Prophylaxis for paediatric emergence delirium in desflurane-based anaesthesia: a network meta-analysis

PURPOSE

The prevalence of postoperative emergence delirium in paediatric patients (pedED) following desflurane anaesthesia is considerably high at 50-80%. Although several pharmacological prophylactic strategies have been introduced to reduce the risk of pedED, conclusive evidence about the superiority of these individual regimens is lacking. The aim of the current study was to assess the potential prophylactic effect and safety of individual pharmacotherapies in the prevention of pedED following desflurane anaesthesia.

METHODS

This frequentist model network meta-analysis (NMA) of randomized controlled trials (RCTs) included peer-reviewed RCTs of either placebo-controlled or active-controlled design in paediatric patients under desflurane anaesthesia.

RESULTS

Seven studies comprising 573 participants were included. Overall, the ketamine + propofol administration [odds ratio (OR) = 0.05, 95% confidence intervals (95%CIs) 0.01-0.33], dexmedetomidine alone (OR = 0.13, 95%CIs 0.05-0.31), and propofol administration (OR = 0.30, 95%CIs 0.10-0.91) were associated with a significantly lower incidence of pedED than the placebo/control groups. In addition, only gabapentin and dexmedetomidine were associated with a significantly higher improvement in the severity of emergence delirium than the placebo/control groups. Finally, the ketamine + propofol administration was associated with the lowest incidence of pedED, whereas gabapentin was associated with the lowest severity of pedED among all of the pharmacologic interventions studied.

CONCLUSIONS

The current NMA showed that ketamine + propofol administration was associated with the lowest incidence of pedED among all of the pharmacologic interventions studied. Future large-scale trials to more fully elucidate the comparative benefits of different combination regimens are warranted.

TRIAL REGISTRATION

PROSPERO CRD42021285200.

Similarity and dissimilarity in alterations of the gene expression profile associated with inhalational anesthesia between sevoflurane and desflurane

Although sevoflurane is one of the most commonly used inhalational anesthetic agents, the popularity of desflurane is increasing to a level similar to that of sevoflurane. Inhalational anesthesia generally activates and represses the expression of genes related to xenobiotic metabolism and immune response, respectively. However, there has been no comprehensive comparison of the effects of sevoflurane and desflurane on the expression of these genes. Thus, we used a next-generation sequencing method to compare alterations in the global gene expression profiles in the livers of rats subjected to inhalational anesthesia by sevoflurane or desflurane. Our bioinformatics analyses revealed that sevoflurane and, to a greater extent, desflurane significantly activated genes related to xenobiotic metabolism. Our analyses also revealed that both anesthetic agents, especially sevoflurane, downregulated many genes related to immune response.

Reducing the carbon footprint of operating rooms through education on the effects of inhalation anesthetics on global warming: A retrospective study

Environmental concerns, especially global warming, have prompted efforts to reduce greenhouse gas emissions. Healthcare systems, including anesthesia practices, contribute to these emissions. Inhalation anesthetics have a significant environmental impact, with desflurane being the most concerning because of its high global warming potential. This study aimed to educate anesthesiologists on the environmental impact of inhalation anesthetics and assess changes in awareness and practice patterns, specifically reducing desflurane use. This study included data from patients who underwent surgery under general anesthesia 1 month before and after education on the effects of inhalation anesthetics on global warming. The primary endpoint was a change in inhalational anesthetic use. Secondary endpoints included changes in carbon dioxide equivalent (CO2e) emissions, driving equivalent, and medical costs. After the education, desflurane use decreased by 50%, whereas sevoflurane use increased by 50%. This shift resulted in a reduction in the overall amount of inhalational anesthetics used. The total CO2e and driving-equivalent values decreased significantly. The cost per anesthesia case decreased, albeit to a lesser extent than expected. Education on the environmental impact of inhalation anesthetics has successfully altered anesthesiologists' practice patterns, leading to reduced desflurane usage. This change has resulted in decreased CO2e emissions and has had a positive effect on mitigating global warming. However, further research is required to assess the long-term impact of such education and the variability in practice patterns across different institutions.

The association between intraoperative anesthesia methods used during gastric cancer surgery and long-term mortality: A retrospective observational study using a Japanese claims database

PURPOSE

Various basic and clinical studies have investigated the association between the types of anesthetic agents and prognosis. However, the results have varied among studies and remain controversial. In the present study, we aimed to investigate whether the risk of all-cause mortality differs between inhaled or intravenous anesthetics in patients with gastric cancer undergoing gastrectomy.

METHODS

Using a Japanese nationwide insurance claims database, we analyzed patients who underwent gastrectomy under general anesthesia for gastric cancer between January 2005 and September 2019. Postoperative outcomes were compared between two groups: those who received inhaled anesthetics (Sevoflurane, Isoflurane, or Desflurane) and those who received intravenous anesthetics (propofol), using a multivariable Cox proportional hazards model. The primary outcome was overall survival.

RESULTS

Among 2671 eligible patients, 2105 were in the inhaled anesthetic group, and 566 were in the intravenous anesthetic group. The median (interquartile range) age was 58 (51-63) years, and 1979 (74.1%) were men. The median follow-up period was 795 days. We identified 56 (2.7%) and 16 (2.8%) deaths during the follow-up period in the inhaled and intravenous anesthetic use groups, respectively. There was no difference in postoperative overall survival between the two groups (hazard ratio, 0.97; 95% confidence interval, 0.56-1.70; P = 0.93).

CONCLUSIONS

We found no significant difference in the postoperative risks of overall survival between inhaled and intravenous anesthesia in patients with gastric cancer undergoing gastrectomy.

Effects of propofol, desflurane, and spinal anesthesia on intraocular pressure during lumbar disc herniation surgery: a randomized controlled study

OBJECTIVE

This study aims to evaluate the effects of total intravenous anesthesia (propofol), volatile anesthesia (desflurane), and spinal anesthesia on intraocular pressure (IOP) during lumbar disc herniation surgery in the prone position.

PATIENTS AND METHODS

This randomized controlled trial was conducted between January 2022 and January 2023. The study included 75 patients with lumbar disc herniation between the ages of 18-75, with the American Society of Anesthesiologists (ASA) 1-2. The patients were randomly divided into 3 groups: propofol, desflurane, and spinal. IOP was measured at 5-time points throughout surgery, including baseline (T1), 10 minutes after anesthesia (T2), 10 minutes after prone positioning (T3: early prone), 30 minutes after prone positioning (T4: late prone), and 10 minutes after returning to the supine position (T5). Hemodynamic parameters were measured at these time points. Hemoglobin and hematocrit values were measured preoperatively and on the first postoperative day.

RESULTS

There were 25 patients in each group. The groups were similar in terms of all characteristics except for weight and body mass index, which were lower in the spinal group. Propofol recipients had significantly higher T3 (prone) IOP compared to desflurane recipients (p = 0.001). We found no significant differences between groups in terms of T1, T2, T4, and T5 IOP. Multivariable linear regression revealed that diabetes mellitus (p = 0.016) and high T1 IOP (p = 0.001) were independently associated with higher T3 IOP. In addition, we found that the desflurane (p < 0.001) and spinal (p = 0.002) groups had significantly lower T3 IOP compared to propofol recipients after adjusting for diabetes mellitus and T1 IOP.

CONCLUSIONS

Our findings suggest that volatile anesthesia (desflurane) and spinal anesthesia are linked to lower IOP in the prone position among patients undergoing spinal surgery, in comparison to those receiving total intravenous anesthesia. There is a need to test the results with more comprehensive, population-based studies in different patient groups. ClinicalTrials gov ID: NCT06070480.

