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Perioperative Care of Patients Undergoing Major Complex Spinal Instrumentation Surgery: Clinical Practice Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol 2021; 34:257-276. [PMID: 34483301 DOI: 10.1097/ana.0000000000000799] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/14/2021] [Indexed: 11/25/2022]
Abstract
Evidence-based standardization of the perioperative management of patients undergoing complex spine surgery can improve outcomes such as enhanced patient satisfaction, reduced intensive care and hospital length of stay, and reduced costs. The Society for Neuroscience in Anesthesiology and Critical Care (SNACC) tasked an expert group to review existing evidence and generate recommendations for the perioperative management of patients undergoing complex spine surgery, defined as surgery on 2 or more thoracic and/or lumbar spine levels. Institutional clinical management protocols can be constructed based on the elements included in these clinical practice guidelines, and the evidence presented.
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Oda Y, Adachi T, Komatsu R, Shimada M, Tanaka Y. Use of desflurane during anesthesia for resection of extra-adrenal pheochromocytoma: a case report. JA Clin Rep 2018; 4:75. [PMID: 32025984 PMCID: PMC6967063 DOI: 10.1186/s40981-018-0212-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 10/10/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Although various agents are used during anesthesia for surgical resection of pheochromocytoma, application of desflurane has rarely been reported. We report the use of desflurane in a case receiving resection of extra-adrenal pheochromocytoma. CASE PRESENTATION A 51-year-old female was transferred to our hospital for sustained hypertension. A diagnosis of extra-adrenal pheochromocytoma was made based on increased plasma catecholamine levels and radiographic findings. Surgical resection was planned after controlling blood pressure. General anesthesia was induced with propofol and fentanyl, followed by maintenance with desflurane 4.3% and remifentanil 0.2-0.4 μg/kg/min. Blood pressure and heart rate were stable during induction, tracheal intubation, and tumor manipulation. Blood pressure abruptly decreased to 62/40 mmHg after removal of the tumor, which was treated with noradrenaline. The surgery was completed uneventfully and the postoperative course was also uneventful. CONCLUSION Desflurane was safely used in combination with remifentanil during anesthesia for resection of extra-adrenal pheochromocytoma.
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Affiliation(s)
- Yutaka Oda
- Department of Anesthesiology, Osaka City Juso Hospital, 2-12-27, Nonaka-kita, Yodogawa-ku, Osaka, 532-0034, Japan.
| | - Takahisa Adachi
- Department of Urology, Osaka City Juso Hospital, 2-12-27, Nonaka-kita, Yodogawa-ku, Osaka, 532-0034, Japan
| | - Ryushi Komatsu
- Department of Cardiology, Osaka City Juso Hospital, 2-12-27, Nonaka-kita, Yodogawa-ku, Osaka, 532-0034, Japan
| | - Motoko Shimada
- Department of Anesthesiology, Osaka City Juso Hospital, 2-12-27, Nonaka-kita, Yodogawa-ku, Osaka, 532-0034, Japan
| | - Yukio Tanaka
- Department of Anesthesiology, Osaka City Juso Hospital, 2-12-27, Nonaka-kita, Yodogawa-ku, Osaka, 532-0034, Japan
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Gupta N, Talwar V, Prakash S, Deuri A, Gogia AR. Evaluation of the efficacy of desflurane with or without labetalol for hypotensive anesthesia in middle ear microsurgery. J Anaesthesiol Clin Pharmacol 2017; 33:375-380. [PMID: 29109639 PMCID: PMC5672504 DOI: 10.4103/joacp.joacp_350_15] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background and Aims: Hypotensive anesthesia technique is used to reduce intraoperative bleeding and to improve the visibility of the operative field. The aim was to evaluate the efficacy of desflurane with and without labetalol for producing hypotensive anesthesia. Material and Methods: Sixty adult patients undergoing elective middle ear surgery were administered general anesthesia and randomly divided into two groups – Group D and Group L. The target mean arterial pressure (MAP) was 55–65 mmHg during hypotensive period. Group D patients received an increasing concentration of desflurane alone. Group L patients received 3% desflurane plus labetalol (loading dose 0.3 mg/kg intravenously, followed by 10 mg increments every 10 min). Student's t-test and paired t-test were used to compare the hemodynamic parameters. Visibility of the operative field, anesthetic and rescue drug requirement, partial pressure of oxygen in arterial blood, time taken for induction and reversal of hypotension and recovery characteristics were noted. Results: Target MAP was achieved in both the groups. Group D was associated with a higher mean heart rate compared with Group L (77.3 ± 11.0/min vs. 70.5 ± 2.5/min, respectively; P < 0.001) during the hypotensive period, along with a higher requirement for desflurane (P = 0.000) and metoprolol (P = 0.01). Time taken to achieve target MAP was lesser in Group L compared with Group D (33.7 ± 7.1 vs. 39.8 ± 6.2 min, respectively; P = 0.000). Time taken to return to baseline MAP was faster in Group D (P = 0.03). Emergence time was longer with desflurane alone (P = 0.000) resulting in greater sedation (P = 0.000) in the immediate postoperative period. Conclusion: Although desflurane is effective for inducing deliberate hypotension in middle ear microsurgery, the combination of desflurane with labetalol is associated with decreased requirement of desflurane, absence of reflex tachycardia, faster induction of hypotension, faster recovery from anesthesia, and less postoperative sedation.
