The environmental footprint and ecotoxicity of sevoflurane and propofol anaesthesia: a retrospective observational modelling study

Matthieu Bernat; Alain Kalmar; Philippe Cuvillon; Manon Roche; Anne Remacle; Bruno Pastene; Marc Leone; Lionel Bouvet; Hans Peter H Arp; Laurent Zieleskiewicz

doi:10.1016/j.bja.2026.03.042

The environmental footprint and ecotoxicity of sevoflurane and propofol anaesthesia: a retrospective observational modelling study

Br J Anaesth. 2026 May 6:S0007-0912(26)00260-6. doi: 10.1016/j.bja.2026.03.042. Online ahead of print.

Authors

Affiliations

¹ Department of Anaesthesia and Intensive Care Medicine, Hôpital Nord, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France. Electronic address: matthieu.bernat@ap-hm.fr.
² Department of Anaesthesia, Intensive Care and Pain Medicine, General Hospital Maria Middelares, Ghent, Belgium; Department of Electronics and Information Systems, IBiTech, Ghent University, Ghent, Belgium.
³ Department of Anaesthesia and Intensive Care, CHU Caremeau, Nimes, France.
⁴ Service Central des Opérations Pharmaceutiques, Assistance Publique des Hôpitaux de Marseille, France; Aix Marseille Université UMR CNRS 7273, ICR, Marseille, France.
⁵ Department of Medical Information, Hôpital Nord, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France.
⁶ Department of Anaesthesia and Intensive Care Medicine, Hôpital Nord, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France.
⁷ Department of Anaesthesia and Intensive Care Medicine, Hôpital Nord, Assistance Publique des Hôpitaux de Marseille, Aix Marseille University, Marseille, France; France Laboratoire C2VN, Inserm 1263, INRAE 1260, Aix-Marseille Université, Marseille, France.
⁸ Department of Anaesthesia and Intensive Care Medicine, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France; Department of Anaesthesiology and Intensive Care Medicine, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France.
⁹ Norwegian Geotechnical Institute (NGI), Oslo, Norway; Department of Chemistry, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.

PMID: 42097956
DOI: 10.1016/j.bja.2026.03.042

Abstract

Background: General anaesthesia contributes to healthcare-related environmental impacts through anaesthetics with high global warming potential and ecotoxicity. Inhalational anaesthetics have high global warming potential, whereas propofol-based total i.v. anaesthesia (TIVA) has potential for aquatic toxicity. However, the lowest global warming potential fluorinated anaesthetics used, such as sevoflurane, degrade to trifluoroacetic acid (TFA), which is accumulating irreversibly in the environment. We compared the water contamination potential across three anaesthetic strategies: TIVA with propofol, target-controlled inhalational anaesthesia (TCIA) with sevoflurane, and manually optimised low-flow sevoflurane anaesthesia.

Methods: This retrospective observational modelling study included adult general anaesthesia procedures from three French university hospitals, each using one strategy (TIVA, TCIA, or manual sevoflurane). Anaesthetic consumption was obtained from pharmacy records. Using published physicochemical data and established regulatory concentration thresholds, we calculated estimated instantaneous and long-term water contamination potential for propofol and sevoflurane-derived TFA.

Results: TIVA, TCIA, and manually optimised sevoflurane strategies were used in 10 717, 7207, and 15 461 cases, respectively. In a 10-yr simulation assuming 1000 h of general anaesthesia per year, TFA accumulated linearly to 29-35 million m³ in halogenated strategies, whereas propofol contamination reached a steady plateau after ∼5 yr in the TIVA strategy to 2.6-2.9 million m³ depending on waste management.

Conclusions: TIVA with propofol generated less water contamination and avoided TFA release while producing locally biodegradable residues. Conversely, sevoflurane-derived TCIA and manual methods led to higher TFA emissions, contributing to its global irreversible accumulation. These findings warrant consideration when minimising the environmental impacts of anaesthetic practises.

Keywords: ecotoxicity; halogenated anaesthetic; propofol; sevoflurane; total intravenous anaesthesia; trifluoroacetic acid.