Effects of volatile anesthetics on circadian rhythm in mice: a comparative study of sevoflurane, desflurane, and isoflurane

PURPOSE

Volatile anesthetics affect the circadian rhythm of mammals, although the effects of different types of anesthetics are unclear. Here, we anesthetized mice using several volatile anesthetics at two different times during the day. Our objective was to compare the effects of these anesthetics on circadian rhythm.

METHODS

Male adult C57BL/6 J mice were divided into eight groups (n = 8 each) based on the anesthetic (sevoflurane, desflurane, isoflurane, or no anesthesia) and anesthesia time (Zeitgeber time [ZT] 6-12 or ZT18-24). Mice were anesthetized for 6 h using a 0.5 minimum alveolar concentration (MAC) dose under constant dark conditions. The difference between the start of the active phase before and after anesthesia was measured as a phase shift. Clock genes were measured by polymerase chain reaction in suprachiasmatic nucleus (SCN) samples removed from mouse brain after anesthesia (n = 8-9 each).

RESULTS

Phase shift after anesthesia at ZT6-12 using sevoflurane (- 0.49 h) was smaller compared with desflurane (- 1.1 h) and isoflurane (- 1.4 h) (p < 0.05). Clock mRNA (ZT6-12, p < 0.05) and Per2 mRNA (ZT18-24, p < 0.05) expression were different between the groups after anesthesia.

CONCLUSION

0.5 MAC sevoflurane anesthesia administered during the late inactive to early active phase has less impact on the phase shift of circadian rhythm than desflurane and isoflurane. This may be due to differences in the effects of volatile anesthetics on the expression of clock genes in the SCN, the master clock of the circadian rhythm.

Randomized controlled trial of the effect of general anesthetics on postoperative recovery after minimally invasive nephrectomy

BACKGROUND

General anesthetic techniques can affect postoperative recovery. We compared the effect of propofol-based total intravenous anesthesia (TIVA) and desflurane anesthesia on postoperative recovery.

METHODS

In this randomized trial, 150 patients undergoing robot-assisted or laparoscopic nephrectomy for renal cancer were randomly allocated to either the TIVA or desflurane anesthesia (DES) group. Postoperative recovery was evaluated using the Korean version of the Quality of Recovery-15 questionnaire (QoR-15K) at 24 h, 48 h, and 72 h postoperatively. A generalized estimating equation (GEE) was performed to analyze longitudinal QoR-15K data. Fentanyl consumption, pain severity, postoperative nausea and vomiting, and quality of life three weeks after discharge were also compared.

RESULTS

Data were analyzed for 70 patients in each group. The TIVA group showed significantly higher QoR-15K scores at 24 and 48 h postoperatively (24 h: DES, 96 [77, 109] vs. TIVA, 104 [82, 117], median difference 8 [95% CI: 1, 15], P = 0.029; 48 h: 110 [95, 128] vs. 125 [109, 130], median difference 8 [95% CI: 1, 15], P = 0.022), however not at 72 h (P = 0.400). The GEE revealed significant effects of group (adjusted mean difference 6.2, 95% CI: 0.39, 12.1, P = 0.037) and time (P < 0.001) on postoperative QoR-15K scores without group-time interaction (P = 0.051). However, there were no significant differences in other outcomes, except for fentanyl consumption, within the first 24 h postoperatively.

CONCLUSIONS

Propofol-based TIVA showed only a transient improvement in postoperative recovery than desflurane anesthesia, without significant differences in other outcomes.

Effect of Remimazolam on Pain Perception and Opioid-Induced Hyperalgesia in Patients Undergoing Laparoscopic Urologic Surgery-A Prospective, Randomized, Controlled Study

Background and Objectives: The effects of midazolam, a benzodiazepine, on pain perception are complex on both spinal and supraspinal levels. It is not yet known whether remimazolam clinically attenuates or worsens pain. The present study investigated the effect of intraoperative remimazolam on opioid-induced hyperalgesia (OIH) in patients undergoing general anesthesia. Materials and Methods: The patients were randomized into three groups: group RHR (6 mg/kg/h initial dose followed by 1 mg/kg/h remimazolam and 0.3 μg /kg/min remifentanil), group DHR (desflurane and 0.3 μg /kg/min remifentanil) or group DLR (desflurane and 0.05 µg/kg /min remifentanil). The primary outcome was a mechanical hyperalgesia threshold, while secondary outcomes included an area of hyperalgesia and clinically relevant pain outcomes. Results: Group RHR had a higher mechanical hyperalgesia threshold, a smaller hyperalgesia postoperative area at 24 h, a longer time to first rescue analgesia (p = 0.04), lower cumulative PCA volume containing morphine postoperatively consumed for 24 h (p < 0.01), and lower pain intensity for 12 h than group DHR (p < 0.001). However, there was no significant difference in OIH between groups RHR and DLR. Conclusions: Group RHR, which received remimazolam, attenuated OIH, including mechanically evoked pain and some clinically relevant pain outcomes caused by a high dose of remifentanil. Further research is essential to determine how clinically meaningful and important the small differences observed between the two groups are.

Propofol-based total intravenous anesthesia is associated with less postoperative recurrence than desflurane anesthesia in thyroid cancer surgery

BACKGROUND

The effects of anesthesia in patients undergoing thyroid cancer surgery are still not known. We investigated the relationship between the type of anesthesia and patient outcomes following elective thyroid cancer surgery.

METHODS

This was a retrospective cohort study of patients who underwent elective surgical resection for papillary thyroid carcinoma between January 2009 and December 2019. Patients were grouped according to the type of anesthesia they received, desflurane or propofol. A Kaplan-Meier analysis was conducted, and survival/recurrence curves were presented from the date of surgery to death/recurrence. Univariable and multivariable Cox regression models were used to compare hazard ratios for recurrence after propensity matching.

RESULTS

A total of 621 patients (22 deaths, 3.5%) under desflurane anesthesia and 588 patients (32 deaths, 5.4%) under propofol anesthesia were included. Five hundred and eighty-eight patients remained in each group after propensity matching. Propofol anesthesia was not associated with better survival compared to desflurane anesthesia in the matched analysis (P = 0.086). However, propofol anesthesia was associated with less recurrence (hazard ratio, 0.38; 95% confidence interval, 0.25-0.56; P < 0.001) in the matched analysis.

CONCLUSIONS

Propofol anesthesia was associated with less recurrence, but not mortality, following surgery for papillary thyroid carcinoma than desflurane anesthesia. Further prospective investigation is needed to examine the influence of propofol anesthesia on patient outcomes following thyroid cancer surgery.

Comparing Recovery from Desflurane and Sevoflurane in Patients with Different Body Fat Percentages: A Randomized Controlled Trial

INTRODUCTION

Increased body fat may influence the partition coefficients of inhaled anesthetics. We compared patient responses to desflurane and sevoflurane anesthesia, as measured by a quicker recovery and fewer complications, in patients with higher body fat percentages, not only obese people.

METHODS

This study included 120 patients. Participants were stratified into low or high body fat percentages groups using bioelectrical impedance analysis and were randomized 1:1 to receive desflurane or sevoflurane as an inhaled anesthetic, recorded as Low-Desflurane, Low-Sevoflurane, High- Desflurane, and High-Sevoflurane. Recovery time, Riker sedation-agitation scale scores, and complications were recorded over 1 hour in the post-anesthesia care unit.

