Environmental and clinical rationale for the use of desflurane: a review of the literature

Abstract

Desflurane is a fluorinated ether anesthetic with several clinical benefits, including resistance to defluorination (reducing nephrotoxicity), rapid emergence, cardioprotective properties, and faster recovery of airway reflexes than other volatile agents. However, its use is increasingly restricted because of environmental concerns, and the European Union has finalized regulations to phase out its use from January 2026, citing its global warming potential. Although its 100-year global warming potential exceeds that of comparable agents, the most appropriate emission metric remains debated. Radiative forcing estimates indicate that current atmospheric concentrations of desflurane contribute approximately 0.00014 W/m², compared with 2.33 W/m² for CO₂, suggesting a minimal overall impact. Since sevoflurane yields lower values for all indicators, it should be prioritized when volatile anesthetics are used, whereas desflurane should be reserved for specific situations. Moreover, alternative anesthetics, including intravenous agents, have their own environmental burdens related to plastic waste, drug disposal, and energy consumption, indicating that restricting desflurane alone will not eliminate anesthetic-related environmental impacts. This review assesses the balance between desflurane’s clinical utility and environmental effects, identifies contexts in which it offers clinical advantages, summarizes its greenhouse gas contributions, and discusses mitigation strategies, including low-flow anesthesia, anesthetic gas capture and recycling. Judicious, environmentally conscious use of desflurane may allow it to remain an additional anesthetic option in selected clinical contexts, alongside other inhaled and intravenous anesthetics, while efforts to minimize its environmental footprint continue.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00540-026-03760-6.

Introduction

Desflurane is a volatile fluorinated ether anesthetic. It is exclusively halogenated with fluorine and is therefore resistant to defluorination, reducing its nephrotoxicity [1]. It also has a faster emergence compared with other inhalational agents, more rapid recovery of airway reflexes, and cardioprotective effects [1]. Although there are known benefits to using desflurane as an anesthetic, there has been debate about whether it should be banned because of concerns surrounding greenhouse gas emissions, which may exacerbate global climate change [2]. Consequently, many institutions and geographical regions are seeking to reduce or restrict its use [3–10], despite disagreement regarding the potential effects of halogenated ethers on the global climate [11–18].

Although other inhalation agents are available, they may not represent the most effective options for certain patients or under specific scenarios. For example, sevoflurane is another commonly used inhalation agent that has a lower global warming potential than desflurane. However, there are instances where desflurane may be a preferred anesthetic, and it has been argued that the decision on the inhalation agent should be patient oriented [19, 20]. Consequently, it is unclear whether an outright ban is warranted or if desflurane can be used in an environmentally conscious manner.

This narrative review specifically compiles available information to describe the advantages and disadvantages of desflurane as an inhalation anesthetic compared with other anesthetic options and to demonstrate whether the data on the effects of desflurane on global climate are sufficiently conclusive to warrant an outright ban. The specific objectives of this review are to (1) determine in what clinical circumstances volatile anesthetics, in particular desflurane, are preferable to other anesthetic options; (2) describe the magnitude of greenhouse gas emissions associated with desflurane use and the relative contribution to global climate change; (3) infer if the potential environmental risks of desflurane use are balanced by its clinical efficacy; and (4) discuss technologies and procedures that can be implemented to reduce and improve greenhouse gas emissions associated with desflurane use.

The clinical efficacy of desflurane

Volatile anesthetics have a range of efficacies; for example, desflurane and sevoflurane are low-soluble inhalation anesthetics that have more rapid induction and recovery from long procedures than isoflurane [21]. Desflurane has faster clearance than either sevoflurane or isoflurane due to its low blood–gas solubility [22]. Furthermore, desflurane has the lowest metabolic breakdown among inhaled halogenated anesthetics (e.g., halothane, enflurane, isoflurane, and sevoflurane), which contributes to reduced hepatic metabolism and potential benefits for organ safety [23]. However, it is more expensive than other volatile anesthetics, which may restrict its use [1].

Desflurane has several well-documented clinical characteristics, including faster emergence and more rapid recovery of cognitive and airway function compared with other volatile anesthetics [24–27]; and a higher perfusion index and more potent vasodilatory properties than sevoflurane [28]. In addition, experimental and clinical data suggest potential cardioprotective effects of desflurane and other volatile anesthetics, particularly against ischemia-reperfusion injury during cardiac surgery [29–31].

