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Hu ZH, Liu Z, Zheng GF, Li ZW, Liu SQ. Postoperative Recovery Outcomes for Obese Patients Undergoing General Anesthesia: A Meta-Analysis of Randomized Controlled Trials. Front Surg 2022; 9:862632. [PMID: 35965859 PMCID: PMC9366090 DOI: 10.3389/fsurg.2022.862632] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose This study was performed to assess the postoperative recovery outcomes in obese patients undergoing general anesthesia. Methods The eligible studies were identified from PubMed, EmBase, and the Cochrane library until December 2020. The standard mean differences (SMDs) with 95% confidence intervals (CIs) were used to calculate the role of desflurane, sevoflurane, and propofol on recovery outcomes, and the analyses using the random-effects model. Results Eleven randomized controlled trials involving 713 obese patients undergoing general anesthesia were selected for final meta-analysis. We noted desflurane was associated with a shorter time to eye-opening than sevoflurane (SMD: −0.86; 95% CI, −1.43 to −0.28; P = 0.003). The use of desflurane with shorter time to extubation as compared with propofol (SMD: −1.13; 95% CI, −1.52 to −0.73; P < 0.001) or sevoflurane (SMD: −1.19; 95% CI, −2.15 to −0.22; P = 0.016), while sevoflurane was associated with longer time to extubation as compared with propofol (SMD: 1.47; 95% CI, 1.03 to 1.91; P < 0.001). Desflurane were associated with shorter time to stating name as compared with propofol (SMD: −1.40; 95% CI, −2.32 to −0.48; P = 0.003) or sevoflurane (SMD: −2.09; 95% CI, −3.33 to −0.85; P = 0.001). In addition, desflurane was associated with a longer time for orientation to place as compared with propofol (SMD: 0.65; 95% CI, 0.22 to 1.07; P = 0.003), while desflurane with shorter time for orientation to place as compared with sevoflurane (SMD: −0.88; 95% CI, −1.46 to −0.30; P = 0.003). Conclusions The use of desflurane could provide better recovery outcomes in obese patients undergoing general anesthesia. Further large-scale trials should be comparison the long-term effectiveness of various anesthetics.
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Esmaeeli S, Valencia J, Buhl LK, Bastos AB, Goudarzi S, Eikermann M, Fehnel C, Pollard R, Thomas A, Ogilvy CS, Shaefi S, Nozari A. Anesthetic management of unruptured intracranial aneurysms: a qualitative systematic review. Neurosurg Rev 2021; 44:2477-2492. [PMID: 33415519 PMCID: PMC9157460 DOI: 10.1007/s10143-020-01441-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 10/31/2020] [Accepted: 11/12/2020] [Indexed: 12/11/2022]
Abstract
Intracranial aneurysms (IA) occur in 3-5% of the general population and may require surgical or endovascular obliteration if the patient is symptomatic or has an increased risk of rupture. These procedures carry an inherent risk of neurological complications, and the outcome can be influenced by the physiological and pharmacological effects of the administered anesthetics. Despite the critical role of anesthetic agents, however, there are no current studies to systematically assess the intraoperative anesthetic risks, benefits, and outcome effects in this population. In this systematic review of the literature, we carefully examine the existing evidence on the risks and benefits of common anesthetic agents during IA obliteration, their physiological and clinical characteristics, and effects on neurological outcome. The initial search strategy captured a total of 287 published studies. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 28 studies were included in the final report. Our data showed that both volatile and intravenous anesthetics are commonly employed, without evidence that either is superior. Although no specific anesthetic regimens are promoted, their unique neurological, cardiovascular, and physiological properties may be critical to the outcome in vulnerable patients. In particular, patients at risk for perioperative ischemia may benefit from timely administration of anesthetic agents with neuroprotective properties and optimization of their physiological parameters. Further studies are warranted to examine if these anesthetic regimens can reduce the risk of neurological injury and improve the overall outcome in these patients.
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Affiliation(s)
- Shooka Esmaeeli
- Department of Anesthesiology, Critical care and pain medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Juan Valencia
- Department of Anesthesiology, Critical care and pain medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Lauren K Buhl
- Department of Anesthesiology, Critical care and pain medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Andres Brenes Bastos
- Department of Anesthesiology, Critical care and pain medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sogand Goudarzi
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Matthias Eikermann
- Department of Anesthesiology, Critical care and pain medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Corey Fehnel
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Richard Pollard
- Department of Anesthesiology, Critical care and pain medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ajith Thomas
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, MA, Boston, USA
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, MA, Boston, USA
| | - Shahzad Shaefi
- Department of Anesthesiology, Critical care and pain medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ala Nozari
- Department of Anesthesiology, Critical care and pain medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
- Department of Anesthesiology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA.
