Scotland NHS ban Desflurane Anesthetic….why should you care? You should.

[Phil Pascoe]

Yes everybody agreed, in theory but who is actually abiding by it. Think it was 20 odd new coal plants last yr and other 30 planned for this ...

I read they are opening two a week. A neighbour worked not long ago in a large city in China. No one went outdoors without a mask - not a piddling bit of dirty tissue, a proper two stage industrial mask. Your throat burned if you didn't, the pollution was so bad.
Germany is bulldozing whole villages to open lignite mines. Good to see the world taking notice of the UK isn't it?

 

[Spectric]

If you look at the COP get togethers they never seem to deliver any action, plenty of hot air and promises with deadlines way beyond London being underwater so yes there is plenty of agreement but it fails to deliver anything either completely or within a reasonable timeframe. The issue is that no one wants to cause any impact on their economy so we have a situation where the ball is just being kicked down the street and people are hoping that global warming has been totally misunderstood and is nothing more than a blip on the charts. Some countries like China are gambling on a short phase of dirty power in order to finance green technologies later on hoping there is enough of the planet left whilst the UK is blindly stumbling through a series of knee jerk reactions that have little or no effect on global warming but a serious hit to the people who live in the Uk.

Then we have the war of words that can justify anything, if anyone has watched that Guy Martin program on power it was interesting to note that the Drax powerstation which is now burning powdered wood pellets imported from the states is producing twice the amount of CO2 now than when it burnt coal because coal has a lot more energy in a given mass. This is ok because unlike coal the CO2 produced is of much more recent origin wheras the CO2 in coal is millions of years old. You also have to take into account the huge cargo ships moving thousands of tons of wood pellets across the alantic and these trees are no longer absorbing CO2 so have we really gained much at all except increasing our imports.

In the Uk they have decided to reduce the smoke from peoples woodburning stoves with a view to banning using coal entirely, compare how much this will reduce pollution globally when compared to the huge volumes of open incineration going on across Asia, they are burning plastic's and anything that will burn that is producing large amounts of toxic gases like dioxins, furans, mercury and polychlorinated biphenyls.

 

[thetyreman]

the ban on peoples woodburning stoves feels like an attack on human rights, if power companies can burn millions of tonnes of the stuff the gov should allow people to burn a few pieces of air dried wood in their own homes providing it's safe and set up properly.

 

[Spectric]

the ban on peoples woodburning stoves feels like an attack on human rights

It is really because people have been keeping warm and cooking on open fires for far longer than we have had gas or electric cookers, again the savings will be less than a spot on a knats todger when compared to other countries pollution. Just think of how many mopeds, scooters and small motorcycles are in regular use across asia and many will be two strokes so in comparison we are saving nothing whilst they continue without change.

 

[Phil Pascoe]

https://notalotofpeopleknowthat.wordpress.com/2023/03/04/challenging-net-zero-with-science/

 

[John Brown]

https://notalotofpeopleknowthat.wordpress.com/2023/03/04/challenging-net-zero-with-science/

Funded by energy companies, not saying that necessarily makes it a lot of b011ocks, but certainly not a good reason to believe it. IMO.

 

[Rewound]

In the Uk they have decided to reduce the smoke from peoples woodburning stoves with a view to banning using coal entirely, compare how much this will reduce pollution globally when compared to the huge volumes of open incineration going on across Asia, they are burning plastic's and anything that will burn that is producing large amounts of toxic gases like dioxins, furans, mercury and polychlorinated biphenyls.

The concern over wood-burning stoves is not one of climate change, burning wood is not directly a contributor of climate change as it is not a fossil fuel, the carbon released in burning wood has only been borrowed from the atmosphere in the last hundred years or so.

The concern about pollution from wood burning stoves in built up areas is the local pollution that it creates that can be damaging to our respiratory health.

As to what some backward and third world nations are doing in far off places; Sadly we have little control over what they do, but surely you are not advocating that we set our pollution limits to match theirs?