There are also agent-specific properties that may make desflurane useful in specific clinical scenarios based on characteristics of the patient or procedure. In patients with obesity, desflurane has low fat-blood solubility and has been associated with faster emergence and recovery of cognitive and ventilatory function compared with other anesthetic techniques [32–35]. In patients with elevated liver enzymes before surgery, such as in patients undergoing laparoscopic cholecystectomy, postoperative improvement in liver enzyme levels was greater in those administered desflurane than in those administered sevoflurane [36].

Furthermore, in older patients, recovery of cognitive function and airway reflexes may occur earlier after desflurane anesthesia than after sevoflurane anesthesia [25, 26]. Recent large-scale data indicate esophageal surgery under desflurane anesthesia is associated with fewer respiratory complications than sevoflurane anesthesia or total intravenous anesthesia [37].

Although many of these differences are statistically significant, their absolute magnitude is often small, and they may not always translate into clinically important outcomes. Nonetheless, in selected contexts, such as high-turnover ambulatory surgery, patients with obesity, older patients requiring rapid cognitive recovery, or cases where early assessment of airway protection is critical, these modest advantages can have tangible clinical relevance. Taken together, the advantages of desflurane should be interpreted as situational rather than universal, emphasizing the need for judicious selection rather than a categorical preference. This suggests that desflurane should not be routinely selected.

Although there are many benefits to desflurane use, there are also instances where it is not an ideal anesthetic. For example, although some volatile agents (e.g., halothane, isoflurane, and sevoflurane) promote bronchodilation, desflurane can promote bronchoconstriction in patients with asthma [38, 39] and is known to cause airway irritation [23]. Isoflurane has also been reported to cause airway irritation [40]. Therefore, its use should be tailored to individual patient physiology and surgical needs rather than adopted or abandoned entirely. Regardless, an outright ban on the use of desflurane will reduce valid anesthetic options for, and, therefore, be potentially detrimental to, patients and clinical situations in which it is the most appropriate anesthetic.

The impact of volatile anesthetics on global warming

Desflurane is reported to have a 100-year global warming potential (GWP) approximately 5 × that of isoflurane, 10 × that of nitrous oxide, and 20 × that of sevoflurane [41]. It also has a substantially greater greenhouse gas contribution than intravenous anesthesia, estimated at four orders of magnitude higher [42]. Furthermore, desflurane has a third of the potency of sevoflurane and a fifth of the potency of isoflurane [15, 41, 43]; therefore, more of it is required, which increases its environmental impact.

Although the use of fluorinated ethers has been restricted, volatile anesthetics were previously exempt from legislation [11]. The European Union (EU) has finalized a regulation that will phase out the use of desflurane from January 2026, permitting it only where medically necessary and where alternatives are unsuitable. Although some derogations apply, the regulation effectively restricts the general use of desflurane [44]. This ban was developed without consultation with major stakeholders, such as the European Society of Anaesthesiology and Intensive Care [11]. Similarly, there are movements to refrain from using desflurane in other parts of the world (Table 1). Countries including Germany, the Netherlands, and Italy have not yet implemented national bans on desflurane; however, they are anticipated to adhere to the forthcoming EU ban, and individual hospitals and regions within these countries are proactively reducing desflurane usage to mitigate environmental impacts [45–47]. However, it is unclear whether such initiatives are truly based on robust scientific evidence [12, 48]. Although the NICE evidence review that underpinned the NHS England guidance on desflurane decommissioning evaluated the potential utility of desflurane in specific contexts such as neurosurgical procedures and anesthesia for patients with obesity, no consistent evidence of clinical or cost-effectiveness superiority over other anesthetic agents was demonstrated [49].

Table 1.

Summary of regional strategies for regulating desflurane use to mitigate its environmental impact

Date	Region	Strategy	Reference
Oct 2014	USA	A new webpage called “Greening the Operating Room and Perioperative Arena” was added to the American Society of Anesthesiologist’s Environmental Sustainability webpage	American Society of Anesthesiologists [3]
May 4, 2022	EU	Proposal to amend fluorinated gas (F-gas) regulations, representing the initial policy framework that later led to formal restrictions on desflurane use	European Commission [4]
Jan 13, 2023	England	NHS England announced desflurane regulation from 2024; this was supported by the Association of Anaesthetists of Great Britain and Ireland and the Royal College of Anaesthetists	Watts et al. [5]
Mar 3, 2023	Scotland	Scotland pledged to phase out desflurane use by 2024	NHS Scotland [6]
Mar 7, 2023	Spain	The Spanish Society of Anesthesiologists approved amendments to the proposed EU regulation and presented them to the EU	Sociedad Española De Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR) [7], European Parliament [8]
Mar 30, 2023	EU	The European Parliament adopted the F-gas regulation bill. The desflurane regulation was partially revised (similar to the proposal from Spain)	European Parliament [9] (p. 44)
Feb 7, 2024. (effective Jan 2026)	EU	Regulation (EU) 2024/573 finalized; routine use of desflurane to be phased out, permitted only when medically necessary and where alternatives are unsuitable	European Union [44]
Nov 2024	Australia and New Zealand	Cessation of desflurane use recommended under the ANZCA Professional Document: Statement on Environmental Sustainability in Anaesthesia and Pain Medicine Practice, highlighting its high global warming potential and availability of lower-impact alternatives	The Australian and New Zealand College of Anaesthetists [10]

