn't mean all the other drugs don't have their place.

This conversation has become ridiculous. Desflurane is a drug that has some advantages over sevoflurane and isoflurane. If you happen to think the cost and environmental impact outweigh those benefits ... well, OK. But don't pretend the benefits don't exist.

 

[triggermaster]

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.

For all the arguments on here there’s one answer- there’s no advantage to using des.

It doesn’t matter if stopping des has a massive impact or is hypocritical or anything else. Des is negative fiscally and environmentally with no positives to balance out the negatives.

Is flying abroad on vacation a negative for the environment? Maybe, but at least there are positives to balance the negative impact against. With des there are no positives so it’s an entirely negative option. If you think it saves time, get better with sevo.

 

[medicine2wallstreet]

Man that's an impressive definitive only one answer conclusion followed by complete heresay and lack of facts opinion.

 

[pgg]

If you think it saves time, get better with sevo.

Heh, I was going to reply, but obviously you didn't read any of my other posts, so I guess there's no point.

 

[UscGhost]

Except des vs. sevo is nowhere the same comparison as neostigmine vs. sugammadex. Sevoflurane is still an excellent, safe, fast anesthetic that is cheaper than the marginally faster desflurane. Sevoflurane is the best and most well-rounded of our volatile anesthetics…still is, despite Desflurane marketing. If I ignore cost and greenhouse effects and had to pick one vaporizer to stock on my anesthesia machine, it would be Sevo, not Des.

I agree.

I just never saw any advantages to desflurance. It's more expensive,

Geez man, it's an analogy. The basic point was to mock the people who state, with faux bewilderment, that people who use desflurane must be bad at anesthesia because they can't wake people up quickly with sevoflurane. Or if they're in an especially flexy mood, isoflurane. I was pointing out that their argument made as much sense as someone being proud of using neostigmine over sugammadex.

No one ever suggested anyone has to give up sevoflurane -but people have stridently demanded everyone give up desflurane. It's hard to do inhalation inductions with desflurane, and it wouldn't be my first choice for someone with severe reactive airway disease, so obviously for those reasons alone it's not a good choice for a single vaporizer on a machine.

If I had to pick one drug to have in the drawer on my desert island, it'd be ketamine. But that doesn't mean all the other drugs don't have their place.

This conversation has become ridiculous. Desflurane is a drug that has some advantages over sevoflurane and isoflurane. If you happen to think the cost and environmental impact outweigh those benefits ... well, OK. But don't pretend the benefits don't exist.

What advantages,?

 

[GravelRider]

Geez man, it's an analogy. The basic point was to mock the people who state, with faux bewilderment, that people who use desflurane must be bad at anesthesia because they can't wake people up quickly with sevoflurane. Or if they're in an especially flexy mood, isoflurane. I was pointing out that their argument made as much sense as someone being proud of using neostigmine over sugammadex.

No one ever suggested anyone has to give up sevoflurane -but people have stridently demanded everyone give up desflurane. It's hard to do inhalation inductions with desflurane, and it wouldn't be my first choice for someone with severe reactive airway disease, so obviously for those reasons alone it's not a good choice for a single vaporizer on a machine.

If I had to pick one drug to have in the drawer on my desert island, it'd be ketamine. But that doesn't mean all the other drugs don't have their place.

This conversation has become ridiculous. Desflurane is a drug that has some advantages over sevoflurane and isoflurane. If you happen to think the cost and environmental impact outweigh those benefits ... well, OK. But don't pretend the benefits don't exist.

Faster onset and emergence. What are the other benefits? I just called out your analogies because the comparison drugs you used provided significant medical advantage over the cheaper alternative. When Sugammadex first arrived, I was using it all the time despite constant warnings from the hospital regarding its cost. We would get monthly statements trying to shame members of the department who were “over-utilizing” Sugammadex. I had no shame. It is a vastly superior alternative to neostigmine in almost every way.

In a way, I feel the opposite of you. It seems like these Desflurane threads are meant to drum up outrage over “these leftist green libs who are handcuffing our ability to practice medicine in favor of fake news about the environment” (exaggeration for effect). The truth for me is I have never been that impressed with Desflurane other than as a curiosity during residency. If hospitals want to streamline their formularies by getting rid of Desflurane, I will lose exactly zero seconds of sleep over it. It’s a drug that provides a minor convenience over its alternative, not a significant medical advantage.