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Affiliation(s)
- Neha Gupta
- Department of Anaesthesia and Intensive Care, PGIMER and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Vandana Talwar
- Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi, India
| | - Smita Prakash
- Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi, India
| | - Achyut Deuri
- Department of Anaesthesia and Intensive Care, Pt. Madan Mohan Malviya Hospital, New Delhi, India
| | - Anoop Raj Gogia
- Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi, India
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Total intravenous anaesthesia versus inhaled anaesthetics in neurosurgery. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rcae.2014.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Anestesia total intravenosa versus anestésicos inhalados en neurocirugía. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rca.2014.07.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Total intravenous anaesthesia versus inhaled anaesthetics in neurosurgery☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1097/01819236-201543001-00003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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Rokamp KZ, Secher NH, Eiberg J, Lønn L, Nielsen HB. O2 supplementation to secure the near-infrared spectroscopy determined brain and muscle oxygenation in vascular surgical patients: a presentation of 100 cases. Front Physiol 2014; 5:66. [PMID: 24611051 PMCID: PMC3933814 DOI: 10.3389/fphys.2014.00066] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 02/03/2014] [Indexed: 12/27/2022] Open
Abstract
This study addresses three questions for securing tissue oxygenation in brain (rScO2) and muscle (SmO2) for 100 patients (age 71 ± 6 years; mean ± SD) undergoing vascular surgery: (i) Does preoxygenation (inhaling 100% oxygen before anesthesia) increase tissue oxygenation, (ii) Does inhalation of 70% oxygen during surgery prevent a critical reduction in rScO2 (<50%), and (iii) is a decrease in rScO2 and/or SmO2 related to reduced blood pressure and/or cardiac output?Intravenous anesthesia was provided to all patients and the intraoperative inspired oxygen fraction was set to 0.70 while tissue oxygenation was determined by INVOS 5100C. Preoxygenation increased rScO2 (from 65 ± 8 to 72 ± 9%; P < 0.05) and SmO2 (from 75 ± 9 to 78 ± 9%; P < 0.05) and during surgery rScO2 and SmO2 were maintained at the baseline level in most patients. Following anesthesia and tracheal intubation an eventual change in rScO2 correlated to cardiac output and cardiac stroke volume (coefficient of contingence = 0.36; P = 0.0003) rather to a change in mean arterial pressure and for five patients rScO2 was reduced to below 50%. We conclude that (i) increased oxygen delivery enhances tissue oxygenation, (ii) oxygen supports tissue oxygenation but does not prevent a critical reduction in cerebral oxygenation sufficiently, and (iii) an eventual decrease in tissue oxygenation seems related to a reduction in cardiac output rather than to hypotension.
