Physicians are not climate scientists and are not trained in the intricacies of how greenhouse gases affect climate change. Hence it is refreshing to read the thought-provoking review article by Slingo and Slingo on the impact of volatile anaesthetic gas emissions on climate change [1]. They have suggested that only desflurane will have full radiative effect on global warming due to its longer atmospheric lifetime of 14 years compared with others. Another key message for us practitioners is the caution against the simplistic use of global warming potential (GWP) to calculate the carbon footprint of volatile agents. While many, including us, have used GWP in the past, we agree with their call for caution in translating GWP to miles driven. Yet, we contend that, even if our contribution to greenhouse gases is not significant, choosing volatile agents with shorter life times seems common sense and aligns with the recommendations of the AR-6 report of the Intergovernmental Panel on Climate Change to curb the use of near-term climate forcers. Additionally, such choices also align with the principles of ‘choosing wisely’ where resource consciousness is taken into consideration. We must refine our practice by both choosing the anaesthetic agent with the most favourable profile and the ideal way to use that agent.

Environmental sustainability aside, there are a multitude of reasons to refrain from using desflurane, which is far from an ideal anaesthetic agent. First, it has lower potency requiring approximately three times more mass of agent for the same clinical effect compared with sevoflurane. Second, its pungency may cause bronchial reactivity, and increase cerebral blood flow and cerebral spinal fluid pressure, causing sympathetic stimulation [2]. These undesirable effects outweigh the marginal clinical benefit of earlier recovery [3]. With a better understanding of the pharmacokinetic properties of sevoflurane, adjustment of the sevoflurane dosage towards the end of surgery negates the latter perceived advantage. Third, the costs of desflurane remain significantly higher than sevoflurane, especially given its reduced potency. Institutions have demonstrated significant cost savings with reduced desflurane use [4]. Moreover, low fresh gas flows should be employed using automated fresh gas flow control, which is lacking in even highly resourced countries such as the USA, one of the highest emitters of healthcare-related greenhouse gases.

Irrespective of our total contribution to climate change, the fact remains that desflurane is more harmful to the environment compared with sevoflurane. Desflurane has significantly higher atmospheric concentrations than sevoflurane and isoflurane, contributing 81% of the radiative forcing of the halogenated anaesthetic agents [5]. Taking the economic and perhaps environmental considerations, all healthcare sectors are beginning to remove desflurane from clinical practice. This is much needed considering the growing surgical burden and the future need to improve access to surgeries in low-income countries.

We agree with the statement by Slingo and Slingo [1] that selecting a volatile agent should be based on clinical judgement; however, even with that in mind, desflurane is disadvantageous from a value-based perspective for both patients and institutions. Further, even if the impact of volatile agents on the environment may seem minimal, action is better than inaction, and small actions in the right direction are to be encouraged to combat the climate emergency. Choosing sevoflurane on the grounds of clinical, economic and environmental reasons aligns with the triple bottom line. Refining practice with automated fresh gas flow or closed circuits to minimise usage is necessary. There are many more strategies anaesthetists need to focus on for combating the climate crisis; choosing anaesthetic agents is only one component. We must keep moving and not get distracted.

医生不是气候科学家，也没有接受过温室气体如何影响气候变化的复杂培训。因此，阅读 Slingo 和 Slingo 关于挥发性麻醉气体排放对气候变化影响的发人深省的评论文章令人耳目一新 [ 1 ]。他们认为，只有地氟烷对全球变暖具有完全的辐射作用，因为与其他物质相比，它在大气中的寿命更长，达到 14 年。对我们从业者来说的另一个关键信息是，不要简单地使用全球变暖潜势（GWP）来计算挥发性物质的碳足迹。虽然包括我们在内的许多人过去都使用过 GWP，但我们同意他们关于谨慎将 GWP 转换为行驶里程的呼吁。然而，我们认为，即使我们对温室气体的贡献并不显着，选择寿命较短的挥发性制剂似乎是常识，并且符合政府间气候变化专门委员会 AR-6 报告中关于限制使用挥发性制剂的建议。近期气候驱动力。此外，这种选择也符合考虑资源意识的“明智选择”原则。我们必须通过选择最有利的麻醉剂和使用该麻醉剂的理想方式来完善我们的实践。

除了环境可持续性之外，还有很多理由避免使用地氟醚，它远非理想的麻醉剂。首先，与七氟烷相比，它的效力较低，需要大约三倍的剂量才能达到相同的临床效果。其次，其刺激性可能引起支气管反应性，并增加脑血流量和脑脊液压力，引起交感神经兴奋[ 2 ]。这些不良影响超过了早期康复的边际临床效益[ 3 ]。随着对七氟醚药代动力学特性的更好了解，在手术结束时调整七氟醚剂量会抵消后者的优势。第三，地氟醚的成本仍然明显高于七氟醚，特别是考虑到其效力降低。各机构已经证明，通过减少地氟醚的使用，可以显着节省成本[ 4 ]。此外，应使用自动新鲜气流控制来采用低新鲜气流，而即使是资源丰富的国家（例如美国，医疗保健相关温室气体排放量最高的国家之一）也缺乏这种控制。

无论我们对气候变化的总体贡献如何，事实仍然是，与七氟醚相比，地氟醚对环境的危害更大。地氟烷的大气浓度明显高于七氟烷和异氟烷，占卤化麻醉剂辐射强迫的 81% [ 5 ]。出于经济和环境方面的考虑，所有医疗保健部门都开始从临床实践中去除地氟醚。考虑到日益增长的手术负担以及未来需要改善低收入国家的手术机会，这是非常必要的。

我们同意 Slingo 和 Slingo [ 1 ] 的说法，即选择挥发性药物应基于临床判断；然而，即使考虑到这一点，从基于价值的角度来看，地氟醚对患者和机构来说都是不利的。此外，即使挥发性物质对环境的影响可能看起来很小，但行动总比不行动好，并且应鼓励采取正确方向的小行动来应对气候紧急情况。基于临床、经济和环境原因选择七氟醚符合三重底线。有必要采用自动新鲜气流或闭合回路进行精炼，以尽量减少使用量。麻醉师需要关注更多策略来应对气候危机；选择麻醉剂只是其中之一。我们必须继续前进，不要分心。