 

[triggermaster]

Heh, I was going to reply, but obviously you didn't read any of my other posts, so I guess there's no point.

‘Anyway, the anti-des argument of "I don't use des and my patients wake up so you just suck if you want to use des and you should learn to be a better anesthesiologist" is a tired and dumb strawman.’

It’s not a tired and dumb straw man because it’s the only possible argument for des and it’s a false argument. It’s only faster in studies that force the alternative anesthetic to be done in a slow way.
If you think it’s a straw man, why don’t you steel man the argument for des? Because there is no valid argument?

 

[pgg]

Faster onset and emergence. What are the other benefits?

That's all. In particular it's less soluble in fat, so the difference is more pronounced in obese people.

I'm glad you recognize that desflurane has some advantages over sevoflurane.

Probably the reason you don't see much advantage to desflurane is because you never bothered to get good with using it. Now you'll never have the chance.

I'm not trying to talk you into using it - even if was still available and you could. Just pointing out how ridiculous the anti-desflurane arguments are. Cost control arguments driven by pharmacists and administrators won out. Climate change was just the excuse. It's unfortunate but life goes on.

 

[Maz777]

‘Anyway, the anti-des argument of "I don't use des and my patients wake up so you just suck if you want to use des and you should learn to be a better anesthesiologist" is a tired and dumb strawman.’

It’s not a tired and dumb straw man because it’s the only possible argument for des and it’s a false argument. It’s only faster in studies that force the alternative anesthetic to be done in a slow way.
If you think it’s a straw man, why don’t you steel man the argument for des? Because there is no valid argument?

I don't use desflurane ever, but maybe on Monday I will. Just to spite those like you who only think in black and white.

 

[GravelRider]

I don't use desflurane ever, but maybe on Monday I will. Just to spite those like you who only think in black and white.

Between you and the guy driving across the street in his pickup truck to get a pizza, we got some real all stars to be proud of in the field of anesthesia.

 

[GravelRider]

That's all. In particular it's less soluble in fat, so the difference is more pronounced in obese people.

I'm glad you recognize that desflurane has some advantages over sevoflurane.

Probably the reason you don't see much advantage to desflurane is because you never bothered to get good with using it. Now you'll never have the chance.

I'm not trying to talk you into using it - even if was still available and you could. Just pointing out how ridiculous the anti-desflurane arguments are. Cost control arguments driven by pharmacists and administrators won out. Climate change was just the excuse. It's unfortunate but life goes on.

There are plenty of drugs I can get better at using, not just Desflurane. I thought Precedex was a dumb drug at first, but I have found plenty of situations where it has come in handy. I’m humble enough to admit it. I also don’t care if you use Desflurane or not. I just think the outrage over its removal…whatever the reason…is out of proportion to its usefulness. There are plenty of areas of hospital cost cutting that are worth getting outraged over, Desflurane is just not one of them.

 

[zizzer]

Desflurane is a bit faster offset, but when you understand the pharmacokinetics of sevoflurane, which many don't, there is very little if any to gain in the speed of wakeup comparison. With essentially no benefits, the cost and climate impact are the reasons against it. It has nothing to do with us "flexing" on people, as you keep trying to make it out to be. I think you're the one not talking the time to understand the responses.

I'm not sure I'm against completely removing them, but it is a bit grating to see people using then routinely, often not on low flows, because they claim the wakeups are faster. I routinely see these people giving patients a full age-adjusted MAC of anesthesia or even more for their cases.

 

[abolt18]

Used desflurane a bunch in residency (low-flows for life). Gradually moved away from it. Found I most enjoyed Iso for everything except peds, for which I preferred Sevo (nitrous to start masking a compliant kid). Just didn't enjoy the intensity with which patients woke up from Des, more coughing and much more abrupt/intense.

Iso, timed well, is more like a nice wakeup of a well narcotized patient. Tap the patient on the forehead and they open their eyes. Tell them to open their mouth and you extubate. Just have to wean early.

New job has sevo everywhere with a handful of iso cassettes. I'm too lazy to ever switch it out or seek out the iso if it's not in my room. I never really miss desflurane. I don't have strong feelings about any of this stuff. I'm just here for the entertainment.

 

[Simba1711]

I don’t really see a significant difference in wake-up between des and sevo either. For me I can’t justify using it given the environmental and price concerns. It’s pretty disgusting how much waste we produce compared to other countries as well. Other countries reuse breathing circuits and don’t use disposable laryngoscopes.