RESULTS

A total of 106 patients were analyzed. There were no significant differences in the overall recovery time between the patient subgroups with higher and lower body fat percentages; in addition, there were no significant differences in the incidence of nausea, vomiting,dizziness, or headache (all p>0.05). However, the incidence of agitation emergence in the HighSevoflurane subgroup was significantly higher compared to the High-Desflurane subgroup (33.3% vs.7.41%; p = 0.043).

CONCLUSION

In conclusion, for patients with a lower body fat percentage, both desflurane and sevoflurane can provide good and fast recovery; for patients with a higher body fat percentage,desflurane may provide better recovery with a lower incidence of agitation emergence compared to sevoflurane.

Effects of Anesthetics on Cardiac Repolarization in Adults: A Network Meta-Analysis of Randomized Clinical Trials

OBJECTIVES

Prolongation of cardiac repolarization, especially the heart rate-corrected QT (QTc) interval, is associated with life-threatening dysrhythmias. This study aimed to identify the anesthetic with the lowest risk of prolonging cardiac repolarization and provide guidance for anesthesia management in patients with cardiac diseases or long QT syndrome.

METHODS

Randomized controlled trials (RCTs) comparing the effects of anesthetics on cardiac repolarization indices were searched for in multiple databases. The primary outcome was QTc; and the secondary outcomes were other repolarization indices. A network meta-analysis was conducted using a frequentist approach and registered with the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42022304970).

RESULTS

Thirteen RCTs investigating 953 adults with normal QTc interval and without cardiovascular diseases were included. Direct meta-analyses found that propofol had less influence than sevoflurane (95% confidence interval (CI): 16.10, 33.54) and desflurane (95% CI: 4.85, 35.36), and sevoflurane had less influence than desflurane (95% CI: 6.96, 19.39) on QTc prolongation. Network analysis found that propofol had less influence than sevoflurane (95% CI: 17.78, 29.63), halothane (95% CI: 11.29, 41.24), desflurane (95% CI: 23.79, 39.88), and isoflurane (95% CI: 20.11, 46.10), and sevoflurane had less influence than desflurane (95% CI: 0.43, 15.82) on QTc prolongation. The rank order of cumulative ranking curve analysis was propofol (100%), sevoflurane (63.8%), halothane (49.5%), desflurane (21.1%), and isoflurane (15.6%). The direct meta-analysis found that propofol had less influence than sevoflurane on QT prolongation (95% CI: 23.12, 57.86). Other secondary outcomes showed no conclusive findings.

CONCLUSIONS

This meta-analysis found that propofol had a minimal effect on QTc prolongation, followed by sevoflurane and desflurane in adults with normal QTc interval and without cardiovascular diseases. Propofol is the best anesthetic for adult patients with long QT syndrome or cardiac diseases, but still needs more robust evidence.

Spontaneous and Visual Stimulation Evoked Firing Sequences Are Distinct Under Desflurane Anesthesia

Recurring spike sequences are thought to underlie cortical computations and may be essential for information processing in the conscious state. How anesthesia at graded levels may influence spontaneous and stimulus-related spike sequences in visual cortex has not been fully elucidated. We recorded extracellular single-unit activity in the rat primary visual cortex in vivo during wakefulness and three levels of anesthesia produced by desflurane. The latencies of spike sequences within 0-200 ms from the onset of spontaneous UP states and visual flash-evoked responses were compared. During wakefulness, spike latency patterns linked to the local field potential theta cycle were similar to stimulus-evoked patterns. Under desflurane anesthesia, spontaneous UP state sequences differed from flash-evoked sequences due to the recruitment of low-firing excitatory neurons to the UP state. Flash-evoked spike sequences showed higher reliability and longer latency when stimuli were applied during DOWN states compared to UP states. At deeper levels, desflurane altered both UP state and flash-evoked spike sequences by selectively suppressing inhibitory neuron firing. The results reveal desflurane-induced complex changes in cortical firing sequences that may influence visual information processing.

Towards a green hospital approach in Oman: A case study of quantifying an environmental impact

INTRODUCTION

The environmental impact of hospitals and healthcare providers practices is substantial, although often unnoticed and infrequently tracked. A green and healthy hospital is one that promotes public health by continuously monitoring and reducing its environmental impact.

METHODS

We adopted a descriptive case study design with a multi-dimensional evaluation and monitoring of carbon emission equivalence (CO2e) using two examples from a tertiary care hospital practice in Oman. One example (1) was related to inhalation anaesthetic gases (IAG) consumption and the second example (2) was related to estimation of telemedicine clinics (TMCs) CO2e travel-related savings.

RESULTS

The cumulative consumption of three different (1) IAG over three years (2019, 2020, 2021) was generated with estimated CO2e for each year for sevoflurane, isoflurane and desflurane. Desflurane had the lowest consumption with a yearly cumulative consumption of 6000 mL, 1500 mL, and 3000 mL for the years 2019, 2020 and 2021. The (2) TMCs during the first two years of the COVID-19 pandemic travel related CO2e savings were in the range of 12.65-3483.1 tonnes. In the second year of launching this service it doubled to a range of 24-6610.5 tonnes of CO2e savings.

CONCLUSION

A green and healthy hospital approach of tracking and monitoring environmental impact of healthcare providers practices is critical for health planning and management of the environmental policy. This case study illustrated the importance of closely tracking hospital-based practices from an environmental perspective towards a green hospital approach.

Effects of remimazolam on hemodynamic changes during cardiac ablation for atrial fibrillation under general anesthesia: a propensity-score-matched retrospective cohort study

PURPOSE

Abrupt hemodynamic changes or life-threatening arrhythmias are frequently observed in individuals receiving anesthesia for cardiac arrhythmia ablation. Remimazolam is a novel ultra-short-acting benzodiazepine that has been associated with better hemodynamic stability than conventional anesthetic agents do. This study aimed to investigate whether remimazolam reduces vasoactive agent use compared with desflurane in individuals undergoing ablation for atrial fibrillation under general anesthesia.

METHODS

In a retrospective cohort study, we reviewed electronic medical records of adult patients who underwent ablation for atrial fibrillation under general anesthesia between July 2021 and July 2022. We divided patients into remimazolam and desflurane groups according to the principal agent used for anesthesia. The primary endpoint was the overall incidence of vasoactive agent use. We compared the groups using propensity-score matching (PSM) analysis.

RESULTS

A total of 177 patients were included-78 in the remimazolam group and 99 in the desflurane group. After PSM, 78 final patients were included in each group. The overall incidence of vasoactive agent use was significantly lower in the remimazolam group than in the desflurane group (41% vs 74% before PSM; 41% vs 73% after PSM; both, P < 0.001). The incidence rate, duration, and maximum dose of continuous vasopressor infusion were also significantly lower in the remimazolam group (P < 0.001). Use of remimazolam was not associated with increased complications after the ablation procedures.

CONCLUSIONS

General anesthesia using remimazolam vs desflurane was associated with significantly reduced vasoactive agent requirement and better hemodynamic stability without increased postoperative complications in patients undergoing ablation for atrial fibrillation.

Project SPRUCE: Saving Our Planet by Reducing Carbon Emissions, a Pediatric Anesthesia Sustainability Quality Improvement Initiative

BACKGROUND

Children are particularly vulnerable to adverse health outcomes related to climate change. Inhalational anesthetics are potent greenhouse gasses (GHGs) and contribute significantly to health care-generated emissions. Desflurane and nitrous oxide have very high global warming potentials. Eliminating their use, as well as lowering fresh gas flows (FGFs), will lead to reduced emissions.