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Mashour GA, Palanca BJA, Basner M, Li D, Wang W, Blain-Moraes S, Lin N, Maier K, Muench M, Tarnal V, Vanini G, Ochroch EA, Hogg R, Schwartz M, Maybrier H, Hardie R, Janke E, Golmirzaie G, Picton P, McKinstry-Wu AR, Avidan MS, Kelz MB. Recovery of consciousness and cognition after general anesthesia in humans. eLife 2021; 10:59525. [PMID: 33970101 PMCID: PMC8163502 DOI: 10.7554/elife.59525] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 05/06/2021] [Indexed: 12/13/2022] Open
Abstract
Understanding how the brain recovers from unconsciousness can inform neurobiological theories of consciousness and guide clinical investigation. To address this question, we conducted a multicenter study of 60 healthy humans, half of whom received general anesthesia for 3 hr and half of whom served as awake controls. We administered a battery of neurocognitive tests and recorded electroencephalography to assess cortical dynamics. We hypothesized that recovery of consciousness and cognition is an extended process, with differential recovery of cognitive functions that would commence with return of responsiveness and end with return of executive function, mediated by prefrontal cortex. We found that, just prior to the recovery of consciousness, frontal-parietal dynamics returned to baseline. Consistent with our hypothesis, cognitive reconstitution after anesthesia evolved over time. Contrary to our hypothesis, executive function returned first. Early engagement of prefrontal cortex in recovery of consciousness and cognition is consistent with global neuronal workspace theory.
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Affiliation(s)
- George A Mashour
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - Ben JA Palanca
- Department of Anesthesiology, Washington University School of MedicineSt. LouisUnited States
| | - Mathias Basner
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Duan Li
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - Wei Wang
- Department of Mathematics and Statistics, Washington UniversitySt. LouisUnited States
| | - Stefanie Blain-Moraes
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - Nan Lin
- Department of Mathematics and Statistics, Washington UniversitySt. LouisUnited States
| | - Kaitlyn Maier
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Maxwell Muench
- Department of Anesthesiology, Washington University School of MedicineSt. LouisUnited States
| | - Vijay Tarnal
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - Giancarlo Vanini
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - E Andrew Ochroch
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Rosemary Hogg
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Marlon Schwartz
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Hannah Maybrier
- Department of Anesthesiology, Washington University School of MedicineSt. LouisUnited States
| | - Randall Hardie
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Ellen Janke
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - Goodarz Golmirzaie
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - Paul Picton
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - Andrew R McKinstry-Wu
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of MedicineSt. LouisUnited States
| | - Max B Kelz
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
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Weber J, Schmidt J, Wirth S, Schumann S, Philip JH, Eberhart LHJ. Context-sensitive decrement times for inhaled anesthetics in obese patients explored with Gas Man®. J Clin Monit Comput 2021; 35:343-354. [PMID: 32067148 PMCID: PMC7943506 DOI: 10.1007/s10877-020-00477-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 01/29/2020] [Indexed: 01/24/2023]
Abstract
Anesthesia care providers and anesthesia decision support tools use mathematical pharmacokinetic models to control delivery and especially removal of anesthetics from the patient's body. However, these models are not able to reflect alterations in pharmacokinetics of volatile anesthetics caused by obesity. The primary aim of this study was to refine those models for obese patients. To investigate the effects of obesity on the elimination of desflurane, isoflurane and sevoflurane for various anesthesia durations, the Gas Man® computer simulation software was used. Four different models simulating patients with weights of 70 kg, 100 kg, 125 kg and 150 kg were constructed by increasing fat weight to the standard 70 kg model. For each modelled patient condition, the vaporizer was set to reach quickly and then maintain an alveolar concentration of 1.0 minimum alveolar concentration (MAC). Subsequently, the circuit was switched to an open (non-rebreathing) circuit model, the inspiratory anesthetic concentration was set to 0 and the time to the anesthetic decrements by 67% (awakening times), 90% (recovery times) and 95% (resolution times) in the vessel-rich tissue compartment including highly perfused tissue of the central nervous system were determined. Awakening times did not differ greatly between the simulation models. After volatile anesthesia with sevoflurane and isoflurane, awakening times were lower in the more obese simulation models. With increasing obesity, recovery and resolution times were higher. The additional adipose tissue in obese simulation models did not prolong awakening times and thus may act more like a sink for volatile anesthetics. The results of these simulations should be validated by comparing the elimination of volatile anesthetics in obese patients with data from our simulation models.