EU European Union, NHS National Health Service, ANZCA The Australian and New Zealand College of Anaesthetists

There is a preponderance of current discourse on the topic of desflurane that focuses heavily on its carbon equivalence relative to other anesthetic options [50], without a significant defense of this agent as a clinically important option [48]. However, there is disagreement about the most accurate emission metric to use when evaluating the relative impact of greenhouse gases. GWP, which is most commonly used [51], does not have an equivalency between short-lived gases, such as desflurane, and longer-lived gases, such as CO₂ [12, 52]. Consequently, radiative forcing is proposed to be a more accurate measure for comparison [12, 53–55]. For example, the average atmospheric concentration of sevoflurane was approximately 0.13 ppt in 2014 [53], which we calculated had a radiative forcing of 0.0000507 W/m², and that the average atmospheric concentration of desflurane was approximately 0.30 ppt [53], with a calculated radiative forcing of 0.000141 W/m². By contrast, the atmospheric concentration of CO₂ in February 2025 was 429.6 ppm [56], with a calculated radiative forcing of 2.33 W/m² (Supplementary File S1). It has also been noted that commonly used metrics, such as GWP, do not fully account for the actual atmospheric abundance of individual anesthetic gases [57]. In this context, modeling studies have estimated that projected emissions of desflurane would result in only a small and reversible increase in global mean surface temperature [58]. In light of these considerations, the carbon footprint of volatile anesthetics, such as desflurane, may warrant further assessment. As with GWP, radiative forcing estimates may evolve with advances in atmospheric measurement techniques and our understanding of anesthetic gas kinetics. As atmospheric science continues to progress, new or refined indicators may emerge, further improving our ability to assess the actual climate impact of volatile anesthetics.

Given these differences in radiative forcing, there are certain differences in the environmental burden of each volatile anesthetic. Sevoflurane, with approximately one-tenth the atmospheric lifetime and less than one-fifth the radiative forcing of desflurane, represents a comparatively lower-impact alternative. However, if these relatively modest environmental differences among volatile anesthetics are to be considered clinically meaningful, it should also be recognized that desflurane may still offer certain advantages in specific contexts, such as in obese patients or in procedures where rapid postoperative neurological evaluation and airway control are critical. Hence, the choice of anesthetic agent should remain context-dependent, guided by both clinical and environmental considerations. While the climate crisis is an urgent global concern, our intention in this review is not to defend or promote any specific anesthetic agent, but to provide a balanced, evidence-based perspective that integrates both environmental and clinical dimensions. The term “minimal environmental effect,” when used in this context, refers specifically to the comparatively small radiative forcing of desflurane relative to major greenhouse gases such as CO₂, rather than implying that its environmental impact is negligible or unworthy of attention. Recent commentary has argued that even a minimal environmental effect should prompt the discontinuation of desflurane, emphasizing a precautionary and ethically driven approach [59].