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Affiliation(s)
- Kim Z Rokamp
- Departments of Anesthesia, Rigshospitalet, University of Copenhagen Copenhagen, Denmark
| | - Niels H Secher
- Departments of Anesthesia, Rigshospitalet, University of Copenhagen Copenhagen, Denmark
| | - Jonas Eiberg
- Vascular Surgery, Rigshospitalet, University of Copenhagen Copenhagen, Denmark
| | - Lars Lønn
- Interventional Radiology, Rigshospitalet, University of Copenhagen Copenhagen, Denmark
| | - Henning B Nielsen
- Departments of Anesthesia, Rigshospitalet, University of Copenhagen Copenhagen, Denmark
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Bignami E, Greco T, Barile L, Silvetti S, Nicolotti D, Fochi O, Cama E, Costagliola R, Landoni G, Biondi-Zoccai G, Zangrillo A. The effect of isoflurane on survival and myocardial infarction: a meta-analysis of randomized controlled studies. J Cardiothorac Vasc Anesth 2012; 27:50-8. [PMID: 22819469 DOI: 10.1053/j.jvca.2012.06.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim of this meta-analysis was to investigate the cardioprotective properties of isoflurane versus any comparator in terms of the rate of myocardial infarction and all-cause mortality. DESIGN Pertinent studies were searched independently in Biomed, Central, PubMed, Embase, and the Cochrane Central Register of clinical trials. The primary endpoint was mortality at the longest follow-up available. SETTING A hospital. PARTICIPANTS Randomized controlled trials. INTERVENTION A meta-analysis of 37 trials. MEASUREMENTS AND MAIN RESULTS The 37 included trials randomized 3,539 patients in cardiac (16 studies) and in noncardiac surgery (21 studies) with noninhalation comparators in 55% of trials. The overall analysis showed no difference in mortality between the isoflurane and control groups (16/1,602 [1.0%] v 23/1,937 [1.2%], odds ratios (OR) = 0.76 [0.39-1.47], p = 0.4 with 37 studies included) and no difference in the rate of myocardial infarction (3/1,312 [0.2%] v 1/1,532 [0.07%], OR = 2.03 [0.27-15.49], p = 0.5 with 30 studies included). Mortality was reduced in the isoflurane group when only studies with a low risk of bias were included in the analyses (0/540 [0%] v 5/703 [0.7%] in the control arm, OR = 0.13 [0.02-0.76], p = 0.02) with 4 cardiac and 6 noncardiac trials included and 5 noninhalation and 5 inhalation agents as the comparator. A trend was noted when a subanalysis was performed with propofol as a comparator (1/544 [0.2%] v 6/546 [1.1%], p = 0.05, with 16 studies included). CONCLUSIONS Isoflurane reduced mortality in high-quality studies and showed a trend toward a reduction in mortality when it was compared with propofol. No differences in the rates of overall mortality and myocardial infarction were noted.
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Affiliation(s)
- Elena Bignami
- Department of Anesthesia and Intensive Care, Università Vita-Salute San Raffaele, Milan, Italy
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JAKOBSSON J. Desflurane: a clinical update of a third-generation inhaled anaesthetic. Acta Anaesthesiol Scand 2012; 56:420-32. [PMID: 22188283 DOI: 10.1111/j.1399-6576.2011.02600.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2011] [Indexed: 12/30/2022]
Abstract
Available volatile anaesthetics are safe and efficacious; however, their varying pharmacology provides small but potentially clinically important differences. Desflurane is one of the third-generation inhaled anaesthetics. It is the halogenated inhaled anaesthetic with the lowest blood and tissue solubilities, which promotes its rapid equilibration and its rapid elimination following cessation of administration at the end of anaesthesia. The low fat solubility of desflurane provides pharmacological benefits, especially in overweight patients and in longer procedures by reducing slow compartment accumulation. A decade of clinical use has provided evidence for desflurane's safe and efficacious use as a general anaesthetic. Its benefits include rapid and predictable emergence, and early recovery. In addition, the use of desflurane promotes early and predictable extubation, and the ability to rapidly transfer patients from the operating theatre to the recovery area, which has a positive impact on patient turnover. Desflurane also increases the likelihood of patients, including obese patients, recovering their protective airway reflexes and awakening to a degree sufficient to minimise the stay in the high dependency recovery area. The potential impact of the rapid early recovery from desflurane anaesthesia on intermediate and late recovery and resumption of activities of daily living requires further study.
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Affiliation(s)
- J. JAKOBSSON
- Department of Anaesthesia and Intensive Care; Institution for Physiology and Pharmacology; Karolinska Institute; Danderyds University Hospital; Stockholm; Sweden
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Abstract
The search for an ideal inhalational general anesthetic agent continues. Desflurane, which was recently introduced in the Indian market, possesses favorable pharmacokinetic and pharmacodynamic properties and is closer to the definition of an ideal agent. It offers the advantage of precise control over depth of anesthesia along with a rapid, predictable, and clear-headed recovery with minimal postoperative sequelae, making it a valuable anesthetic agent for maintenance in adults and pediatric patients in surgeries of all durations. The agent has advantages when used in extremes of age and in the obese. Its use may increase the direct costs of providing anesthetic care. Methods or techniques, such as low-flow anesthesia, to reduce the overall cost and along with minimal environmental implications must be followed.