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Affiliation(s)
- Jonas Weber
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Johannes Schmidt
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Steffen Wirth
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefan Schumann
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - James H Philip
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Leopold H J Eberhart
- Department of Anaesthesiology and Intensive Care, Philipps-Universität Marburg, Marburg, Germany
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Doyle CR, Aarnes TK, Ballash GA, Wendt-Hornickle EL, Baldo CF, Johnson RA, Wittum TE, McLoughlin MA. Anesthetic risk during subsequent anesthetic events in brachycephalic dogs that have undergone corrective airway surgery: 45 cases (2007-2019). J Am Vet Med Assoc 2021; 257:744-749. [PMID: 32955391 DOI: 10.2460/javma.257.7.744] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine whether previous corrective upper airway surgery in brachycephalic dogs would decrease perianesthetic complications in subsequent anesthetic events. ANIMALS 45 client-owned dogs. PROCEDURES Brachycephalic dogs undergoing any combination of staphylectomy, nasal alaplasty, or laryngeal sacculectomy that were anesthetized at a later date for additional surgical procedures or imaging from August 2, 2007, to February 8, 2019, had their medical records reviewed during both anesthetic events for signalment, American Society of Anesthesiologists status, perianesthetic drug administration, anesthetic duration, presence and total time of positive-pressure ventilation, procedure invasiveness, and perianesthetic complications such as bradycardia, hypothermia, hypotension, cardiac arrhythmias, hypertension, vomiting or regurgitation, dysphoria, respiratory distress, hypoxemia, reintubation, and prolonged periods of recovery. RESULTS The odds of having complications during the postanesthetic period following subsequent anesthetic events were decreased by 79% in dogs having previous surgical intervention to correct clinical signs of brachycephalic airway syndrome. Intra-anesthetic bradycardia increased the odds of developing a postanesthetic complication by 4.56 times. Every 15-minute increase in anesthetic duration increased the odds of having a postanesthetic complication by 12% and having an intra-anesthetic complication by 11%. CONCLUSIONS AND CLINICAL RELEVANCE Previous corrective upper airway surgery decreased odds of postanesthetic complications in brachycephalic dogs that underwent subsequent anesthetic events. Findings in this study indicated that corrective upper airway surgery for brachycephalic dogs may reduce postanesthetic complications following subsequent anesthetic events, which may reduce perianesthetic morbidity in patients undergoing multiple surgical or diagnostic imaging procedures.
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Arain SR, Yu S, Dugan S, Pagel PS, Ebert TJ. Titration of sevoflurane anesthesia to optimize the time to regain airway reflexes in patients undergoing elective surgery: A randomized clinical trial comparing desflurane and sevoflurane anesthesia. Acta Anaesthesiol Scand 2020; 64:729-734. [PMID: 32057088 DOI: 10.1111/aas.13565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/04/2020] [Accepted: 02/11/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Desflurane has adverse environmental effects, but has clinical advantages to speed emergence and return of protective airway reflexes compared with sevoflurane. We hypothesized that weaning of the inspired sevoflurane during the final 15 minutes of surgery would eliminate differences in airway reflex recovery between these agents. METHODS After obtaining IRB approval and informed consent, 40 patients undergoing elective surgery (≥1-hour) randomly received desflurane or sevoflurane. Patients swallowed 20 mL of water without drooling or coughing, and then received sedation and PONV pre-medication. Anesthesia was induced using propofol and fentanyl and maintained with desflurane or sevoflurane through a laryngeal mask airway maintaining a bispectral index of 45-50 and 50-60 during the final 15 minutes before surgery end. Cardiorespiratory variables and age-adjusted minimal alveolar concentration were recorded. The duration between anesthetic discontinuation and first appropriate response to command was measured; the laryngeal mask airway was removed. Two minutes after responding to command, patients were positioned semi-upright and attempted to swallow water. If successful swallowing was not achieved, the test was repeated every 4 minutes after each failure until successful swallowing was achieved. RESULTS Average anesthetic concentration and bispectral index was similar in patients receiving desflurane vs sevoflurane. Response times after discontinuation of anesthetics were similar. There were no differences in the recovery of swallowing ability between desflurane and sevoflurane groups. CONCLUSION Weaning of sevoflurane during the final 15 minutes of surgery eliminates clinical advantages of the more rapid return of airway reflexes with desflurane.
