Introduction

This guidance describes the context of the national decommissioning of desflurane, a volatile anaesthetic agent with higher global warming potential than alternative, readily available general anaesthetic agents. It provides clarity to clinicians and systems in the NHS in England regarding the limited, permitted use of desflurane from 1 April 2024 onwards.

The Association of Anaesthetists and the Royal College of Anaesthetists (RCoA) supported the NHS England announcement of the decommissioning of desflurane in routine practice by early 2024. Following the decommissioning announcement, made on 10 January 2023, work commenced to understand whether any circumstances exist for which the use of desflurane should be permitted, considering patient outcomes and possible impact on NHS resource. The completion of this work has led to the development of this guidance.

The development of this guidance was led by the National Clinical Director for Perioperative and Critical Care with the support of the NHS England Medicines Policy and Strategy Team and Greener NHS (GNHS). The information within this guidance builds on NICE’s desflurane evidence summary and has been informed by the involvement of key stakeholders, including anaesthetists and the following professional bodies:

• the Association of Anaesthetists (the Association)
• the Royal College of Anaesthetists (RCoA)
• the Neuro Anaesthesia and Critical Care Society (NACCS)
• the Society for Obesity and Bariatric Anaesthesia (SOBA)
• the Age Anaesthesia Association (AAA)
• the Association of Paediatric Anaesthetists (APAGBI)
• National Institute for Health and Care Excellence (NICE)

This guidance should be considered alongside the other resources available to support desflurane decommissioning from the Greener NHS programme at NHS England, the Association, and the RCoA. The FutureNHS platform also includes useful information and is available to NHS colleagues.

The policy and this supporting guidance are limited to the decommissioning of the volatile anaesthetic agent desflurane, barring specific clinical exceptions. It does not include recommendations on wider sustainable anaesthesia issues such as the relative impact of alternatives to desflurane on climate change. Similarly, this guidance does not cover the use of volatile capture technologies; decisions to implement these technologies should continue to be locally made, considering best available evidence on their effectiveness and any cost implications.

Background – The reduction in use of desflurane

In recent years, clinicians have been leading efforts to reduce the use of desflurane, an inhalational anaesthetic used in surgery. This reduction has been motivated by the detrimental impact desflurane has on the climate when compared to alternative, readily available general anaesthetic agents, such as sevoflurane. 

Following the NHS commitment to reach net zero by 2045, targets to reduce the volume of desflurane used as a proportion of total volatile anaesthetics have been included in the NHS Standard Contract: from 10% in 2021/22, to 5% in 2022/23, then in 2023/24 to 2% with a view to full decommissioning in routine practice by early 2024. These targets have been overachieved each year, with desflurane use now accounting for well below 1% of the total proportion of volatile anaesthetics by volume. At the time of this guidance’s development, almost 90 trusts in England which range from community hospitals to highly specialised trusts and perform a wide range of procedures, have stopped using desflurane altogether in recent years.

Considering the reduction of desflurane use over recent years, on 10 January 2023, NHS England announced, with the support of the Association and the RCoA, that desflurane would no longer be used in routine practice by early 2024. This was the first time NHS England had committed to stop using a medicine in routine practice because of its climate impact, marking a big milestone on the path to a net zero health service. The NHS England commitment aligned with commitments made by other healthcare systems. In 2022, NHS Scotland announced that it was working to end its use of desflurane, and in the same year, the European Union proposed to prohibit the use of desflurane from 1 January 2026 (except when such use is strictly required, and no other anaesthetic can be used on medical grounds).

Identifying clinical exceptions and desflurane use

NHS England consulted with anaesthetists and professional bodies, and reviewed existing evidence, to identify potential clinical areas whereby the use of desflurane over alternative, readily available general anaesthetic agents warranted further investigation. It was agreed that further evidence review was only required in two clinical contexts: anaesthesia in neurological procedures and anaesthesia for patients living with obesity (defined as patients with a body mass index above 30 kg/m²).  

NHS England commissioned NICE to undertake an evidence review of the clinical and cost benefits of using desflurane for maintenance of anaesthesia compared with other general anaesthetic agents in these two clinical contexts.

The NICE evidence summary followed the standard NICE evidence summaries process and included consultation with subject matter experts nominated by relevant professional bodies. Overall, the NICE evidence summary concluded that:

• the results of the included studies did not favour one type of general anaesthetic over another
• no evidence was identified to suggest that using desflurane instead of other general anaesthetic agents for maintenance of anaesthesia is associated with improved clinical or cost outcomes in people undergoing neurological procedures, or any patient population with a body mass index (BMI) of at least 30 kg/m² having any procedure. 

Following the review, representatives of the Association, APAGBI, NACCS, RCoA and SOBA, as well as independent clinical experts, attended a consensus building workshop chaired by the National Clinical Director for Perioperative and Critical Care and supported by members of the NHS England’s Medicines Policy and Strategy and GNHS teams. The purpose of this workshop was to reach consensus on whether any clinical circumstances exist whereby the use of desflurane should be permitted, considering the NICE desflurane evidence summary and the views and experience of their members and as independent clinical experts. 

Decision on desflurane and clinical use

The workshop resulted in consensus and the agreement that:

• Desflurane can be withdrawn from general use in the NHS without clinical risk to patients
• Neuroanaesthetists raised concerns that a small number of very specific, long procedures may constitute grounds for clinical exceptions. In recognition of the diversity of experience and opinions expressed among the NACCS members, it was also agreed that, currently, some specific clinical exceptions may be warranted; for example, selected patients undergoing long cranial neurosurgical procedures under general anaesthesia.

To ensure clarity for patients and the NHS, NACCS agreed to define these specific clinical exceptions and keep them updated on its website.

While the use of desflurane will be exceptionally permitted in a small number of selected circumstances identified and published by NACCS, the clinical engagement showed that these procedures are also routinely, and successfully, performed without the use of desflurane. Anaesthetists should continue to decide on a case-by-case basis the best anaesthesia approach for these procedures.

Outside these specified exceptional clinical circumstances, NHS trusts should no longer procure and use desflurane. For trusts undertaking the specified neurosurgical procedures, desflurane will continue to be made available to procure via existing National Framework Agreements, held by NHS England.

Next steps

This policy builds on the best available evidence, as well as current climate science consensus at the time of publication. It includes a small number of clinically defined exceptions, as will be published by NACCS on their website. NHS England, the RCoA and the Association will continue to evaluate new clinical evidence regarding the use of desflurane and consider any change in scientific consensus.

Aside from avoiding the general use of desflurane, decisions regarding the choice of anaesthetic agent, or anaesthetic modality (such as local versus regional versus general anaesthesia) should remain clinically based and reviewed by the anaesthetic team on a patient-by-patient basis and in accordance with local and/or national guidance and evidence.

In addition to decommissioning desflurane, healthcare professionals and trust colleagues can further reduce the environmental impact of anaesthetic practices by minimising unnecessary waste, such as from piped nitrous oxide and single use plastics. The Association and RCoA have a range of resources and more information regarding making sustainable choices in anaesthesia, and NHS colleagues can find information regarding achieving a net zero NHS via the Greener NHS workspace on the FutureNHS platform, which is available to NHS staff only.

This guidance has been endorsed by the Association of Anaesthetists and by the Royal College of Anaesthetists.

Publication reference: PRN01005