METHODS

Using published calculations for converting volatile anesthetic concentrations to carbon dioxide equivalents (CO 2 e), we derived the average kilograms (kg) CO 2 e/min for every anesthetic administered in the operating rooms at our pediatric hospital and ambulatory surgical center between October 2017 and October 2022. We leveraged real-world data captured from our electronic medical record systems and used AdaptX to extract and present those data as statistical process control (SPC) charts. We implemented recommended strategies aimed at reducing emissions from inhalational anesthetics, including removing desflurane vaporizers, unplugging nitrous oxide hoses, decreasing the default anesthesia machine FGF, clinical decision support tools, and educational initiatives. Our primary outcome measure was average kg CO 2 e/min.

RESULTS

A combination of educational initiatives, practice constraints, protocol changes, and access to real-world data were associated with an 87% reduction in measured GHG emissions from inhaled anesthesia agents used in the operating rooms over a 5-year period. Shorter cases (<30 minutes duration) had 3 times higher average CO 2 e, likely due to higher FGF and nitrous oxide use associated with inhalational inductions, and higher proportion of mask-only anesthetics. Removing desflurane vaporizers corresponded with a >50% reduction of CO 2 e. A subsequent decrease in anesthesia machine default FGF was associated with a similarly robust emissions reduction. Another significant decrease in emissions was noted with educational efforts, clinical decision support alerts, and feedback from real-time data.

CONCLUSIONS

Providing environmentally responsible anesthesia in a pediatric setting is a challenging but achievable goal, and it is imperative to help mitigate the impact of climate change. Large systems changes, such as eliminating desflurane, limiting access to nitrous oxide, and changing default anesthesia machine FGF rates, were associated with rapid and lasting emissions reduction. Measuring and reporting GHG emissions from volatile anesthetics allows practitioners to explore and implement methods of decreasing the environmental impact of their individual anesthesia delivery practices.

Automated Closed-Loop Propofol Anesthesia Versus Desflurane Inhalation Anesthesia in Obese Patients Undergoing Bariatric Surgery: A Comparative Randomized Analysis of Recovery Profile

INTRODUCTION

Precision general anesthesia (GA) techniques that minimize the presence of residual anesthetic and facilitate recovery, are desirable in patients with morbid obesity. Automated administration of propofol total intravenous anesthesia (TIVA), which facilitates precision propofol delivery by factoring in continuous patient input variable (bispectral index) to establish a closed feedback loop system, may help mitigate concerns related to propofol's lipid solubility and adverse accumulation kinetics in patients with morbid obesity. This randomized study evaluated the recovery of patients with morbid obesity undergoing bariatric surgery under propofol TIVA automated by a closed-loop anesthesia delivery system (CLADS) versus desflurane GA.

METHODS

Forty patients, randomly allocated to receive propofol TIVA (CLADS group) or desflurane GA (desflurane group), were evaluated for postoperative recovery (early and intermediate) (primary objective); they were evaluated for intraoperative hemodynamics, anesthesia depth consistency, anesthesia delivery performance characteristics, patient satisfaction, and incidence of adverse events (sedation, pain, postoperative nausea, and vomiting) (secondary objective).

RESULTS

No difference was found for the time-to-eye-opening (CLADS group: 4.7 [3.0, 6.7] min vs. desflurane group: 5.6 [4.0, 6.9] min, P = 0.576), time-to-tracheal-extubation (CLADS group: 6.7 [4.7, 9.3] min vs. desflurane group: 7.0 [5.8, 9.2] min, P = 0.528), ability-to-shift score from operating room table to the transport bed (CLADS group: 3 [3.0, 3.5] vs. desflurane group: 3 [3.0, 4.0], P = 0.703), and time to achieve a modified Aldrete score 9/10 (CLADS group: 15 [15.0, 37.5] min vs. desflurane group: 15 [15.0, 43.7] min, P = 0.867).

CONCLUSION

Automated propofol TIVA as administered by CLADS, which matched desflurane GA with respect to depth of anesthesia consistency and postanesthesia recovery profile, can be explored further as an alternative anesthesia technique in patients with morbid obesity.

Automated Closed-Loop Propofol Anesthesia Versus Desflurane Inhalation Anesthesia in Obese Patients Undergoing Bariatric Surgery: A Comparative Randomized Analysis of Recovery Profile

INTRODUCTION

Precision general anesthesia (GA) techniques that minimize the presence of residual anesthetic and facilitate recovery, are desirable in patients with morbid obesity. Automated administration of propofol total intravenous anesthesia (TIVA), which facilitates precision propofol delivery by factoring in continuous patient input variable (bispectral index) to establish a closed feedback loop system, may help mitigate concerns related to propofol's lipid solubility and adverse accumulation kinetics in patients with morbid obesity. This randomized study evaluated the recovery of patients with morbid obesity undergoing bariatric surgery under propofol TIVA automated by a closed-loop anesthesia delivery system (CLADS) versus desflurane GA.

METHODS

Forty patients, randomly allocated to receive propofol TIVA (CLADS group) or desflurane GA (desflurane group), were evaluated for postoperative recovery (early and intermediate) (primary objective); they were evaluated for intraoperative hemodynamics, anesthesia depth consistency, anesthesia delivery performance characteristics, patient satisfaction, and incidence of adverse events (sedation, pain, postoperative nausea, and vomiting) (secondary objective).

RESULTS

No difference was found for the time-to-eye-opening (CLADS group: 4.7 [3.0, 6.7] min vs. desflurane group: 5.6 [4.0, 6.9] min, P = 0.576), time-to-tracheal-extubation (CLADS group: 6.7 [4.7, 9.3] min vs. desflurane group: 7.0 [5.8, 9.2] min, P = 0.528), ability-to-shift score from operating room table to the transport bed (CLADS group: 3 [3.0, 3.5] vs. desflurane group: 3 [3.0, 4.0], P = 0.703), and time to achieve a modified Aldrete score 9/10 (CLADS group: 15 [15.0, 37.5] min vs. desflurane group: 15 [15.0, 43.7] min, P = 0.867).

CONCLUSION

Automated propofol TIVA as administered by CLADS, which matched desflurane GA with respect to depth of anesthesia consistency and postanesthesia recovery profile, can be explored further as an alternative anesthesia technique in patients with morbid obesity.

Efficacy of a propofol bolus against placebo to prevent cough at emergence from general anesthesia with desflurane: a randomized controlled trial

PURPOSE

Emergence from anesthesia is a critical period and cough can result in adverse effects. Propofol inhibits airway reflexes and when infused it reduces cough more than inhalation anesthesia does. We evaluated the effect of a propofol bolus given at emergence on the incidence of coughing following a desflurane-based anesthesia.

METHODS

One hundred and fifty-four patients scheduled for elective surgery were prospectively randomized to propofol (0.5 mg·kg-1) or normal saline (NS) administered at the end of the surgery at 1 minimum alveolar concentration (MAC) of desflurane. A "no touch" emergence technique was used until extubation. The primary outcome was the incidence of cough at the discontinuation of desflurane (T0) and reaching a MAC adjusted for age (MACage) of 0.15. Secondary outcomes included incidence and severity of cough until five minutes postextubation (T0-T5), time to extubation, nausea and vomiting, sedation, hemodynamic variations, postoperative hypoventilation, hypoxemia, and sore throat.