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Affiliation(s)
- Shahbaz R. Arain
- Anesthesia Service The Clement J. Zablocki Veterans Affairs Medical Center Milwaukee WI USA
- Department of Anesthesiology The Medical College of Wisconsin Milwaukee WI USA
| | - Sherman Yu
- Anesthesia Service The Clement J. Zablocki Veterans Affairs Medical Center Milwaukee WI USA
- Department of Anesthesiology The Medical College of Wisconsin Milwaukee WI USA
| | - Shannon Dugan
- Anesthesia Service The Clement J. Zablocki Veterans Affairs Medical Center Milwaukee WI USA
- Department of Anesthesiology The Medical College of Wisconsin Milwaukee WI USA
| | - Paul S. Pagel
- Anesthesia Service The Clement J. Zablocki Veterans Affairs Medical Center Milwaukee WI USA
- Department of Anesthesiology The Medical College of Wisconsin Milwaukee WI USA
| | - Thomas J. Ebert
- Anesthesia Service The Clement J. Zablocki Veterans Affairs Medical Center Milwaukee WI USA
- Department of Anesthesiology The Medical College of Wisconsin Milwaukee WI USA
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7
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Sudhakaran R, Makkar JK, Jain D, Wig J, Chabra R. Comparison of bispectral index and end-tidal anaesthetic concentration monitoring on recovery profile of desflurane in patients undergoing lumbar spine surgery. Indian J Anaesth 2018; 62:516-523. [PMID: 30078854 PMCID: PMC6053885 DOI: 10.4103/ija.ija_172_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background and Aims: Several techniques have evolved over time to monitor depth of anesthesia and ensure enhanced recovery. This randomized double-blinded trial was designed to compare bispectral index (BIS) or end-tidal anaesthetic concentration (ETAC) monitoring on the recovery characteristics of patients undergoing thoracolumbar spine surgeries. Methods: Seventy American Society of Anesthesiologist I–II patients of either sex were randomized to Group B – BIS-guided protocol, Group E – ETAC-guided protocol, or Group S – Standard protocol. After intravenous induction, anaesthesia was maintained with desflurane in O2/N2O (50:50) mixture. In BIS, ETAC and Standard groups, inspired end-tidal desflurane concentration was varied to achieve BIS of 45–55, 0.8–1.0 age-corrected minimum alveolar concentration, and haemodynamic parameters within 20% of the baseline, respectively. Time to eye opening (emergence time, the primary outcome), time to extubation, and time to name recall from the discontinuation of the anaesthetic agent were recorded. Incidence of nausea, vomiting, and total analgesic consumption was noted for 24 h. Results: Emergence time (mean ± SD) in ETAC (5.1 ± 1.53 min) and BIS (5.0 ± 2.12 min)-guided groups was significantly lower than Standard group (7.5 ± 2.90 min). Extubation time in ETAC (6.3 ± 2.22 min) and BIS-guided group (6.5 ± 1.78 min) was significantly lower than Standard group (9.0 ± 3.20 min) (P < 0.001). Time to achieve fast track score of more than 12 was significantly less in BIS-guided group (13.12 ± 2.59 min). Conclusion: ETAC-guided anaesthesia is comparable to BIS-guided anaesthesia in achieving early recovery.
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Affiliation(s)
- R Sudhakaran
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jeetinder K Makkar
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Divya Jain
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jyotsna Wig
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - R Chabra
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Maier KL, McKinstry-Wu AR, Palanca BJA, Tarnal V, Blain-Moraes S, Basner M, Avidan MS, Mashour GA, Kelz MB. Protocol for the Reconstructing Consciousness and Cognition (ReCCognition) Study. Front Hum Neurosci 2017; 11:284. [PMID: 28638328 PMCID: PMC5461274 DOI: 10.3389/fnhum.2017.00284] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/15/2017] [Indexed: 01/07/2023] Open
Abstract
Important scientific and clinical questions persist about general anesthesia despite the ubiquitous clinical use of anesthetic drugs in humans since their discovery. For example, it is not known how the brain reconstitutes consciousness and cognition after the profound functional perturbation of the anesthetized state, nor has a specific pattern of functional recovery been characterized. To date, there has been a lack of detailed investigation into rates of recovery and the potential orderly return of attention, sensorimotor function, memory, reasoning and logic, abstract thinking, and processing speed. Moreover, whether such neurobehavioral functions display an invariant sequence of return across individuals is similarly unknown. To address these questions, we designed a study of healthy volunteers undergoing general anesthesia with electroencephalography and serial testing of cognitive functions (NCT01911195). The aims of this study are to characterize the temporal patterns of neurobehavioral recovery over the first several hours following termination of a deep inhaled isoflurane general anesthetic and to identify common patterns of cognitive function recovery. Additionally, we will conduct spectral analysis and reconstruct functional networks from electroencephalographic data to identify any neural correlates (e.g., connectivity patterns, graph-theoretical variables) of cognitive recovery after the perturbation of general anesthesia. To accomplish these objectives, we will enroll a total of 60 consenting adults aged 20-40 across the three participating sites. Half of the study subjects will receive general anesthesia slowly titrated to loss of consciousness (LOC) with an intravenous infusion of propofol and thereafter be maintained for 3 h with 1.3 age adjusted minimum alveolar concentration of isoflurane, while the other half of subjects serves as awake controls to gauge effects of repeated neurobehavioral testing, spontaneous fatigue and endogenous rest-activity patterns.
