• Metha Brattwall, Margareta Warrén-Stomberg, Fredrik Hesselvik, and Jan Jakobsson.
• Department of Anesthesiology & Intensive care, Institution for clinical sciences, Sahlgrenska Academy, Gothenburg, Sweden.
• Can J Anaesth. 2012 Aug 1;59(8):785-97.

PurposeThe aim of this brief review is to provide an update on the theory regarding minimal fresh gas flow techniques for inhaled general anesthesia. The article also includes an update and discussion of the practical aspects associated with minimal-flow anesthesia, including the advantages, potential limitations, and safety considerations of this important anesthetic technique.Principal FindingsReducing the fresh gas flow to < 1 L·min(-1) during maintenance of anesthesia is associated with several benefits. Enhanced preservation of temperature and humidity, cost savings through more efficient utilization of inhaled anesthetics, and environmental considerations are three key reasons to implement minimal-flow and closed-circuit anesthesia, although potential risks are hypoxic gas mixtures and inadequate depth of anesthesia. The basic elements of the related pharmacology need to be considered, especially pharmacokinetics of the inhaled anesthetics. The third-generation inhaled anesthetics, sevoflurane and desflurane, have low blood and low tissue solubility, which facilitates rapid equilibration between the alveolar and effect site (brain) concentrations and makes them ideally suited for low-flow techniques. The use of modern anesthetic machines designed for minimal-flow techniques, leak-free circle systems, highly efficient CO(2) absorbers, and the common practice of utilizing on-line real-time multi-gas monitor, including essential alarm systems, allow for safe and cost-effective minimal-flow techniques during maintenance of anesthesia. The introduction of new anesthetic machines with built-in closed-loop algorithms for the automatic control of inspired oxygen and end-tidal anesthetic concentration will further enhance the feasibility of minimal-flow techniques.ConclusionsWith our modern anesthesia machines, reducing the fresh gas flow of oxygen to 0.3-0.5 L·min(-1) and using third-generation inhaled anesthetics provide a reassuringly safe anesthetic technique. This environmentally friendly practice can easily be implemented for elective anesthesia; furthermore, it will facilitate cost savings and improve temperature homeostasis.

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