 

[HeartwoodJack]

@Swiftedge There is always some bias on everyone, I’m sure I’m no exception. My work in this area was over 30 years ago, and I have done an awful lot in between that is more memorable

The number of new gas anaesthetics developed in the last thirty years is one I believe. That’s not indicative of the drugs company’s seeing lots of scope to develop new stuff. Anaesthetic drug development is both extremely expensive, 30 years ago it was well over a few billion just because your treating people with every ailment and need to be sure it doesn’t interact with other drugs they are taking as well as maintaining people alive when they are in lots of circumstances their most ill. It also takes decades of testing. To throw away one of about 5 known anaesthetic gases to me is a ridiculous decision, one of which; Halothane is no longer used in the west as it can have nasty side effects and is now only really used in the developing countries. Desflurane has specific advantages that no other anaesthetic matches.

Perhaps your contributions to your own thread would be more honest and fruitful if you didn't usel language designed to trick or annoy. For example, 'to throw away [this anesthetic option]' (it's not being, it is instead, as you clearly stated earlier, being withdrawn from widespread use. Also try to avoid the dishonest discounting of other arguments and positions ('so called climate effects', 'tree hugging loonies' etc.).
It's seeming to me like a conversation with Jeremy Clarkson here. Over sensationalised hyperbole, not adding to mutual enlightenment. Shame; you raise an interesting topic.

P.s. my bias is that I'll likely live on the planet, with the consequences of our collective decisions, for a bit longer than those already retired. That admittedly shapes my thinking.

 

[Jameshow]

Perhaps your contributions to your own thread would be more honest and fruitful if you didn't usel language designed to trick or annoy. For example, 'to throw away [this anesthetic option]' (it's not being, it is instead, as you clearly stated earlier, being withdrawn from widespread use. Also try to avoid the dishonest discounting of other arguments and positions ('so called climate effects', 'tree hugging loonies' etc.).
It's seeming to me like a conversation with Jeremy Clarkson here. Over sensationalised hyperbole, not adding to mutual enlightenment. Shame; you raise an interesting topic.

P.s. my bias is that I'll likely live on the planet, with the consequences of our collective decisions, for a bit longer than those already retired. That admittedly shapes my thinking.

Plenty of that on both sides!!

 

[gasman]

Interesting subject. I've been an anaesthetist for more than 30 years - I am just about to retire from the NHS. I have used pretty much all the available anaesthetic agents from tricholoethylene to desflurane. I havent used xenon which is the cleanest drug but is by far the most expensive.
Desflurane was lauded as the great new hope when it first emerged - but it is expensive and is the worst greenhouse gas anaesthetic - but importantly although patients open their eyes a few minutes earlier with desflurane that rarely translates into economic savings - ie they don't actually go home any quicker - so it doesnt mean you can do more ops per day etc. The one group of patients where it does make more of a difference is in morbidly obese patients - however it is still perfectly possible to use sevoflurane or even isoflurane - it also comes down to the timing of how you give the anaesthetic drugs.
I didn't see any mention of propofol. Anaesthesia is being driven at present towards the use of non-volatile agents - total intravenous anaesthesia (TIVA) with propofol which on balance is probably better for the environment. A fair summary here https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15785
My view, for what it is worth, is that the way these drugs are marketed plays more of a role than the scientific evidence behind whether one is 'better' than the other. Unless there are obvious disadvantages - like halothane which as well as causing liver damage under hypoxic conditions was also associated with heart problems. A good example is sevoflurane which, when it was introduced was 20 times the price of isoflurane without huge benefits but quickly became market leader due to the marketing.
At the end of the day, the risks of an anaesthetic are very low. On its own (ie not taking into account other medical conditions, emergencies etc), the risk of anaesthesia is very very low - almost down to the sort of level of risk of being struck by lightning. Certainly minute-for-minute you are safer under anaesthetic per minute than you are than driving a car which kind-of puts it into perspective.

