In recent years, the conversation around anaesthetic practice has expanded beyond theatre efficiency and clinical outcomes to include a new, urgent dimension: environmental sustainability. As healthcare organisations evaluate their carbon footprint, anaesthesia has come under the spotlight – not for lack of safety or efficacy, but because volatile gases carry a surprisingly heavy environmental cost.
A growing body of evidence now positions Total Intravenous Anaesthesia (TIVA) as a clinically strong and environmentally responsible alternative. Let’s explore why this shift is gaining momentum.
🌍 1. Why Sustainability Matters More Than Ever
Inhalational anaesthetic agents have long been central to general anaesthesia, but their environmental impact has become increasingly difficult to overlook. Volatile agents such as sevoflurane and desflurane are potent greenhouse gases that persist in the atmosphere for extended periods. Recent commentary in the BMJ Practice (October 2024) highlights that volatile anaesthetics can contribute up to 3% of national healthcare emissions in high‑income countries, placing them firmly on the agenda for sustainability planning.
Adding depth to this concern, a comprehensive life‑cycle assessment conducted by Sherman et al. (2012) evaluated the cradle‑to‑grave climate impact of commonly used anaesthetic drugs, including sevoflurane, desflurane, isoflurane, nitrous oxide, and propofol. Their analysis showed that desflurane has the highest greenhouse gas burden – 15 times that of isoflurane and 20 times that of sevoflurane per MAC‑hour in an O₂/air mixture. Crucially, the study found that for all volatile agents, the environmental impact is dominated by uncontrolled emissions of waste anaesthetic gases released directly into the atmosphere. In contrast, propofol’s life‑cycle emissions are nearly four orders of magnitude lower, largely attributable not to atmospheric release but to the electricity used to power infusion pumps.[2]
These findings reinforce the advantages of Total Intravenous Anaesthesia (TIVA), which generates no atmospheric emissions at the point of use and therefore aligns closely with healthcare decarbonisation strategies. The life‑cycle data makes it clear that switching from volatile anaesthetics to intravenous techniques offers a meaningful opportunity to reduce perioperative greenhouse gas emissions.[2]
Further supporting this, a 2024 observational study by Bernat et al. examined the carbon footprint associated with anaesthetic drugs themselves, adding contemporary evidence to the growing consensus that increased use of TIVA can substantially reduce the environmental impact of anaesthetic practice.[3]
- TIVA vs Mixed Volatile- TIVA findings: The TIVA strategy hospital produced 2.42 kg of CO2e per intervention, while the mixed-strategy hospital generated 48.85 kg of CO2e per intervention. This difference represents a reduction of approximately 20 times for the TIVA strategy, making it one of the most impactful “quick wins” for environmentally responsible care.
💉 2. Clinical Performance: TIVA Holds its Ground – and Sometimes Outperforms
The shift toward TIVA is not just about the environment. Clinically, TIVA brings several well‑recognised benefits:
- Smoother recovery and less postoperative nausea and vomiting (PONV)
Propofol‑based TIVA consistently reduces postoperative nausea and vomiting compared with inhalational agents, improving patient comfort and shortening recovery times. This is reflected in multiple evaluations, including the BMJ Practice editorial.
- Better early postoperative experience
Patients often report a more “clear‑headed” emergence, an effect supported by both pharmacokinetics and practical experience in modern recovery units.
- Suitable for specialised airway and surgical cases such as:
- Neurosurgery and spinal surgery
- Malignant hyperthermia (MH) susceptibility
- Airway surgery/procedures
- Patients at high risk of severe PONV
- Cases where a more rapid, ‘clear-headed’ recovery is desired
These advantages strengthen TIVA’s role as a versatile, patient‑centred technique.
⚙️ 3. Technological Readiness: TIVA is Easier Than Ever to Deliver
Adopting TIVA once required a steep learning curve, but recent advances have smoothed the pathway:
- Target‑Controlled Infusion (TCI) Systems
Modern pumps provide precise pharmacokinetic models, helping anaesthetists titrate anaesthesia with far greater accuracy. Reviews from 2023 [4] highlight that TCI and depth‑of‑anaesthesia monitoring have made TIVA safer, more predictable, and easier to use.
- Newer Agents and Adjuvants
Emerging drugs such as remimazolam, ciprofol, and adjuncts like dexmedetomidine and esketamine are broadening the TIVA pharmaco‑toolkit. These medications can reduce total propofol requirements and provide improved haemodynamic stability – key factors when transitioning away from volatiles.
Together, these innovations make TIVA far more accessible for departments previously hesitant to transition.
🛠️ 4. What About Barriers? The BMJ Offers Practical Solutions
The BMJ Practice editorial acknowledges that transitioning to TIVA requires planning – but it also provides a roadmap.
- Training & Familiarity
Widespread adoption depends on staff confidence with pumps, pharmacology, and monitoring. Structured educational initiatives are recommended.
- Standardised Safety Protocols
Checklists such as “Peruse Before You Infuse” help reduce line‑setup errors, avoid misconnections, and support safe implementation.
- Reliable Supply Chains
Consistent access to propofol, remifentanil, and adjuncts is essential. This is not a barrier unique to TIVA, but planning helps ensure smooth adoption.
The message is clear: with coordinated education and procurement, TIVA can be implemented safely and effectively across organisations.
🌱 5. A Future‑Focused Perspective
The shift from inhaled to intravenous anaesthesia is not about replacing one tool with another but about choosing wisely. Volatile agents remain excellent options in many contexts – paediatrics, difficult intravenous access, and certain airway scenarios – but the routine default is changing.
Between robust clinical outcomes and powerful environmental benefits, TIVA is emerging as a cornerstone of the modern, sustainable operating theatre.
Conclusion
The case for switching from inhaled anaesthesia to TIVA is stronger than ever. The environmental benefits are compelling, the clinical advantages are well‑documented, and recent technological developments make TIVA easier, safer, and more versatile than in years past.
As hospitals and health systems work toward greener, patient‑centred care, TIVA stands out as one of the most impactful and achievable changes available to anaesthesia teams today.
Key References
- Fleming R, Kossakowska G, Trivedi A, Shelton C. Switching from inhaled to intravenous general anaesthesia. The BMJ Practice. 2024 Oct 2;387:e079323.
- Bernat M, Boyer A, Roche M, et al. Reducing the carbon footprint of general anaesthesia. Anaesthesia. 2024.
- Sherman, J., Le, C., Lamers, V. & Eckelman, M. (2012) Life cycle greenhouse gas emissions of anesthetic drugs. Anesthesia & Analgesia, 114(5), pp. 1086–1090. DOI: 10.1213/ane.0b013e31824f6940. [europepmc.org]
- Bajwa SJS, Vinayagam S, et al. Recent advancements in total intravenous anaesthesia and anaesthetic pharmacology. Indian J Anaesth. 2023.
- Lin C, Wang J, et al. Dose‑dependent efficacy of esketamine in spinal surgery under TIVA. Front Med. 2025.