RESULTS

We could not draw inferences on the incidence of cough between T0 and MACage of 0.15 because only 27/68 (40%) patients in the NS group and 13/73 (18%) patients in the propofol group regained consciousness before reaching a MACage of 0.15. There were no significant differences between the groups in coughing incidence and severity between T0 and T5 (NS group, 57/68 [84%] vs propofol group, 70/73 [96%] ). The mean time to extubation in the propofol group was prolonged by 3 min 27 sec (95% confidence interval, 1 min 7 sec to 4 min 47 sec; P < 0.001) and more vasopressors were used at emergence (P = 0.02). The incidence of respiratory complications, nausea and vomiting, agitation, and sedation were not different between groups.

CONCLUSION

In the present trial, a propofol bolus administered at emergence did not reduce the incidence of cough occurring between T0 and T5 following a desflurane-based general anesthesia compared with placebo.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02932397); registered 13 October 2016.

The green anaesthesia dilemma: to which extent is it important to preserve as many drugs available as possible

PURPOSE OF REVIEW

This article aims to summarize the current literature describing the availability of different anaesthetic drugs, and to discuss the advantages and limitations of a self-imposed restriction on the scarcely existing anaesthetic drugs.

RECENT FINDINGS

Earth temperature has risen 1.2°C since the beginning of industrial age, and it is expected to exceed a 1.5°C increase by 2050. The Intergovernmental Panel on Climate Change depicts five different scenarios depending on how these increased temperatures will be controlled in the future. The European Commission has formulated a proposal to regulate fluorinated greenhouse gases (F-gases), among which desflurane, isoflurane and sevoflurane belong to, due to their high global warming potential. This proposal shall ban, or severely restrict, the use of desflurane starting January 2026. It is not clear what might happen with other F-gas anaesthetics in the future. Due to climate change, a higher number of health crisis are expected to happen, which might impair the exiting supply chains, as it has happened in previous years with propofol scarcity.

SUMMARY

There are just a handful number of available anaesthetics that provide for a safe hypnosis. Major stakeholders should be consulted prior making such severe decisions that affect patient safety.

Comparative effects of desflurane and sevoflurane on intraoperative peripheral perfusion index: a retrospective, propensity score matched, cohort study

Desflurane is known to have a larger vasodilatory effect than that of sevoflurane. However, its generalizability and effect size in actual clinical practice are yet to be proven. Patients aged ≥ 18 years who underwent noncardiac surgery under general anesthesia using inhalation anesthetics (desflurane or sevoflurane) were matched 1:1 by propensity score. The mean intraoperative perfusion index (PI) of each patient were compared between the two groups. Propensity score matching of 1680 patients in the study cohort identified 230 pairs of patients. PI was significantly higher in the desflurane group (median of paired difference, 0.45; 95% CI 0.16 to 0.74, p = 0.002). PI durations below 1.0 and 1.5 were significantly longer in the sevoflurane group. Mean arterial pressure (MAP) and durations of low MAP did not differ significantly between the two groups. Generalized linear mixed models revealed that the use of sevoflurane, mean MAP, mean heart rate, age, and duration of anesthesia had significant negative effects (lower PI), whereas mean age-adjusted minimum alveolar concentration of inhalation agent had a positive effect on PI (higher value). Intraoperative PI was significantly higher in patients administered desflurane than sevoflurane. However, the impact of the choice between desflurane and sevoflurane on intraoperative PI in this clinical setting was minimal.

A call for immediate climate action in anesthesiology: routine use of minimal or metabolic fresh gas flow reduces our ecological footprint

PURPOSE

Climate change is a global threat, and inhalational anesthetics contribute to global warming by altering the photophysical properties of the atmosphere. On a global perspective, there is a fundamental need to reduce perioperative morbidity and mortality and to provide safe anesthesia. Thus, inhalational anesthetics will remain a significant source of emissions in the foreseeable future. It is, therefore, necessary to develop and implement strategies to minimize the consumption of inhalational anesthetics to reduce the ecological footprint of inhalational anesthesia.

SOURCE

We have integrated recent findings concerning climate change, characteristics of established inhalational anesthetics, complex simulative calculations, and clinical expertise to propose a practical and safe strategy to practice ecologically responsible anesthesia using inhalational anesthetics.

PRINCIPAL FINDINGS

Comparing the global warming potential of inhalational anesthetics, desflurane is about 20 times more potent than sevoflurane and five times more potent than isoflurane. Balanced anesthesia using low or minimal fresh gas flow (≤ 1 L·min-1) during the wash-in period and metabolic fresh gas flow (0.35 L·min-1) during steady-state maintenance reduces CO2 emissions and costs by approximately 50%. Total intravenous anesthesia and locoregional anesthesia represent further options for lowering greenhouse gas emissions.

CONCLUSION

Responsible anesthetic management choices should prioritize patient safety and consider all available options. If inhalational anesthesia is chosen, the use of minimal or metabolic fresh gas flow reduces the consumption of inhalational anesthetics significantly. Nitrous oxide should be avoided entirely as it contributes to depletion of the ozone layer, and desflurane should only be used in justified exceptional cases.

Reducing Volatile Anesthetic Waste Using a Commercial Electronic Health Record Clinical Decision Support Tool to Lower Fresh Gas Flows

BACKGROUND

Volatile anesthetic consumption can be reduced by minimizing excessive fresh gas flows (FGFs). Currently, it is unknown whether decision support tools embedded within commercial electronic health record systems can be successfully adopted to achieve long-term reductions in FGF rates. The authors describe the implementation of an electronic health record-based clinical decision support tool aimed at reducing FGF and evaluate the effectiveness of this intervention in achieving sustained reductions in FGF rates and volatile anesthetic consumption.

METHODS

On August 29, 2018, we implemented a decision support tool within the Epic Anesthesia Information Management System (AIMS) to alert providers of high FGF (>0.7 L/min for desflurane and >1 L/min for sevoflurane) during maintenance of anesthesia. July 22, 2015, to July 10, 2018, served as our baseline period before the intervention. The intervention period spanned from August 29, 2018, to December 31, 2019. Our primary outcomes were mean FGF (L/min) and volatile agent consumption (mL/MAC-h). Because a simple comparison of 2 time periods may result in false conclusions due to underlying trends independent of the intervention, we performed segmented regression of the interrupted time series to assess the change in level at the start of the intervention and the differences in slopes before and after the intervention. The analysis was also adjusted for potential confounding variables. Data included 44,899 cases using sevoflurane preintervention with 26,911 cases postintervention, and 17,472 cases using desflurane with 1185 cases postintervention.

RESULTS

Segmented regression of the interrupted times series demonstrated a decrease in mean FGF by 0.6 L/min (95% CI, 0.6-0.6 L/min; P < .0001) for sevoflurane and 0.2 L/min (95% CI, 0.2-0.3 L/min; P < .0001) for desflurane immediately after implementation of the intervention. For sevoflurane, mL/MAC-h decreased by 3.8 mL/MAC-h (95% CI, 3.6-4.1 mL/MAC-h; P < .0001) after implementation of the intervention and decreased by 4.1 mL/MAC-h (95% CI, 2.6-5.6 mL/MAC-h; P < .0001) for desflurane. Slopes for both FGF and mL/MAC-h in the postintervention period were statistically less negative than the preintervention slopes (P < .0001 for sevoflurane and P < .01 for desflurane).

CONCLUSIONS

A commercial AIMS-based decision support tool can be adopted to change provider FGF management patterns and reduce volatile anesthetic consumption in a sustainable fashion.