 

[Noel]

Interesting subject. I've been an anaesthetist for more than 30 years - I am just about to retire from the NHS. I have used pretty much all the available anaesthetic agents from tricholoethylene to desflurane. I havent used xenon which is the cleanest drug but is by far the most expensive.
Desflurane was lauded as the great new hope when it first emerged - but it is expensive and is the worst greenhouse gas anaesthetic - but importantly although patients open their eyes a few minutes earlier with desflurane that rarely translates into economic savings - ie they don't actually go home any quicker - so it doesnt mean you can do more ops per day etc. The one group of patients where it does make more of a difference is in morbidly obese patients - however it is still perfectly possible to use sevoflurane or even isoflurane - it also comes down to the timing of how you give the anaesthetic drugs.
I didn't see any mention of propofol. Anaesthesia is being driven at present towards the use of non-volatile agents - total intravenous anaesthesia (TIVA) with propofol which on balance is probably better for the environment. A fair summary here https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15785
My view, for what it is worth, is that the way these drugs are marketed plays more of a role than the scientific evidence behind whether one is 'better' than the other. Unless there are obvious disadvantages - like halothane which as well as causing liver damage under hypoxic conditions was also associated with heart problems. A good example is sevoflurane which, when it was introduced was 20 times the price of isoflurane without huge benefits but quickly became market leader due to the marketing.
At the end of the day, the risks of an anaesthetic are very low. On its own (ie not taking into account other medical conditions, emergencies etc), the risk of anaesthesia is very very low - almost down to the sort of level of risk of being struck by lightning. Certainly minute-for-minute you are safer under anaesthetic per minute than you are than driving a car which kind-of puts it into perspective.

Thanks Gasman, good to learn from somebody at the coal face. Interesting topic.
Enjoy your retiremen.

 

[deema]

@gasman thank you for your insights, it’s around 30 years since I was working with Desflurane and was fully familiar with the studies of its effectiveness and a lot will have changed since then. I believe the main advantages claimed were to do with post operative recovery complication and length of time in ICU / time to discharge particularly moving from over night stays to day cases, ie walk in and walk out same day surgery. It didn’t I believe affect the time to carry out an op, other than reducing induction times by a few minutes. I found the following interesting

Washout and Awakening Times after Inhaled Sedation of Critically Ill Patients: Desflurane Versus Isoflurane
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7915095/
The most interesting graph being

To me, and I’d appreciate your perspective, if I were critically unwell, or obese as examples I would be far better off being anaesthetised using Desflurane than Isoflurane, a conclusion I reached when I was involved in it and still appears to be the case today?

 

[gasman]

No I don't agree you would be better anaesthetised with propofol - an intravenous sedative. Using volatile agents in ICU for sedation makes no sense because of the difficulty in scavenging the waste gases when suctioning endotracheal tubes etc.
Your graphs are interesting and for sure show quicker eye opening etc with desflurane - but I repeat my initial point this does not translate to getting an extra patient onto the operating list or reducing the rate of overnight admissions and therefore saving any money. I am not aware of any decent randomised controlled trials (the gold standard for 'proving' something in medicine) showing desflurane any better than sevo or iso (and it costs more plus the negative aspects about greenhouse gases).
I have used desflurane quite a bit and even, years ago, helped Penlon develop a desflurane vaporiser as an alternative to the tec6 but, given all the above, it's a no brainer in my view to get rid of it as an anaesthetic agent in 2023

 

[Spectric]

The one group of patients where it does make more of a difference is in morbidly obese patients - however it is still perfectly possible to use sevoflurane or even isoflurane

The fact they are like that is more than likely down to lifestyle choice and with the vast amount of information we are surrounded by today then they know the score, big bulky people are at much more risk from both medical conditions and higher risk from operations etc as was demonstrated during Covid, a lot of them died due to obesity or maybe they could not be fully cared for in hospital. If this is the only downside to using this anaesthetic then what is the problem, choice of helping climate change or losing a few more obese people.

