We are spolied for choice here in Australia: Sevoflurane, desflurane and isoflurane. But do we really need all three? My opinion is: No!
There are many pharmacokinetic differences between these three volatiles, but when you actually look for clinically significant differences, there is little. In my view the important differences between the volatiles are suitability for gas induction, time to MAC awake, environmental impact, and cost.
When compared to sevoflurane:
- Isoflurane: Poor for gas induction, longer to MAC awake, and higher life cycle greenhouse effect. Isoflurane is a lot cheaper, but the cost of sevoflurane could be driven down if institutions buy more of it at the expense of isoflurane and desflurane. I worked in Sweden were we only had access to Sevoflurane. By standardising the available drug and buying tonnes of it, you can drive the price down.
- Desflurane: Poor for gas induction, slightly shorter time to MAC awake, much higher (2000%!) life cycle greenhouse gas effect, and more expensive. In my practice, the only time I use desflurane is for the last hour of an all day long (> 8 hours) case. This gives enough time for the sevoflurane to wash out, but minimises the use of the evil desflurane.
Some centres have recently stopped stocking desflurane citing environmental concerns. Other ways to avoid the volatiles include using regional techniques and propofol infusions.