In Defense of Desflurane: Is There a Specific Role for Desflurane in Neuroanesthesia?

Abstract

It is challenging to counter the widespread criticism of desflurane as the volatile anesthetic agent with the most significant greenhouse gas effect, one which is likely to exacerbate global warming. In 2022, the journal “Anaesthesia” published guidelines for minimizing the impact of anesthetic gases on global warming, which the anesthetic community has largely embraced. One of its recommendations was the removal of desflurane from drug formularies. However, this review underlines the likely benefits of desflurane in the context of actual and potential neurological injuries. With an estimated 13.8 million neurosurgical operations performed annually, desflurane could offer advantages to some of these patients. Therefore, it is imperative to develop an environmentally safe approach for its use rather than remove it from formularies. We discuss desflurane's environmental impact, its unique anesthetic and chemical properties, and its specific application in neuroanesthesia practice. Based on existing evidence, we argue that desflurane could hasten the wake-up of neurosurgical patients. We propose switching to desflurane toward the end of surgery for patients at risk of, or with, neurological injuries. Predictable, early, and monitorable wake-up in these cases could prevent surgical delays, avoid additional investigations, or enable early detection of new deficits. Instead of a blanket ban, desflurane's use should be investigated—systematically and carefully. With education, well-defined indications, limited use, intelligent vaporizers, scavenging, and recycling systems, the use of desflurane could be justified under specific circumstances. Moreover, the problem of environmental damage from inhaled anesthetics must be comprehensively evaluated. Minimizing the use of desflurane is a positive step to protect the environment, but anesthesiologists should enforce other measures to protect the environment with equal urgency.