Memsorb™, a novel CO2 removal device part II: in vivo performance with the Zeus IE®

Memsorb™ (DMF Medical, Halifax, Canada) is a novel device based upon membrane oxygenator technology designed to eliminate CO₂ from exhaled gas when using a circle anesthesia circuit. Exhaled gases pass through semipermeable hollow fibers and sweep gas flowing through these fibers creates a diffusion gradient for CO₂ removal. In vivo Memsorb™ performance was tested during target-controlled closed-circuit anesthesia (TCCCA) with desflurane in O₂/air using a Zeus IE® anesthesia workstation (Dräger, Lübeck, Germany). Clinical care protocols for using this novel device were guided by in vitro performance results from a prior study (submitted simultaneously). After IRB approval, written informed consent was obtained from 10 ASA PS I-III patients undergoing robot-assisted radical prostatectomy. TCCCA targets were 39% inspired O₂ concentration (F_IO₂) and 5.0% end-expired desflurane concentration (F_ETdes). Minute ventilation (MV) was adjusted to maintain 4.5-6.0% F_ETCO₂. The O₂/air (40% O₂) sweep flow into the Memsorb™ was manually adjusted in an attempt to keep inspired CO₂ concentration (F_ICO₂) ≤ 0.8%. The following data were collected: F_IO₂, F_ETdes, F_ICO₂, F_ETCO₂, MV, fresh gas flow (FGF, O₂ and air), sweep flow, and cumulative desflurane usage (Vdes). Vdes of the Zeus IE®-Memsorb™ combination was compared with historical Vdes observed in a previous study when soda lime (DrägerSorb 800 +) was used. Results are reported as median and inter-quartiles. A combination of manually adjusting sweep flow (26 [21,27] L/min) and MV sufficed to maintain F_ICO₂ ≤ 0.8% and F_ETCO₂ ≤ 6.0%, except in one patient in whom the target Zeus IE® FGF had to be increased to 0.7 L/min for 6 min. F_IO₂ and F_ETdes were maintained close to their targets. Zeus IE® FGF after 5 min was 0 [0,0] mL/min. Average Vdes after 50 min was higher with Memsorb™ (20.3 mL) compared to historical soda lime canister data (12.3 mL). During target-controlled closed-circuit anesthesia in patients undergoing robot-assisted radical prostatectomy, the Memsorb™ maintained F_ICO₂ ≤ 0.8% and F_ETCO₂ ≤ 6.0%, and F_IO₂ remained close to target. Modest amounts of desflurane were lost with the use of the Memsorb™. The need for adjustments of sweep flow, minute ventilation, and occasionally Zeus IE® FGF indicates that the Memsorb™ system should preferentially be integrated into an automated closed-loop system.

Comparison of the synergistic effects of sevoflurane and desflurane on muscle relaxant vecuronium in laparoscopic colon cancer surgery

Sevoflurane and desflurane are commonly used inhalation anesthetics in clinical practice. This study compared the synergistic effects of sevoflurane and desflurane on the muscarinic agent vecuronium in laparoscopic colon cancer surgery. The aim of this study was to compare sevoflurane and desflurane in a synergistic effect on the muscle relaxant vecuronium in laparoscopic colon cancer surgery. Sixty patients undergoing elective laparoscopic radical resection of colon cancer were randomly divided into sevoflurane (n = 30) and desflurane (n = 30) groups. After anesthesia and successful tracheal intubation, patients in both groups were maintained with combined remifentanil. Muscle relaxant effects were monitored in both groups using a muscle relaxant monitor (train of stimuli-Watch), the onset time, T1 and T2 recovery time, and muscle relaxant dosage of vecuronium were observed. Hemodynamic changes were observed in both groups, and the dosage of vasoactive drugs was recorded. The quality of recovery of the patients was evaluated using the Mini-Mental State Examination (MMSE) and the discharge from the Aldrete score criteria. There was no significant difference in the onset time of vecuronium between the two groups (P > .05). The desflurane group's T1 and T2 recovery times were later than that of the sevoflurane group. The dosage of vecuronium was statistically significantly less than that in the sevoflurane group (P < .05); the extubation time in the desflurane group was statistically significantly longer than that in the sevoflurane group (P < .05). There were no significant differences in preoperative and intraoperative mean arterial pressure, heart rate, ephedrine and atropine dosage, MMSE score, and Aldrete score between the 2 groups (P > .05). Compared with sevoflurane, desflurane has a stronger synergistic effect on the muscle relaxant of vecuronium without increasing the incidence of cardiovascular adverse reactions and affecting patient recovery.

Comparison of the effects of sevoflurane and desflurane on the severity score of postoperative pain and discomfort after thyroidectomy: A prospective, double-blinded, randomized controlled study

BACKGROUND

Thyroidectomy is performed under general anesthesia using inhaled anesthetics such as sevoflurane or desflurane in many cases. The objective of this study was to investigate whether the incidence of postoperative pain and discomfort after thyroidectomy differed with the type of inhaled anesthetic.

METHODS

Eighty-one female patients who underwent thyroidectomy were randomly assigned to the Sevo group (n = 42) or the Des group (n = 39). On the day of surgery and on the first, third, and seventh days after surgery, one registered nurse in charge of the entire questionnaire survey conducted the questionnaire assessment through face-to-face interviews or phone calls with the patients. The questionnaire evaluated the severity scores for seven items (sore throat, wound pain, nausea and vomiting, dizziness, occipital headache, posterior neck pain, and shoulder pain) regarding postoperative pain and discomfort experienced by patients and assessed which of these seven items caused the greatest discomfort to the patient on each day.

RESULTS

Except for the severity score for dizziness on the day of surgery, the severity scores of postoperative pain and discomfort experienced by patients on the day of surgery and on the first, third, and seventh days after surgery showed no statistically significant differences between the two groups. In addition, on the day of surgery and on the first, third, and seventh days after surgery, patients reported that sore throat caused the greatest discomfort.

CONCLUSION

In patients undergoing thyroidectomy under general anesthesia using sevoflurane or desflurane, except for dizziness on the day of surgery, no other manifestation of postoperative pain and discomfort was influenced by the type of inhaled anesthetic. Moreover, after thyroidectomy, postoperative sore throat caused the greatest discomfort to patients from the day of surgery to the seventh day after surgery.

Comparison of regional cerebral oxygen saturation during one-lung ventilation under desflurane or propofol anesthesia: A randomized trial

BACKGROUND

During one-lung ventilation (OLV), deterioration of pulmonary oxygenation reduces arterial oxygen saturation and cerebral oxygen saturation (rSO2). However, oxidative stress during OLV causes lung injury, so the fraction of inspiratory oxygen (FiO2) should be kept as low as possible. We investigated the changes in rSO2 under propofol or desflurane anesthesia while percutaneous oxygen saturation (SpO2) was kept as low as possible during OLV.

METHODS

Thirty-six patients scheduled for thoracic surgery under OLV in the lateral decubitus position were randomly assigned to propofol (n = 19) or desflurane (n = 17) anesthesia. FiO2 was set to 0.4 at the start of surgery under two-lung ventilation (measurement point: T3) and then adjusted to maintain an SpO2 of 92% to 94% after the initiation of OLV. The primary outcome was the difference in the absolute value of the decrease in rSO2 from T3 to 30 minutes after the initiation of OLV (T5), which was analyzed by an analysis of covariance adjusted for the rSO2 value at T3.

RESULTS

The mean rSO2 values were 61.5% ± 5.1% at T3 and 57.1% ± 5.3% at T5 in the propofol group and 62.2% ± 6.0% at T3 and 58.6% ± 5.3% at T5 in the desflurane group. The difference in the absolute value of decrease between groups (propofol group - desflurane group) was 0.95 (95% confidence interval, [-0.32, 2.2]; P = .152).

