title: Life cycle greenhouse gas emissions of anesthetic drugs.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Anesthesiology, Yale School of Medicine/Yale-New Haven Hospital, New Haven, Connecticut 06520, USA. jodi.sherman@yale.edu
authors.forename: Jodi
authors.initials: J
authors.lastname: Sherman
authors.forename: Cathy
authors.initials: C
authors.lastname: Le
authors.forename: Vanessa
authors.initials: V
authors.lastname: Lamers
authors.forename: Matthew
authors.initials: M
authors.lastname: Eckelman
mesh_terms: D000397:Air Pollution / Q000009:adverse effects* / Q000032:analysis / Q000517:prevention & control; D018685:Anesthetics, Inhalation / Q000032:analysis / Q000737:chemistry*; D018686:Anesthetics, Intravenous / Q000032:analysis / Q000138:chemical synthesis; D000077335:Desflurane; D004345:Drug Industry; D017752:Greenhouse Effect; D006207:Half-Life; D007530:Isoflurane / Q000031:analogs & derivatives / Q000032:analysis / Q000737:chemistry; D008738:Methyl Ethers / Q000032:analysis / Q000737:chemistry; D015233:Models, Statistical; D009609:Nitrous Oxide / Q000032:analysis / Q000737:chemistry; D015742:Propofol / Q000032:analysis / Q000737:chemistry; D000077149:Sevoflurane
chemical_list: D018685:Anesthetics, Inhalation; D018686:Anesthetics, Intravenous; D008738:Methyl Ethers; D000077149:Sevoflurane; D000077335:Desflurane; D007530:Isoflurane; D009609:Nitrous Oxide; D015742:Propofol