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Affiliation(s)
- Kaitlyn L. Maier
- Department of Pharmacology, Perelman School of Medicine, University of PennsylvaniaPhiladelphia, PA, United States
| | - Andrew R. McKinstry-Wu
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphia, PA, United States
| | - Ben Julian A. Palanca
- Department of Anesthesiology, Washington University School of Medicine, Washington University in St. LouisSt. Louis, MO, United States
| | - Vijay Tarnal
- Department of Anesthesiology, University of MichiganAnn Arbor, MI, United States
| | | | - Mathias Basner
- Department of Psychiatry, Perelman School of Medicine, University of PennsylvaniaPhiladelphia, PA, United States,Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, University of PennsylvaniaPhiladelphia, PA, United States
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, Washington University in St. LouisSt. Louis, MO, United States
| | - George A. Mashour
- Department of Anesthesiology, University of MichiganAnn Arbor, MI, United States
| | - Max B. Kelz
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphia, PA, United States,Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, University of PennsylvaniaPhiladelphia, PA, United States,*Correspondence: Max B. Kelz
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9
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Dalal KS, Choudhary MV, Palsania AJ, Toal PV. Desflurane for ambulatory anaesthesia: A comparison with sevoflurane for recovery profile and airway responses. Indian J Anaesth 2017; 61:315-320. [PMID: 28515519 PMCID: PMC5416721 DOI: 10.4103/ija.ija_513_16] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background and Aims: Desflurane and sevoflurane have low blood gas solubility co-efficients, allowing a rapid awakening from anaesthesia. However, desfluraneis pungent and may cause airway irritability. We compared desflurane and sevoflurane with respect to recovery and occurrence of adverse airway responses in spontaneously breathing patients while using the ProSeal™ laryngeal mask airway (LMA). Methods: Ninety-four adult patients undergoing hysteroscopic procedures were divided into sevoflurane (S) group or desflurane (D) group. Patients were premedicated with midazolam 0.03 mg/kg and fentanyl 1μg/kg. Anaesthesia was induced with propofol 2.0–2.5 mg/kg, followed by insertion of a ProSeal™ LMA. Adverse airway responses such as cough, hiccups, laryngospasm and breathholding were recorded. In the post-operative period: time to awakening, response to verbal commands, orientation, ability to sit with support and the recovery room Aldrete score were recorded. Results: Three patients in group S (6.4%) and six patients (13.3%) in Group D had adverse airway events. The mean time to eye opening (Group S-10.75 ± 7.54 min, Group D-4.94 ± 1.74 min), obeying verbal commands (Group S-13.13 ± 8.75 min, Group D-6.55 ± 1.75 min), orientation (Group S-15.42 ± 8.46 min, Group D-6.23 ± 2.4 min) and to sit with support (Group S-36.09 ± 12.68 min, Group D-14.35 ± 3.75 min) were found to be lesser with desflurane than with sevoflurane (P < 0.001). The mean time to recovery was delayed in Group S-46.00 ± 12.86 min compared to Group D-26.44 ± 5.33 min (P < 0.001). Conclusion: Desflurane has faster awakening properties than sevoflurane without an increase in adverse airway events when used during spontaneous ventilation through a ProSeal™ LMA along with propofol and fentanyl.