Although inhaled anesthetics potentially impact the global climate, there are also negative environmental impacts of their alternatives, such as intravenous anesthetic agents. Evidence-based conclusions have not been obtained regarding comparisons of the environmental impacts of inhaled versus intravenous anesthetics [60]. Drug administration waste contributes to environmental contamination [61] and occurs with both inhaled and intravenous anesthetic techniques [62]. However, even though intravenous agents have a lower environmental impact related to greenhouse gases [2, 63], they produce waste associated with the use of syringes, plastic tubing, and needles, which can lead to environmental contamination and increased overall electricity consumption, thereby indirectly contributing to increased greenhouse gas emissions [64–66]. Anesthetic agent selection and delivery practices have therefore been identified as one of several factors influencing the overall environmental footprint of anesthesia [67]. Studies have highlighted that total intravenous anesthesia generates substantial pharmaceutical and material by-products, incurring both environmental and financial costs [68]. In Japan, unused propofol, injection materials, and infusion equipment are routinely discarded as hazardous waste and subsequently incinerated, resulting in direct CO2 emissions and landfill disposal of residual ash. Propofol residues have also been identified as emerging aquatic pollutants, raising additional environmental concerns [69, 70]. In facilities where residual anesthetic drugs, including propofol, are discharged into wastewater systems rather than collected as hazardous waste, there is potential for these compounds to enter municipal sewage and, eventually, surface waters. Such practices may contribute to the accumulation of pharmaceutical contaminants in aquatic environments, with potential ecotoxicological effects on aquatic organisms and implications for long-term water quality management. Therefore, intravenous anesthesia cannot be regarded as a zero-emission alternative. Instead, a balanced coexistence of anesthetic techniques, guided by both clinical needs and realistic environmental considerations, should be pursued to achieve sustainable anesthesia practices.

Considering that the environmental impact differences between volatile anesthetics (sevoflurane, desflurane, and isoflurane) are relatively modest, the choice of anesthetic should remain flexible and individualized. Because desflurane may still offer clinical advantages in certain situations, we consider that maintaining a balanced, case-by-case approach that integrates multiple clinical, environmental, and economic perspectives is most consistent with sustainable anesthesia practice. This suggests that desflurane should not be the routine choice, but rather be selected based on individualized clinical judgment.

Relative environmental risks of desflurane

The environmental impacts of inhalation anesthesia are primarily related to the atmospheric release of anesthetic agents themselves, which are greenhouse gases that contribute to global climate change. However, the relative emissions, atmospheric lifetimes, and atmospheric effects vary among the available and currently used volatile anesthetics, such as halothane, enflurane, isoflurane, desflurane, sevoflurane, and nitrous oxide [2, 60, 71–75] (Table 2). Additionally, other environmental impacts of volatile anesthetics should be considered, such as ecological contamination with per- and polyfluoroalkyl substances (PFAS) [84].

Table 2.

Comparison of estimated climatological impacts of various anesthetics relative to their clinical benefits over other anesthetics

Compound	Est. CO2 equivalents (kg/MAC-h)	Atmospheric lifetime (years)	Radiative forcing (W/m)	Radiative efficiency (W/m/ppb)	Benefits
CO2	–	Indefinite (100 +) [12, 76]	2.16 [12]	0.013665 [77]	–
Desflurane	72.78 [51]	12.3–14 [71, 78]	0.00017 [12]	0.469 [78]	• Fast induction [21] • Fast recovery in long procedures [21] and for obese patients [20] • Faster clearance [22] • Lower incidence of post-anesthetic agitation [34]
Sevoflurane	1.58 [51]	1.1–2 [71, 78]	0.00003 [12]	0.351 [78]	• Fast induction [21] • Fast recovery in long procedures [21] • Less airway irritation [40]
Isoflurane	2.98 [51]	3.2 [78]	0.00006 [12]	0.453 [78]	• Promotes bronchodilation in asthmatic patients [38, 39]
Halothane	N/A	3.6 [79]	0.000012 [53]	0.165 [78]	• Promotes bronchodilation in asthmatic patients [38, 39] • Low cost [80]
Enflurane	N/A	4.5 [71]	N/A	0.447 [78]	• Developed in the 1960s because it was easy to synthesize; however, rarely used now because of side effects [81]
Nitrous oxide	29.98 [51]	103–109 [51]	0.21 [12]	0.00303 [78]	• Subanesthetic concentrations produce a mild analgesic effect [82]

Enflurane largely disappeared from clinical practice in the 1990s and has been phased out from both human and veterinary medicine across high- and low-income countries by the 2020s. Halothane has fallen out of clinical use in most regions, with only limited use reported in parts of Africa as of 2024, and was removed from the World Health Organization's list of essential medicines in 2025 [83]. Enflurane and halothane are listed here for historical and comparative reference. MAC minimum alveolar concentration, N/A not applicable, ppb parts per billion, W/m², watts per square meter

The annual greenhouse gas emissions due to anesthetics worldwide have been reported to be approximately 0.09%, with healthcare responsible for 4.6% of greenhouse gas emissions and anesthetics representing 2% of emissions from healthcare [65]. In 2014, an equivalent of 3 million tons of CO₂ was released by hydrofluorocarbon and chlorofluorocarbon anesthetic gases, of which 80% of the emissions were from desflurane [85, 86]. Moreover, halogenated anesthetic use in medicine accounted for 0.004% of the 59 gigatons of CO₂ equivalents of global anthropogenic greenhouse gas impact in 2019 [86]. Additionally, the use of desflurane in Japan, which is the fifth-largest emitter of CO₂ worldwide, accounts for only 0.032% of Japan’s annual CO₂ emissions [16].