CONCLUSIONS

Both propofol and desflurane anesthesia maintain comparable cerebral oxygenation and can be used safely, even when the SpO2 is kept as low as possible during OLV.

The science behind banning desflurane: A narrative review

Potent inhaled anaesthetics are halogenated hydrocarbons with a large global warming effect. The use of fluorinated hydrocarbons (most are not anaesthetics) are being restricted but volatile anaesthetics have been exempted from legislation, until now: the EU has formulated a proposal to ban or at least severely restrict the use of desflurane starting January 2026. This narrative review addresses the implications of a politics-driven decision - without prior consultation with major stakeholders, such as the European Society of Anaesthesiology and Intensive Care (ESAIC) - on daily anaesthesia practice and reviews the potential scientific arguments that would support stopping the routine use of desflurane in anaesthetic practice. Of note, banning or severely restricting the use of one anaesthetic agent should not distract the user from sensible interventions like reducing fresh gas flows and developing technology to capture and recycle or destroy the wasted potent inhaled anaesthetics that we will continue to use. We call to join efforts to minimise our professional environmental footprint.

The deleterious impact of exposure to different inhaled anesthetics is time dependent

In this study, the effects of exposure to isoflurane, sevoflurane and desflurane on the oxidative response and inflammation at different times was analyzed in the lungs of adult C57BL/6 mice. 120 animals were divided into 3 groups (n = 40): Isoflurane (ISO), Sevoflurane (SEV) and Desflurane (DES) and exposed to these anesthetics for 1 h (n = 10), 2 h (n = 10) and 3 h (n = 10), at a minimum alveolar concentration (MAC) equal to 1. The control group (CG) (n = 10) was exposed to ambient air. 24 h after the experimental protocol, the animals were euthanized and the bronchoalveolar lavage fluid (BALF), blood and lung tissue samples were collected. In the BALF, animals exposed to isoflurane for 2 h and 3 h showed a greater influx of leukocytes, especially macrophages compared to the CG. The ISO3h had lower leukocyte counts in the peripheral blood compared to CG, ISO1h and ISO2h. There was an increase in CCL-2 levels in the ISO3h compared to the CG. Superoxide dismutase activity was higher in ISO1h compared to CG. The activity of catalase was higher in the ISO1h and ISO2h compared to the CG. The lipid peroxidation, as well as carbonylated protein were higher in the ISO3h compared to the CG (p < 0.05). Similar results were observed in the exposure of SEV and DES compared to inflammation and redox imbalance in different periods. This study demonstrated that time is a determinant to promote a local and systemic inflammatory response to different inhalational anesthetics in a healthy murine model.

Propofol-based total intravenous anesthesia is associated with better survival than desflurane anesthesia in limb-salvage surgery for osteosarcoma: A retrospective analysis

Previous studies have demonstrated that anesthetic techniques can affect the outcomes of cancer surgery. We investigated the association between anesthetic techniques and patient outcomes after elective limb-salvage surgery for osteosarcoma (OS). This was a retrospective cohort study of patients who underwent elective limb-salvage surgery for OS between January 2007 and December 2018. Patients were grouped according to the administration of propofol-based total intravenous anesthesia (TIVA) or desflurane (DES) anesthesia. Kaplan-Meier analysis was performed, and survival curves were constructed from the date of surgery to death. Univariate and multivariate Cox regression models were applied to compare the hazard ratios (HRs) for death after propensity matching. Subgroup analyses were done for postoperative recurrence, metastasis, and tumor-node-metastasis (TNM) staging. A total of 30 patients (17 deaths, 56.7%) who received DES anesthesia and 26 (4 deaths, 15.4%) who received TIVA were eligible for analysis. After propensity matching, 22 patients were included in each group. In the matched analysis, patients who received TIVA had better survival with a HR of 0.30 (95% confidence interval [CI], 0.11-0.81; P = .018). Subgroup analyses also showed significantly better survival in the presence of postoperative metastasis (HR, 0.24; 95% CI, 0.06-0.87; P = .030) and with TNM stage II to III (HR, 0.26; 95% CI, 0.09-0.73; P = .011) in the matched TIVA group. In addition, patients administered with TIVA had lower risks of postoperative recurrence and metastasis than those administered with DES anesthesia in the matched analyses. Propofol-based TIVA was associated with better survival in patients who underwent elective limb-salvage surgery for OS than DES anesthesia. Prospective studies are needed to assess the effects of TIVA on oncological outcomes in patients with OS.

Greenhouse gas reduction in anaesthesia practice: a departmental environmental strategy

Sustainability interventions were implemented at the Royal Brisbane and Women’s Hospital (RBWH) following identification of inhaled anaesthetic gases as a target for reducing medical carbon emissions. This quality improvement study assessed and evaluated the impact of sustainability interventions on the environmental and financial cost of inhaled anaesthetic gas use in order to guide future initiatives and research in reducing carbon emissions from healthcare practice.

Ethical exemption was granted from the RBWH Research Ethics Committee (EX/2021/QRBW/76078). Usage (bottles) and expenditure for desflurane and sevoflurane from January 2016 to December 2021 were obtained. Global warming potential and carbon dioxide equivalent (CO₂e) were used to report environmental impact of volatile agents. Methods to estimate this were performed in Excel based on Campbell and Pierce methodology. An Environmental Protection Agency greenhouse gas equivalency calculator was used to convert CO₂e to equivalent petrol carbon emissions and kilometres travelled by a typical passenger vehicle.

The total number of bottles of sevoflurane and desflurane purchased between January 2016 and December 2021 decreased by 34.76% from 1991 to 1299. The number of desflurane bottles purchased decreased by 95.63% from 800 to 35 bottles. The number of sevoflurane bottles purchased increased by 6.13% from 1191 bottles to 1264 bottles. This was achieved by implementing quality improvement interventions such as staff education of desflurane-sparing practices, distribution of posters and progressive removal of desflurane from operating theatres. Total carbon emission from volatile anaesthetics equalled 2326 tonnes CO₂e. Combined desflurane and sevoflurane emissions decreased by 87.88%. In 2016, desflurane made up 92.39% of the annual CO₂e, which steadily decreased to 33.36% in 2021. Combined sevoflurane and desflurane usage costs decreased by 58.33%.

Substantial reductions in carbon emissions from volatile anaesthetics demonstrate the significant degree to which environmentally sustainable practices have been implemented. Applying desflurane-sparing practice can heavily limit anaesthetic drug expenditure and contribution to environmental waste. This is important given the global health sector’s challenge to optimise patient outcomes in the face of global climate change crisis.

Long-term oncological outcomes after oral cancer surgery using propofol-based total intravenous anesthesia versus sevoflurane-based inhalation anesthesia: A retrospective cohort study

Background

Previous studies have shown that the anesthetic technique may influence long-term outcomes after cancer surgery. However, the association between the anesthetic technique and long-term oncological outcomes after oral cancer surgery remains unclear. Therefore, we conducted this study to address this gap.

Methods

We reviewed the electronic medical records of patients who underwent elective oral cancer surgery between January 2014 and December 2015. The patients were grouped based on the anesthesia maintenance: either propofol or sevoflurane. Propensity score matching in a 1:1 ratio was performed to deal with the potential confounding effects of baseline characteristics. Univariate and multivariate Cox regression analyses were performed to compare hazard ratios (HRs) and identify the risk factors for death and recurrence. Survival analysis was performed using the Kaplan–Meier method, and survival curves were constructed from the date of surgery to death.