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Affiliation(s)
- Mukul Chandra Kapoor
- Department of Anaesthesiology, Pushpanjali Crosslay Hospital, Ghaziabad, Uttar Pradesh, India
| | - Mahesh Vakamudi
- Department of Anaesthesiology, Sri Ramachandra Medical College and Research Institute, Porur, Chennai, Tamil Nadu, India
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Hypotensive anaesthesia with remifentanil combined with desflurane or isoflurane in tympanoplasty or endoscopic sinus surgery: a randomised, controlled trial. The Journal of Laryngology & Otology 2008; 122:691-5. [DOI: 10.1017/s0022215107001545] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AbstractObjective:To compare the effect of remifentanil combined with desflurane or isoflurane on the quality of the operative field and surgical conditions, blood loss, and recovery during tympanoplasty or endoscopic sinus surgery.Design:Randomised, double-blinded clinical study.Subjects:Sixty-four patients were scheduled for elective tympanoplasty or endoscopic sinus surgery. The patients were randomly divided into two groups: desflurane or isoflurane. After anaesthesia induction, all patients received a continuous remifentanil infusion of 0.2–0.5 µg/kg/min until a mean arterial pressure of 65–75 mmHg was achieved. Heart rate and mean arterial pressure were recorded throughout anaesthesia. Blood loss was measured at the end of surgery. Achievement of a bloodless operative field was rated on a 100 mm visual analogue scale. Following completion of surgery, the time to extubation and to achievement of an Aldrete score of nine or more was recorded.Results:Sixty-three patients were evaluated. The total dose of remifentanil and the total blood loss were similar in both groups (p > 0.05). Time to extubation and to an Aldrete score of nine or more for the desflurane group was significantly less than for the isoflurane group (p < 0.05). No differences were found in the extent of achievement of a bloodless operative field, as assessed via visual analogue scale, comparing the study groups (p > 0.05).Conclusion:Although desflurane and isoflurane both enabled good surgical conditions (in terms of quality of operative field) and convenient induction of hypotension for tympanoplasty and endoscopic sinus surgery, the recovery characteristics of desflurane were better than those of isoflurane. Therefore, desflurane may be preferable to isoflurane in such circumstances.
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12
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Abstract
For half a century, controlled hypotension has been used to reduce bleeding and the need for blood transfusions, and provide a satisfactory bloodless surgical field. It has been indicated in oromaxillofacial surgery (mandibular osteotomy, facial repair), endoscopic sinus or middle ear microsurgery, spinal surgery and other neurosurgery (aneurysm), major orthopaedic surgery (hip or knee replacement, spinal), prostatectomy, cardiovascular surgery and liver transplant surgery. Controlled hypotension is defined as a reduction of the systolic blood pressure to 80-90 mm Hg, a reduction of mean arterial pressure (MAP) to 50-65 mm Hg or a 30% reduction of baseline MAP. Pharmacological agents used for controlled hypotension include those agents that can be used successfully alone and those that are used adjunctively to limit dosage requirements and, therefore, the adverse effects of the other agents. Agents used successfully alone include inhalation anaesthetics, sodium nitroprusside, nitroglycerin, trimethaphan camsilate, alprostadil (prostaglandin E1), adenosine, remifentanil, and agents used in spinal anaesthesia. Agents that can be used alone or in combination include calcium channel antagonists (e.g. nicardipine), beta-adrenoceptor antagonists (beta-blockers) [e.g. propranolol, esmolol] and fenoldopam. Agents that are mainly used adjunctively include ACE inhibitors and clonidine. New agents and techniques have been recently evaluated for their ability to induce effective hypotension without impairing the perfusion of vital organs. This development has been aided by new knowledge on the physiology of peripheral microcirculatory regulation. Apart from the adverse effects of major hypotension on the perfusion of vital organs, potent hypotensive agents have their own adverse effects depending on their concentration, which can be reduced by adjuvant treatment. Care with use limits the major risks of these agents in controlled hypotension; risks that are generally less important than those of transfusion or alternatives to transfusion. New hypotensive drugs, such as fenoldopam, adenosine and alprostadil, are currently being evaluated; however, they have disadvantages and a high treatment cost that limits their development in this indication. New techniques of controlled hypotension subscribe to the use of the natural hypotensive effect of the anaesthetic drug with regard to the definition of the ideal hypotensive agent. It must be easy to administer, have a short onset time, an effect that disappears quickly when administration is discontinued, a rapid elimination without toxic metabolites, negligible effects on vital organs, and a predictable and dose-dependent effect. Inhalation agents (isoflurane, sevoflurane) provide the benefit of being hypnotic and hypotensive agents at clinical concentrations, and are used alone or in combination with adjuvant agents to limit tachycardia and rebound hypertension, for example, inhibitors of the autonomic nervous system (clonidine, beta-blockers) or ACE inhibitors. When they are used alone, inhalation anaesthetics require high concentrations for a significant reduction in bleeding that can lead to hepatic or renal injury. The greatest efficacy and ease-of-use to toxicity ratio is for techniques of anaesthesia that associate analgesia and hypotension at clinical concentrations without the need for potent hypotensive agents. The first and oldest technique is epidural anaesthesia, but depending on the surgery, it is not always appropriate. The most recent satisfactory technique is a combination treatment of remifentanil with either propofol or an inhalation agent (isoflurane, desflurane or sevoflurane) at clinical concentrations. In light of the current literature, and because of their safety and ease of use, these two techniques are preferred.
