Factors affecting the concentration of compound A resulting from the degradation of sevoflurane by soda lime and Baralyme in a standard anesthetic circuit

Compound A, formaldehyde and methanol concentrations during low-flow sevoflurane anaesthesia: comparison of three carbon dioxide absorbers

AIM

To determine compound A, formaldehyde and methanol concentrations in low-flow anaesthesia using different carbon dioxide absorbers.

METHODS

Fifteen patients scheduled for general or urological surgery were exposed to low-flow (500 ml/min) anaesthesia with sevoflurane. The patients were randomly allocated to three groups: soda lime, DrägerSorb Free or Amsorb Plus. The concentrations of compound A, formaldehyde and methanol were sampled and analysed from the limbs of the anaesthesia circuit at T30 (30 min after the start of low-flow sevoflurane anaesthesia), T90 (90 min) and T150 (150 min). The temperatures of the absorbers were measured at the same time.

RESULTS

Statistically significant differences (P < 0.05) were found in the production of compound A from soda lime (with the highest values), DrägerSorb Free and Amsorb Plus at each measurement time. Only traces of methanol (ranging from < 0.131 to 3.799 mg/m(3)) were measured, higher with Amsorb Plus (statistically significant differences were found only at T90). The formaldehyde values (ranging from < 0.1227 to 17.79 mcg/m(3) p.p.b.) were higher with soda lime, and the difference was statistically significant at T150 and, in the inspiratory limb only, at T90. The temperatures of the absorbers were higher for soda lime and lower for Amsorb Plus; the difference was statistically significant at T0 in the upper canister and at T30 in both canisters.

CONCLUSION

The concentrations of harmful products in the circuit were negligible and were lower using the new-generation absorbers. Using Amsorb Plus, the temperatures in the canisters were lower than with the other two absorbers.

Formation and toxicity of anesthetic degradation products

Toxic degradation products are formed from a range of old and modern anesthetic agents. The common element in the formation of degradation products is the reaction of the anesthetic agent with the bases in the carbon dioxide absorbents in the anesthesia circuit. This reaction results in the conversion of trichloroethylene to dichloroacetylene, halothane to 2-bromo-2-chloro-1,1-difluoroethylene, sevoflurane to 2-(fluoromethoxy)-1,1,3,3,3-pentafluoro-1-propene (Compound A), and desflurane, isoflurane, and enflurane to carbon monoxide. Dichloroacetylene, 2-bromo-2-chloro-1,1-difluoroethylene, and Compound A form glutathione S-conjugates that undergo hydrolysis to cysteine S-conjugates and bioactivation of the cysteine S-conjugates by renal cysteine conjugate beta-lyase to give nephrotoxic metabolites. The elucidation of the mechanisms of formation and bioactivation of degradation products has allowed for the safe use of anesthetics that may undergo degradation in the anesthesia circuit.

Sevoflurance: approaching the ideal inhalational anesthetic. a pharmacologic, pharmacoeconomic, and clinical review

Sevoflurane is a safe and versatile inhalational anesthetic compared with currently available agents. Sevoflurane is useful in adults and children for both induction and maintenance of anesthesia in inpatient and outpatient surgery. Of all currently used anesthetics, the physical, pharmacodynamic, and pharmacokinetic properties of sevoflurane come closest to that of the ideal anesthetic (200). These characteristics include inherent stability, low flammability, non-pungent odor, lack of irritation to airway passages, low blood:gas solubility allowing rapid induction of and emergence from anesthesia, minimal cardiovascular and respiratory side effects, minimal end-organ effects, minimal effect on cerebral blood flow, low reactivity with other drugs, and a vapor pressure and boiling point that enables delivery using standard vaporization techniques. As a result, sevoflurane has become one of the most widely used agents in its class.

Cysteine conjugate beta-lyase-dependent biotransformation of the cysteine S-conjugates of the sevoflurane degradation product 2-(fluoromethoxy)-1,1,3,3,3-pentafluoro-1-propene (compound A)

2-(Fluoromethoxy)-1,1,3,3,3-pentafluoro-1-propene (1, Compound A) is a fluoroalkene formed by the base-catalyzed degradation of sevoflurane that is nephrotoxic in rats. Fluoroalkene 1 is a structural analog of other nephrotoxic haloalkenes that undergo glutathione S-conjugate formation and cysteine S-conjugate beta-lyase-dependent bioactivation to reactive intermediates. The present experiments were designed to study the beta-lyase-dependent biotransformation of S-[2-(fluoromethoxy)-1,1,3,3,3-pentafluoropropyl]-L-cysteine (4) and S-[2-(fluoromethoxy)-1,3,3,3-tetrafluoro-1-propenyl]-L-cysteine (5) by 19F NMR and UV spectroscopy and GC/MS. Incubation of cysteine S-conjugate 4 with rat kidney cytosol or a pyridoxal model system showed the formation of inorganic fluoride, pyruvate, and 2-(fluoromethoxy)-3,3,3-trifluoropropanoic acid (9), the expected products of a beta-lyase-catalyzed reaction. The ratio of fluoride to pyruvate ranged from 2.3 to 2.5. The amount of acid 9 formed in the rat kidney cytosol and the pyridoxal model system was, however, less than 5% of the amount of pyruvate formed. Incubation of conjugate 4 with rat kidney cytosol and analysis by 19F NMR spectroscopy showed resonances that were assigned to 3,3,3-trifluorolactic acid (10); the formation of acid 10 was observed in the pyridoxal model only after prolonged incubation (> 18 h). Lactic acid 10 was identified as a degradation product of acid 9. Cysteine S-conjugate 5 was not stable in pH 7.4 buffer and underwent a rapid cyclisation reaction (t1/2 approximately 5 min) to form 2-[1-(fluoromethoxy)-2,2,2-trifluoroethyl]-4,5-dihydro-1,3-thiazol e-4 -carboxylic acid (14). These data show that fluoroalkene 1-derived cysteine S-conjugates are substrates for renal beta-lyase and that acid 9 is formed as a terminal product. Acid 9 is, however, unstable and affords lactic acid 10 as a degradation product.