 

[Jacob]

..... If this is the only downside to using this anaesthetic then what is the problem, choice of helping climate change or losing a few more obese people.

Hmm dunno.
Could be the thin end of a wedge (no pun intended).
Anorexics or brexitards next?
Or cyclists?

 

[Blackswanwood]

The fact they are like that is more than likely down to lifestyle choice and with the vast amount of information we are surrounded by today then they know the score, big bulky people are at much more risk from both medical conditions and higher risk from operations etc as was demonstrated during Covid, a lot of them died due to obesity or maybe they could not be fully cared for in hospital. If this is the only downside to using this anaesthetic then what is the problem, choice of helping climate change or losing a few more obese people.

I think that’s an unnecessarily offensive thing to say particularly as the post you quoted points out there are alternatives for those who are obese and so the choice is not one of letting them die.

It’s hardly confidence inspiring for anyone watching the forum and contemplating joining who may be struggling with obesity (or perhaps has a relative who is) to see a moderator (responsible for forum conduct) espousing such callous views.

Just saying.

 

[Spectric]

This is why we have such an issue with obesity and so many other problems in todays society, no one wants to accept responsibility and it is always someone elses fault. Why is it so difficult to accept that obesity in many cases is down to nothing more than lifestyle and that in some situations such as a pandemic that there chance of survival is much lower, if a doctor is faced with saving someone they will always save the one that has the better chance of survival, so being obese or very old then you are not top of the queue.

 

[Agent_zed]

This is why we have such an issue with obesity and so many other problems in todays society, no one wants to accept responsibility and it is always someone elses fault. Why is it so difficult to accept that obesity in many cases is down to nothing more than lifestyle and that in some situations such as a pandemic that there chance of survival is much lower, if a doctor is faced with saving someone they will always save the one that has the better chance of survival, so being obese or very old then you are not top of the queue.

So you would agree there should be an increase in limiting the use of cars and an increase in cycle infrastructure? That would reduce obesity in those that walk or cycle to work and it would be everyones own responsibility to choose where to live/work in relation to that change. People would be accepting responsibility for reducing local air pollution and noise. Increases in physical activitity come with a huge range of health benefits and ultimately would lead to a more healthy productive society.

 

[Blackswanwood]

This is why we have such an issue with obesity and so many other problems in todays society, no one wants to accept responsibility and it is always someone elses fault. Why is it so difficult to accept that obesity in many cases is down to nothing more than lifestyle and that in some situations such as a pandemic that there chance of survival is much lower, if a doctor is faced with saving someone they will always save the one that has the better chance of survival, so being obese or very old then you are not top of the queue.

Of course you are right - how daft of me to have thought your comment about letting people die was offensive.

Let’s add smokers, drinkers and people who played rugby to the list …

 

[deema]

@Blackswanwood If we play the offended card, nobody would ever be able to say anything. Someone will always be offended by anything said. So, for instance, I wasn’t in the slightest offended by @Spectric comments, they seemed perfectly rational. There are a small number of medical conditions that cause obesity that the person has little control over, these affect a tiny number of people. The majority it’s a lifestyle choice. If we consider the downsides of obesity including the medical impact that places them at a higher risks for a significant number of conditions we probably as a society should view it as morally acceptable as smoking or drug abuse. Today, we think nothing of smoke-shaming and indeed have laws restricting where you can indulge. We equally have laws concerning the use of recreational drugs all of which is driven by the harm it can do. For some reason, it seems acceptable and in fact intolerable to fat-shame. When we divorce moral responsibility from actions we are on a slippery slope. In fact I would suggest condoning being obese is in fact a form of abuse. There are a number of conditions that the NHS will not perform elective surgery for if you are mortally obese.