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Affiliation(s)
- Kajal Sachin Dalal
- Department of Anesthesiology, Bhabha Atomic Research Centre, Mumbai, Maharashtra, India
| | | | - Adit Jagdish Palsania
- Department of Anesthesiology, Bhabha Atomic Research Centre, Mumbai, Maharashtra, India
| | - Pratibha Vinayak Toal
- Department of Anesthesiology, Bhabha Atomic Research Centre, Mumbai, Maharashtra, India
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10
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Ergönenç J, Ergönenç T, İdin K, Uzun U, Dirik A, Gedikli G, Bican G. The recovery time of sevoflurane and desflurane and the effects of anesthesia on mental and psychomotor functions and pain. Anesth Essays Res 2015; 8:367-71. [PMID: 25886337 PMCID: PMC4258961 DOI: 10.4103/0259-1162.143151] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: Inhalation anesthetics have many advantages for outpatient general anesthesia, such as minimal postoperative side-effects and rapid and full recovery. The aim of this randomized study was to compare the postoperative recovery time of sevoflurane and desflurane and to observe the effects of anesthesia on mental, psychomotor and cognitive functions and pain in outpatients undergoing arthroscopic surgery. Patients and Methods: This study included 40 American Society of Anesthesiologists I-II patients who were divided into two groups via sealed envelopes. For maintenance of anesthesia, a mixture of 66% N2O and 33% O2 and 4–7% desflurane was used in Group D, and a mixture of 66% N2O and 33% O2 and 1–2.5% sevoflurane was used in Group S. The modified Aldrete score (MAS) was evaluated postoperatively at time points determined previously. An MAS of 8 or higher was considered to indicate alertness. Mental and psychomotor functions of the patients were evaluated using the short cognitive examination (SCE), and postoperative pain levels were evaluated using the visual analogue scale (VAS). Results: There was no difference between the groups in terms of demographic data (P > 0.05). The mean time to reach MAS 8, eye-opening, and orientation were higher in Group S as compared to Group D (P < 0.01). The mean MAS initially and at 5 and 10 min was higher in Group D as compared to Group S (P < 0.001). The mean SCE at 5 and 15 min was higher in Group D as compared to Group S (P < 0.01). There was no significant difference between the groups in terms of VAS scores (P > 0.05). Conclusion: It has been determined that desflurane provided better quality and more rapid recovery than sevoflurane, and the return of cognitive functions in the early postoperative period was faster. In conclusion, both agents can apparently be used safely in outpatient anesthetic procedures.
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Affiliation(s)
- Jalan Ergönenç
- Department of Anesthesiology and Reanimation, Sakarya University Training and Research Hospital, Istanbul, Turkey
| | - Tolga Ergönenç
- Department of Anesthesiology and Reanimation, Sakarya University Training and Research Hospital, Istanbul, Turkey
| | - Kadir İdin
- Department of Anesthesiology and Intensive care, Bezmialem Vakıf University, Faculty of Medicine, Istanbul, Turkey
| | - Uğur Uzun
- Department of Anesthesiology and Intensive care, Bulancak State Hospital, Giresun, Turkey
| | - Ali Dirik
- Department of Anesthesiology and Intensive care, Güney Hospital, Istanbul, Turkey
| | - Gökhan Gedikli
- Department of Anesthesiology and Intensive care, Bilge Hospital, Sakarya, Istanbul, Turkey
| | - Gülşen Bican
- Department of Anesthesiology and Intensive care, Haseki Education and Research Hospital, Istanbul, Turkey
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11
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Kaur A, Jain AK, Sehgal R, Sood J. Hemodynamics and early recovery characteristics of desflurane versus sevoflurane in bariatric surgery. J Anaesthesiol Clin Pharmacol 2013; 29:36-40. [PMID: 23493107 PMCID: PMC3590538 DOI: 10.4103/0970-9185.105792] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Context: Morbidly obese patients are prone for intraoperative hemodynamic disturbances and postoperative airway complications. Aim: Comparison of intraoperative hemodynamics and postoperative recovery characteristics of desflurane versus sevoflurane in morbidly obese patients undergoing laparoscopic bariatric surgery. Settings and Design: Randomized controlled trial Materials and Methods: After institutional ethics committee approval and written informed consent, 40 morbidly obese patients (BMI > 35 kg/m2) were randomized to receive desflurane or sevoflurane as part of a standardized general anesthesia technique. Volatile anesthetic concentration was titrated to maintain electroencephalographic bispectral index score (BIS) in the range of 40-60. Mean arterial pressure (MAP) and heart rate (HR) were recorded preoperatively, at induction and intubation, then at regular intervals. After extubation, early recovery was recorded by time to emergence and orientation to time and place. In post anesthesia care unit, intermediate recovery was assessed by modified Aldrete Score and Digit Symbol Substitution Test (DSST). Results: Intraoperative MAP and HR did not differ between the two groups (P > 0.05). The time to response to painful stimuli, obeying verbal commands and spontaneous eye opening was shorter (P = 0.001) and modified Aldrete Score was higher after desflurane anesthesia than after sevoflurane anesthesia (P = 0.049). DSST also returned towards normal faster after desflurane (28.50 ± 6.30 min vs. 35.0 ± 5.62 min, P = 0.03). Conclusions: Both desflurane and sevoflurane produce similar hemodynamic changes but the immediate and intermediate recovery was significantly faster after desflurane thus contributing to fast tracking and early discharge of patients.
