Desflurane – balancing the environmental costs and cognitive benefits. A reply
Notice bibliographique
Résumé
I thank Dr. Freeman for an important comment about the recent Association of Anaesthetists’ Guidelines for the peri-operative care of people with dementia, which correctly pointed out the incorrect referencing of our assertion that desflurane may be preferable to sevoflurane or isoflurane for general anaesthesia in people with cognitive impairment 1. The correct reference should have been attributed to Jiang and Jiang, who recently reviewed the evidence for the effects of inhaled anaesthetic agents on the neuropathogenesis of Alzheimer's disease 2. In experimental (tissue and mouse) studies, isoflurane and sevoflurane, more so than desflurane, have been found to activate capsases, increasing the synthesis and accumulation of β-amyloid protein, and to induce hyperphosphorylation of tau protein, both of which mechanisms are involved in the neuropathogenesis of Alzheimer's disease. Dr. Freeman is absolutely correct to challenge the clinical relevance of this experimental research in the context of imminent environmental collapse 3. Personally, I fully agree with Dr. Freeman that the marginal (if any) benefits of desflurane compared with sevoflurane or isoflurane administration in this (or any other) instance are far outweighed by the very significant environmental impact of desflurane 4, 5. Inhalational anaesthetic agents are chlorofluorocarbons, ‘greenhouse gases’ that have between 349 (sevoflurane) and 3714 (desflurane) times the global warming potential over a 20 year time horizon of carbon dioxide (isoflurane 1401), equivalent to driving a car 18 (sevoflurane) to ~350 miles (desflurane) per hour of anaesthetic use (isoflurane 30 miles); these figures do not account for the additional carbon cost of heating desflurane vaporisers. Together with nitrous oxide, inhalational anaesthetic agents contribute ~2.5% of the 22.8 million tonnes of carbon dioxide equivalents the NHS produces annually 6, but their use is not proscribed by the 2016 Kigali amendment to the 1987 Montreal protocol for reducing hydrofluorocarbon use, on the grounds of medical necessity 7. Given that effective waste gas scavenging, although available (with an energy cost), is not currently used (or even practical) during patient transfer to or recovery within the recovery area, and that even low-flow anaesthesia used throughout an anaesthetist's career contributes significantly to global warming 8, as individuals and as a profession we have to consider whether the continued use of inhalational anaesthetic agents supports the ‘triple bottom line’ of accounting for people, place and finance when considering the global impact of any technology, or whether it now represents cultural and professional baggage; safe, reliable alternatives to inhalational anaesthesia exist (total intravenous anaesthesia, regional anaesthesia) and their use may have environmental as well as clinical benefits for people with dementia who require surgery.
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Comment cette classification a été obtenuedéplier
Prédiction distillée sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Apprise à partir de 10 348 étiquettes directes de Codex et de 10 348 étiquettes directes de Gemma. Le mode candidate est l'union des têtes enseignantes seuillées; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont ni des étiquettes humaines ni des étiquettes directes de modèles de pointe.
Scores Codex et Gemma par catégorie
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,000 | 0,000 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,000 | 0,000 |
| Bibliométrie | 0,000 | 0,000 |
| Études des sciences et des technologies | 0,000 | 0,001 |
| Communication savante | 0,000 | 0,000 |
| Science ouverte | 0,001 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,002 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,000 | 0,001 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule tête enseignante, pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».