Disproportionate carbon footprint of isoflurane in super-refractory status epilepticus
Abstract
<title>Abstract</title> <p> <bold>Background</bold> Greenhouse gas emissions are an emerging concern in intensive care units (ICUs), and medications are a major contributor to the environmental footprint of critical care. Super-refractory status epilepticus (SRSE) requires prolonged deep sedation to achieve burst suppression on continuous electroencephalography. Therapeutic options include intravenous agents and volatile anesthetics, but no high-quality comparative evidence has demonstrated the superiority of one strategy over another. In this context of clinical equipoise, the environmental impact of treatments may represent a decision-making factor. <bold>Methods</bold> We conducted a comparative carbon footprint analysis of seven sedative regimens used for SRSE. Six intravenous agents (propofol 1% and 2%, midazolam, thiopental, ketamine, esketamine) and one volatile agent (isoflurane) were compared over one day of treatment. Carbon emissions (kgCO₂eq) were estimated using process-based life cycle assessment (ISO 14040/44) with the validated Carebone® tool (AP-HP), at minimum, mean, and maximum doses for a 70 kg patient. The analysis encompassed active pharmaceutical ingredient, excipients, packaging, medical devices, dilution solutions, transport, and disposal. A cost analysis was also performed. <bold>Results</bold> At mean recommended doses over 24 hours, midazolam had the lowest emissions (1.17 [1.07–1.27] kgCO₂eq/day), followed by propofol 2% (2.66 [2.18–3.14] kgCO₂eq/day), esketamine (5.03 [3.59–6.47] kgCO₂eq/day), ketamine (5.91 [4.23–7.59] kgCO₂eq/day), propofol 1% (7.77 [7.05–8.49] kgCO₂eq/day), and thiopental (16.23 [11.91–20.55] kgCO₂eq/day). Isoflurane showed markedly higher emissions (218.61 [182.37-254.85] kgCO₂eq/day), approximately 14- to 186-fold greater than intravenous alternatives, reaching 380 kgCO₂eq/day at maximum doses. Isoflurane was also the most expensive strategy (2,269.77 €/day) whereas intravenous agents ranged from 15.07 €/day (midazolam) to 132.64 €/day (thiopental). <bold>Conclusions</bold> Isoflurane is associated with a markedly higher environmental impact than intravenous sedatives used for SRSE management. In the absence of demonstrated clinical superiority, environmental impact may be a relevant complementary criterion for therapeutic decision-making, supporting the use of intravenous alternatives such as midazolam and propofol 2%. </p>
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