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Affiliation(s)
- Amandeep Kaur
- Junior Intensivist, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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12
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Mallik T, Aneja S, Tope R, Muralidhar V. A randomized prospective study of desflurane versus isoflurane in minimal flow anesthesia using "equilibration time" as the change-over point to minimal flow. J Anaesthesiol Clin Pharmacol 2012; 28:470-5. [PMID: 23225926 PMCID: PMC3511943 DOI: 10.4103/0970-9185.101916] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND In the administration of minimal flow anesthesia, traditionally a fixed time period of high flow has been used before changing over to minimal flow. However, newer studies have used "equilibration time" of a volatile anesthetic agent as the change-over point. MATERIALS AND METHODS A randomized prospective study was conducted on 60 patients, who were divided into two groups of 30 patients each. Two volatile inhalational anesthetic agents were compared. Group I received desflurane (n = 30) and group II isoflurane (n = 30). Both the groups received an initial high flow till equilibration between inspired (Fi) and expired (Fe) agent concentration were achieved, which was defined as Fe/Fi = 0.8. The mean (SD) equilibration time was obtained for both the agent. Then, a drift in end-tidal agent concentration during the minimal flow anesthesia and recovery profile was noted. RESULTS The mean equilibration time obtained for desflurane and isoflurane were 4.96 ± 1.60 and 16.96 ± 9.64 min (P < 0.001). The drift in end-tidal agent concentration over time was minimal in the desflurane group (P = 0.065). Recovery time was 5.70 ± 2.78 min in the desflurane group and 8.06 ± 31 min in the isoflurane group (P = 0.004). CONCLUSION Use of equilibration time of the volatile anesthetic agent as a change-over point, from high flow to minimal flow, can help us use minimal flow anesthesia, in a more efficient way.
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Affiliation(s)
- Tanuja Mallik
- Department of Anaesthesiology and Intensive Care Unit, Indraprastha Apollo Hospital, New Delhi, India
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13
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Jindal R, Kumra VP, Narani KK, Sood J. Comparison of maintenance and emergence characteristics after desflurane or sevoflurane in outpatient anaesthesia. Indian J Anaesth 2011; 55:36-42. [PMID: 21431051 PMCID: PMC3057243 DOI: 10.4103/0019-5049.76604] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Both sevoflurane and desflurane have shorter emergence times compared to isoflurane based anaesthesia. Because of its pharmacological properties, desflurane appears to yield a rapid early and intermediate recovery compared with sevoflurane. The aim of this study was to assess the maintenance and emergence characteristics after anaesthesia with sevoflurane or desflurane. One hundred female patients scheduled to undergo daycare laparoscopic gynaecological surgery were enrolled for this prospective study. Patients were randomised into two groups to receive either desflurane [group I (D); n = 50] or sevoflurane [group II (S); n = 50] for maintenance of anaesthesia. The demographic data and the duration of procedure were comparable in both the groups. The early recovery time was shorter after maintenance of anaesthesia with desflurane compared with sevoflurane. However, this faster early recovery failed to lead to early readiness for home discharge. The intraoperative haemodynamic characteristics were comparable with both sevoflurane and desflurane. Both sevoflurane and desflurane provide a similar time to home readiness despite a faster early recovery with desflurane. The intraoperative haemodynamics are similar with both the agents.
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Affiliation(s)
- Ravi Jindal
- Department of Anaesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi, India
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14
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Chang DJ, Choi SH, Choi YS, Min KT. Effect of charcoal filter on the emergence from sevoflurane anesthesia in a semi-closed rebreathing circuit. Yonsei Med J 2011; 52:668-72. [PMID: 21623611 PMCID: PMC3104448 DOI: 10.3349/ymj.2011.52.4.668] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE A charcoal filter attached within the anesthetic circuit has been shown to efficiently adsorb halothane or isoflurane, thus hastening anesthetic recovery in low or minimal flow system. This study was intended to demonstrate whether the charcoal filter enhances the recovery time from sevoflurane anesthesia using a semi-closed circuit system. MATERIALS AND METHODS Thirty healthy patients scheduled for elective surgery under sevoflurane anesthesia were randomly assigned to the charcoal filter or control group. Upon completion of surgery, the end-tidal concentration of sevoflurane was maintained at 2.0 vol%. A charcoal filter was attached to the expiratory limb of the breathing circuit of charcoal filter group subjects. After sevoflurane was discontinued, ventilation was controlled with the same minute volume as the intra-operative period at a fresh gas flow rate of 5 L·min⁻¹ with 100% O₂. The elimination kinetics of sevoflurane from end-tidal concentration, Bispectral index and times of eye opening and extubation were obtained. RESULTS The exponential time constant (τ) of alveolar sevoflurane concentration in the charcoal filter group was significantly shorter than that in the control group (1.7±0.5 vs. 2.5±1.1 min, p=0.008). The charcoal filter hastened rapid eye opening (11.1±3.8 vs. 14.8±3.0 min, p=0.007) and extubation (11.9±3.9 vs. 15.3±3.2 min, p=0.014), compared to the control group. CONCLUSION A charcoal filter enhances the recovery from sevoflurane anesthesia with a semi-closed rebreathing circuit.
