title: Economic and Environmental Considerations During Low Fresh Gas Flow Volatile Agent Administration After Change to a Nonreactive Carbon Dioxide Absorbent.
abstract: BACKGROUND
  Reducing fresh gas flow (FGF) during general anesthesia reduces costs by decreasing the consumption of volatile anesthetics and attenuates their contribution to greenhouse gas pollution of the environment. The sevoflurane FGF recommendations in the Food and Drug Administration package insert relate to concern over potential toxicity from accumulation in the breathing circuit of compound A, a by-product of the reaction of the volatile agent with legacy carbon dioxide absorbents containing strong alkali such as sodium or potassium hydroxide. Newer, nonreactive absorbents do not produce compound A, making such restrictions moot. We evaluated 4 hypotheses for sevoflurane comparing intervals before and after converting from a legacy absorbent (soda lime) to a nonreactive absorbent (Litholyme): (1) intraoperative FGF would be reduced; (2) sevoflurane consumption per minute of volatile agent administration would be reduced; (3) cost savings due to reduced sevoflurane consumption would (modestly) exceed the incremental cost of the premium absorbent; and (4) residual wastage in discarded sevoflurane bottles would be <1%.
  
  
  METHODS
  Inspired carbon dioxide (PICO2), expired carbon dioxide, oxygen, air, and nitrous oxide FGF, inspired volatile agent concentrations (FiAgent), and liquid volatile agent consumption were extracted from our anesthesia information management system for 8 4 week intervals before and after the absorbent conversion. Anesthesia providers were notified by e-mail and announcements at Grand Rounds about the impending change and were encouraged to reduce their average intraoperative sevoflurane FGF to 1.25 L/min. Personalized e-mail reports were sent every 4 weeks throughout the study period regarding the average intraoperative FGF (i.e., from surgery begin to surgery end) for each agent. Batch means methods were used to compare FGF, volatile agent consumption, net cost savings, and residual sevoflurane left in bottles to be discarded in the trash after filling vaporizers. The time from reaching a PICO2 = 3 mm Hg for 3 minutes until agent exhaustion (PICO2 = 5 mm Hg for 5 minutes) was evaluated.
  
  
  RESULTS
  A total of N = 20,235 cases were analyzed (80.2% sevoflurane, 15.1% desflurane, and 4.7% isoflurane). Intraoperative FGF was reduced for cases in which sevoflurane was administered by 435 mL/min (95% confidence interval [CI], 391 to 479 mL/min; P < 10). Hypothesis 1 was accepted. Sevoflurane consumption per minute of administration decreased by 0.039 mL/min (95% CI, 0.029 to 0.049 mL/min; P < 10) after the change to the nonreactive absorbent. Hypothesis 2 was accepted. The difference in mean cost for the sum of the sevoflurane and absorbent purchases for each of the 10 4-week intervals before and after the absorbent switch was -$293 per 4-week interval (95% CI, -$2853 to $2266; P = 0.81). Hypothesis 3 was rejected. The average amount of residual sevoflurane per bottle was 0.67 ± 0.06 mL (95% CI, 0.54 to 0.81 mL per bottle; P < 10 vs 2.5 mL). Hypothesis 4 was accepted. Once the PICO2 reached 3 mm Hg for at least 3 consecutive minutes, the absorbent became exhausted within 95 minutes in most (i.e., >50%) canisters.
  
  
  CONCLUSIONS
  We showed that an anesthesia department can transition to a premium, nonreactive carbon dioxide absorbent in a manner that is at least cost neutral by reducing FGF below the lower flow limits recommended in the sevoflurane package insert. This was achieved, in part, by electronically monitoring PICO2, automatically notifying the anesthesia technicians when to change the absorbent, and by providing personalized feedback via e-mail to the anesthesia providers.
authors.affiliation: From the *Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania; †Division of Management Consulting, Department of Anesthesia, University of Iowa, Iowa City, Iowa; and ‡Department of Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania.
authors.forename: Richard H
authors.initials: RH
authors.lastname: Epstein
authors.forename: Franklin
authors.initials: F
authors.lastname: Dexter
authors.forename: David P
authors.initials: DP
authors.lastname: Maguire
authors.forename: Niraj K
authors.initials: NK
authors.lastname: Agarwalla
authors.forename: David M
authors.initials: DM
authors.lastname: Gratch
mesh_terms: D000768:Anesthesia, General / Q000009:adverse effects / Q000191:economics*; D018685:Anesthetics, Inhalation / Q000008:administration & dosage* / Q000009:adverse effects / Q000191:economics*; D017610:Calcium Compounds / Q000008:administration & dosage / Q000191:economics; D002245:Carbon Dioxide / Q000008:administration & dosage* / Q000191:economics*; D004781:Environmental Exposure / Q000191:economics* / Q000517:prevention & control; D005260:Female; D006801:Humans; D008297:Male; D008738:Methyl Ethers / Q000008:administration & dosage / Q000191:economics; D008875:Middle Aged; D010087:Oxides / Q000008:administration & dosage / Q000191:economics; D000077149:Sevoflurane; D012972:Sodium Hydroxide / Q000008:administration & dosage / Q000191:economics
chemical_list: D018685:Anesthetics, Inhalation; D017610:Calcium Compounds; D008738:Methyl Ethers; D010087:Oxides; D002245:Carbon Dioxide; D000077149:Sevoflurane; C004569:soda lime; D012972:Sodium Hydroxide