FROM LITTLE THINGS, BIG THINGS GROW:

‘‘From Little Things Big Things Grow’’ is a well-known song in Australia. It is also saying that conveys a sense of encouragement and dignity in the face of inertia or odds that seem overwhelming. Gollapudy et al have compared propofol with desflurane anesthesia for functional endoscopic sinus surgery (FESS) in a well-conducted small randomized controlled trial (RCT). No difference was reported in quality of surgical field, blood loss, or any secondary outcome, although there was a trend toward faster extubation using propofol-based anesthesia, which did not reach statistical significance. Unfortunately, the authors have not acknowledged the deleterious environmental effects of desflurane use. In anesthesiology, it is increasingly accepted that best practice includes both quality patient care and environmental outcomes. Fortunately, we can influence our environmental impact through the drugs we choose every day. Inhalational anesthetic agents undergo very little in vivo metabolism and are routinely discharged into the atmosphere. Desflurane has a 100-year global warming potential (GWP index) and life cycle greenhouse gas (GHG) emissions (gCO2e) nearly 20 times greater than that of sevoflurane per hour of routine clinical use. It is estimated that desflurane use accounts for 80% of all GHG emissions attributable to inhaled anesthetic agents. In contrast, the carbon footprint of intravenous propofol is primarily related to the electricity consumption of the syringe pump. Only trace amounts are excreted, and life cycle analysis (including manufacture, transport, administration, and disposal or discharge) indicates that the entire impact of propofol use on GHG emissions is around 10,000 times lower than that of desflurane. However, propofol is biotoxic and should not be allowed to leach into the environment via general waste streams. Although the impact of inhalational anesthetics is extremely small compared to CO2 emissions from fossil fuel combustion worldwide, these agents are estimated to be responsible for 5% of the carbon footprint of the entire acute hospital sector in the United Kingdom, which is equivalent to half of all emissions attributable to heating. Selection of desflurane cannot be justified unless improved patient outcome or some other quality benefit can be demonstrated. Ask your anesthesiology provider to choose propofol for FESS instead because ‘‘From Little Things Big Things Grow.’’