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Affiliation(s)
- Dong Jin Chang
- Department of Anesthesiology and Pain Medicine, Hallym University Sacred Health Hospital, Anyang, Korea
| | - Seung Ho Choi
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Suk Choi
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kyeong Tae Min
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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15
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Sakai EM, Connolly LA, Klauck JA. Inhalation Anesthesiology and Volatile Liquid Anesthetics: Focus on Isoflurane, Desflurane, and Sevoflurane. Pharmacotherapy 2005; 25:1773-88. [PMID: 16305297 DOI: 10.1592/phco.2005.25.12.1773] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Clinical pharmacists rarely are involved in the selection and dosing of anesthetic agents. However, when practicing evidence-based medicine in a cost-conscious health care system, optimizing drug therapy is imperative in all areas. Thus, we provide general information on anesthesiology, including the different types of breathing systems and the components of anesthesia machines. Modern inhalation anesthetics that are predominantly used in clinical practice include one gas--nitrous oxide--and new volatile liquid agents--isoflurane, desflurane, and sevoflurane. Desflurane and sevoflurane are the low-soluble inhalation anesthetics, and they offer some clinical advantages over isoflurane, such as fast induction and faster recovery with long procedures. However, efficient use of isoflurane can match the speed of induction and recovery of the other agents in certain cases. In addition, the patient characteristics, duration and type of procedure, type of breathing system, and efficiency in monitoring must be considered when selecting the most optimal therapy for each patient. Maximizing the clinical advantages of these agents while minimizing the waste of an institution's operating room and pharmacy budget requires an understanding of the characteristics, pharmacokinetics, and pharmacodynamics of these anesthetic agents and the collaborated effort from both the anesthesia and pharmacy departments. An anesthetic agent algorithm is provided as a sample decision-process tree for selecting among isoflurane, desflurane, and sevoflurane.
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Affiliation(s)
- Eileen M Sakai
- Department of Pharmacy, Froedtert Memorial Lutheran Hospital, and the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
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16
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Martín-Cancho MF, Carrasco-Jiménez MS, Lima JR, Ezquerra LJ, Crisóstomo V, Usón-Gargallo J. Assessment of the relationship of bispectral index values, hemodynamic changes, and recovery times associated with sevoflurane or propofol anesthesia in pigs. Am J Vet Res 2004; 65:409-16. [PMID: 15077681 DOI: 10.2460/ajvr.2004.65.409] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate bispectral index (BIS) values in pigs during anesthesia maintained with sevoflurane-fentanyl or propofol-fentanyl as a predictor of changes in hemodynamic parameters and duration of recovery from anesthesia. ANIMALS 12 pigs. PROCEDURE Pigs were randomly allocated to undergo 1 of 2 anesthetic regimens. Anesthesia was induced with propofol (2 mg/kg, i.v.); 6 pigs were administered sevoflurane via inhalation (1 minimum alveolar concentration [MAC] at a fresh gas flow rate of 3 L/min; group I), and 6 were administered propofol (11 mg/kg/h, i.v.; group II). All pigs received fentanyl (2.5 mg/kg, i.v., q 30 min). After abdominal surgery, pigs were allowed to recover from anesthesia. Cardiovascular variables and BIS values were recorded at intervals throughout the procedure; duration of recovery from anesthesia was noted. RESULTS No correlation was established between arterial blood pressure and BIS and between heart rate and BIS. Mean BIS at discontinuation of administration of the anesthetic agent was greater in group-II pigs (65.2 +/- 10.6 minutes) than in group-I pigs (55.8 +/- 2.9 minutes). However, recovery from anesthesia was significantly longer in group II (59.80 +/- 2.52 minutes) than in group I (9.80 +/- 2.35 minutes). CONCLUSIONS AND CLINICAL RELEVANCE In swine anesthetized with sevoflurane or propofol and undergoing abdominal surgery, the BIS value derived from an electroencephalogram at the end of anesthesia was not useful for predicting the speed of recovery from anesthesia. Moreover, BIS was not useful as a predictor of clinically important changes in arterial blood pressure and heart rate in those anesthetized pigs.
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17
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Delgado-Herrera L, Ostroff RD, Rogers SA. Sevoflurance: approaching the ideal inhalational anesthetic. a pharmacologic, pharmacoeconomic, and clinical review. CNS DRUG REVIEWS 2001; 7:48-120. [PMID: 11420572 PMCID: PMC6741648 DOI: 10.1111/j.1527-3458.2001.tb00190.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- L Delgado-Herrera
- Abbott Laboratories, Hospital Products Division, 200 Abbott Park Road, Abbott Park, IL 60064, USA.
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