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Affiliation(s)
- Christian-Serge Degoute
- Service d'Anesthésie-réanimation, Centre Hospitalier-Universitaire Lyon-Sud, Pierre-Bénite, France.
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Kurt F, Derbent A, Demirag K, Eris O, Uyar M, Islekel S. Old method, new drugs: comparison of the efficacy of sevoflurane, isoflurane, and desflurane in achieving controlled hypotension in spinal surgery. Adv Ther 2005; 22:234-40. [PMID: 16236684 DOI: 10.1007/bf02849932] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
This study compared the efficacy of isoflurane, sevoflurane, and desflurane in achieving hemodynamic stability in spinal procedures using moderate levels of controlled hypotension. After obtaining ethics committee approval and written informed consent, 32 American Surgical Association I-II patients were randomly allocated to receive isoflurane (n=12), sevoflurane (n=10), or desflurane (n=10) in O2-N2O (1:1) for maintenance of anesthesia. The induction of anesthesia, fentanyl dosage, and initial and maintenance volume replacements were standardized. Blood pressure was invasively monitored and maintained within a target systolic blood pressure (SBP) range of 80 to 90 mm Hg during the study. SBP outside this range was recorded. Volatile anesthetic concentration was adjusted according to the same protocol for all 3 agents. SPB control was maintained better with sevoflurane and isoflurane than desflurane; median SBP was outside the target range during 32% (range, 15%-55%) of study time with isoflurane, 26% (12%-42%) with sevoflurane, and 44% (20%-80%) with desflurane. Total blood loss did not differ among the groups. Sevoflurane and isoflurane administered in 2 L/min fresh gas flow were more effective than desflurane in achieving controlled hypotension in spinal surgery.
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Affiliation(s)
- Filiz Kurt
- Department of Anesthesiology and Reanimation, Department of Neurosurgery, Ege University Hospital, Izmir, Turkey
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Induced hypotension for tympanoplasty: a comparison of desflurane, isoflurane and sevoflurane. Eur J Anaesthesiol 2004. [DOI: 10.1097/00003643-200411000-00012] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dutton RP. Controlled hypotension for spinal surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2004; 13 Suppl 1:S66-71. [PMID: 15197633 PMCID: PMC3592182 DOI: 10.1007/s00586-004-0756-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2004] [Accepted: 05/07/2004] [Indexed: 10/26/2022]
Abstract
Controlled, deliberate hypotension during anesthesia for major spinal surgery reduces intraoperative blood loss and transfusion requirement. Hypotension may be achieved with increased doses of volatile anesthetic agents or by continuous infusion of vasodilating drugs. Safe application of this technique requires knowledge of the physiology of hemorrhagic shock and close intraoperative monitoring to avoid vasoconstriction and end-organ ischemia.
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Affiliation(s)
- Richard P Dutton
- Division of Trauma Anesthesiology, R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 South Greene St, Baltimore, MD 21201, USA.
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Abstract
The spectrum of spinal surgery in adult life is considerable. Anaesthesia for major spinal surgery, such as spinal stabilization following trauma or neoplastic disease, or for correction of scoliosis, presents a number of challenges. The type of patients who would have been declined surgery 20 yr ago for medical reasons, are now being offered extensive procedures. They commonly have preoperative co-morbid conditions such as serious cardiovascular and respiratory impairment. Airway management may be difficult. Surgery imposes further stresses of significant blood loss, prolonged anaesthesia, and problematical postoperative pain management. The perioperative management of these patients is discussed. The advent of techniques to monitor spinal cord function has reduced postoperative neurological morbidity in these patients. The anaesthetist has an important role in facilitating these methods of monitoring.
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Affiliation(s)
- D A Raw
- University Department Anaesthesia, The Duncan Building, Daulby Street, Liverpool, L69 3GA, UK.
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