A recent multinational analysis of volatile anesthetic-associated greenhouse gas emissions across 41 countries reported that Japan and South Korea had the highest per-capita emissions in 2023, and that Japan’s temporal trend differed from those observed in many other regions, including Europe [87]. In parallel, perspectives from Japan have emphasized the importance of avoiding overly simplified conclusions based solely on environmental metrics, calling for a more nuanced discussion of desflurane use that accounts for local clinical needs and healthcare system characteristics [55]. Together, these observations highlight substantial geographic variability in anesthetic-related emissions and suggest that national emission profiles are shaped by broader system-level and practice-related factors rather than the use of a single anesthetic agent alone.

Future directions

Technology and procedures currently exist to capture, recycle, and/or destroy volatile anesthetics during use, thereby reducing greenhouse gas emissions associated with their implementation [51, 88]. For example, using low-flow anesthesia can help reduce emissions, waste, and costs [66]. Although volatile anesthetics are not typically reused in humans at present, recaptured sevoflurane was first reused in Austria in 2024 [89]. There is already regulatory approval for this technique in Canada, Austria, and Germany [90]. The use of volatile capture devices for isoflurane has also shown promise in veterinary healthcare [91]. Moreover, recycling of packaging materials associated with volatile anesthetics, including aluminum containers, has been proposed as one of several potential approaches to reduce material-related environmental burdens [92].

These mitigation strategies, including capture, recycling, and low-flow techniques, are not desflurane-specific but are equally applicable to other volatile anesthetics such as sevoflurane and isoflurane. Several emerging technologies aim to reduce the environmental impact of inhaled anesthetics. Among these, volatile recovery systems are still in development and not yet widely adopted due to high costs, anesthetic losses through piping systems, and disposal challenges after recovery [88]. Recent studies have reported variable recovery efficiencies [93, 94]. Notably, a pilot implementation in Austria has already demonstrated the human-use reuse of collected anesthetic gas, indicating practical feasibility, albeit on a limited scale [95]. Although high recovery rates have been demonstrated under laboratory conditions, clinical performance is often limited by system leaks, humidity, and imperfect circuit connections, resulting in lower recovery efficiency. Alternatively, development and implementation of decomposition and adsorption technologies may offer more practical and sustainable approaches for mitigating environmental impact. However, the manufacture, operation, and transport associated with both recovery and decomposition systems also generate CO₂ emissions. Unless their overall life-cycle performance achieves a net positive carbon balance, the true climate benefit of large-scale implementation remains uncertain. Therefore, volatile capture and recycling should be viewed not as a definitive solution, but as one of several complementary strategies toward sustainable anesthetic practice, alongside upstream emission reductions and clinical optimization.

Furthermore, the embodied energy associated with the raw materials, manufacturing, packaging, and transportation of volatile anesthetics, such as desflurane, also contributes to greenhouse gas emissions. Therefore, prioritizing emission reductions at these upstream stages may, in some settings, yield greater near-term benefits for mitigating the overall environmental impact of volatile anesthetics than downstream interventions, such as capture or decomposition systems.

Conclusions

Addressing the climate crisis requires evidence-based reductions in greenhouse gas emissions. The contribution of desflurane to overall greenhouse gas emissions appears to be minimal when assessed by radiative forcing, suggesting a limited role in global warming. No conclusive evidence demonstrates that desflurane has a disproportionately large environmental impact, and its clinical value in specific contexts also remains under discussion. Through situation-specific anesthetic selection, minimization of waste and fresh gas flow, and continued development of approaches to reduce the environmental impact of anesthetic practice, efforts to reconcile clinical efficacy with environmental responsibility should be pursued. Maintaining a balanced coexistence of multiple anesthetic options represents a realistic, reasonable, and sustainable approach both in the short and long term.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by TT and TA. The first draft of the manuscript was written by TT, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

Open Access funding provided by Nagoya University. Except for medical writing support from the Department of Perioperative Management System, Nagoya University Graduate School of Medicine, we did not receive any specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Conflict of interest

None.

Ethical approval

This study is a narrative review of previously published data; therefore, ethical approval was not required.