Results

In total, 1347 patients were eligible for analysis, with 343 and 1004 patients in the propofol and sevoflurane groups, respectively. After propensity score matching, 302 patients remained in each group. Kaplan–Meier survival curves demonstrated the 5-year overall and recurrence-free survival rates of 59.3% and 56.0% and 62.7% and 56.5% in the propofol and sevoflurane groups, respectively. There was no significant difference in overall survival or recurrence-free survival between the groups. The multivariate Cox analysis verified this conclusion with HRs of 1.10 and 1.11 for overall survival and recurrence-free survival, respectively, in the sevoflurane group. Older age, advanced tumor-node-metastasis (TNM) stage, and American Society of Anesthesiologists class III were associated with poor overall survival. Patients with advanced TNM stage and poorly differentiated squamous cell carcinoma had a higher recurrence risk than their counterparts.

Conclusion

The overall and recurrence-free survival rates were similar between propofol-based intravenous anesthesia and sevoflurane volatile anesthesia in patients who underwent oral cancer surgery.

The effect of anesthetic agents on intraocular pressure during laparoscopic gynecological surgery performed in the Trendelenburg position: A randomized clinical trial

BACKGROUND

Intraocular pressure (IOP) increases due to pneumoperitoneum and the Trendelenburg position during laparo-scopic surgery. Apart from ketamine and suxamethonium, anesthetic agents generally reduce IOP by various extents. The present study investigated the effects of combinations of four anesthetic agents on IOP during laparoscopic gynecological surgery.

METHODS

Patients (n=100) were assigned to one of the four groups: Group 1 (n=25; pentothal induction + desflurane/remifen-tanil maintenance), Group 2 (n=25; propofol induction + sevoflurane/remifentanil maintenance), Group 3 (n=25; propofol induction + desflurane/remifentanil maintenance), and Group 4 (n=25; pentothal induction + sevoflurane/remifentanil maintenance). The IOPs recorded before anesthesia induction, after intubation, after carbon dioxide insufflation, in the Trendelenburg position, and after ex-tubation were compared among the groups. Hemodynamic parameters were also evaluated.

RESULTS

Induction in Group 2 and Group 3 used propofol. When the IOP in the Trendelenburg position was compared with the IOP before induction, there was no statistically significant difference in Groups 2 and 3 (p>0.05). In Groups 1 and 4, pentothal was used for induction. The IOP in Groups 1 and 4 was statistically significantly higher in the Trendelenburg position than it was before induction (0.027-0.001).

CONCLUSION

To minimize the variation in IOP in the Trendelenburg position during laparoscopic gynecological surgeries, we recommend the use of propofol for induction, independent of desflurane or sevoflurane use.

Comparison of the Effect of Anesthetic Agents on Blood Levels of Parathyroid Hormone and Ionized Calcium: A Prospective Randomized Controlled Trial

The aim of this randomized control trial is to compare the effect of anesthetic agents on blood levels of parathyroid hormone and ionized calcium. 77 American Society of Anesthesiologists I-II patients who would undergo laparoscopic cholecystectomy were enrolled into this prospective study and randomized into 3 groups with sealed envelope technique as Group S: sevoflurane, Group D: desflurane, and Group TIVA: total intravenous anesthesia. The first blood sample was used to check the baseline blood levels of parathyroid hormone and ionized calcium. In Group S or D, maintenance of anesthesia was being performed with 1 MAC (minimum alveolar concentration) sevoflurane or desflurane, respectively, while in Group TIVA, it was performed with 150 mcg/kg/min propofol and 1 mcg/kg/min remifentanil IV infusions. At the 30^th minute of anesthesia and at the 1^st hour of end of anesthesia, 2^nd and 3^rd blood samples, respectively, were used to check the blood levels of PTH and Ca. During perioperative period, hemodynamic parameters were also noted. Blood levels of parathyroid hormone at the 30^th min after anesthesia were found to be significantly different between groups (P=0,01). The PTH level at the 30^th min after anesthesia was found significantly higher in Group S than that of Groups D and TIVA (P=0.005 and P=0.001, respectively). Blood levels of ionized calcium at 30^th min after anesthesia were found significantly different between groups (P=0,048). It was found significantly higher in Group TIVA than that in Group S (P=0.024). Desflurane seems to be the best agent for parathyroidectomy procedures. Future research studies are needed to be conducted to reach out more correct and valuable outcomes.

The effect of cerium oxide on lung injury following lower extremity ischemia-reperfusion injury in rats under desflurane anesthesia

OBJECTIVES

To examine the effects of desflurane and cerium oxide (CO) on lung tissue following ischemia-reperfusion injury (IRI).

METHODS

Experiments were conducted in Gazi University Animal Laboratory, Ankara, Turkey. Thirty rats were divided into 5 groups: control (C), IRI, IRI-CO, IRI-desflurane (IRID), IRI-CO-desflurane (IRICOD). Cerium oxide was given intraperitoneally. Lower extremity IRI was induced. Desflurane was applied during IRI. Lung histopathological examinations and serum biochemical analyses were performed.

RESULTS

Serum nitric oxide (NO) and malondialdehyde (MDA) levels were higher in group IRI (p=0.006) than in group C (p=0.001). Serum MDA and NO levels were significantly lower in groups IRICO and IRICOD than in group IRI. Significantly greater alveolar wall thickening and neutrophil infiltration were recorded in group IRI than in group C. Co-administration of desflurane and CO significantly decreased alveolar wall thickening and neutrophil infiltration compared to group IRI. Total lung injury scores were significantly lower in groups IRID, IRICO, and IRICOD than in group IRI.

CONCLUSION

Intraperitoneal CO with desflurane, reduced oxidative stress and corrected the damage in lung. Cerium oxide given before and desflurane given during IRI have been shown to have protective effects on lung damage in rats.

Study protocol for a randomised controlled clinical trial comparing desflurane-based versus propofol-based anaesthesia on postanaesthesia respiratory depression in patients with obstructive sleep apnoea after major abdominal surgery

INTRODUCTION

Patients with obstructive sleep apnoea (OSA) are more sensitive to postanaesthesia respiratory depression. Whether different anaesthetic regimens (intravenous-based or inhalational-based general anaesthesia) affect the postanaesthesia respiratory depression is controversial. Although desflurane has been reported that presents favourable rapid recovery profile in special patients including whom with OSA, the strong clinical evidence of the benefit on postanaesthesia respiratory depression is far from being revealed. This study aims to fill this knowledge gap by investigating the postanaesthesia respiratory depression in postanaesthesia care unit (PACU) in patients with OSA after major abdominal surgery, followed by desflurane-based anaesthesia compared with propofol-based anaesthesia.

METHODS AND ANALYSIS

Eight hundred and fifty-four patients with OSA scheduled for elective major abdominal surgery will be randomly 1:1 assigned to desflurane-based (n=427) or propofol-based anaesthesia (n=427) using a computer-generated randomisation scheme with permuted block size maintained by a centralised randomisation centre. Patients will be assessed before and a consecutive 3 days after their surgery according to the standardised tasks. Demographic data as well as surgical and anaesthesia information will be collected for the duration of the procedure. Incidence of postanaesthesia respiratory depression in PACU as well as anaesthesia recovery, emergence delirium, postoperative nausea and vomiting, rescue analgesia, duration of PACU and hospital stay, and any other adverse events will be assessed at the given study time point. Investigators performing postoperative follow-up are not involved in both anaesthesia implementation and postoperative care.

ETHICS AND DISSEMINATION

This study protocol has been approved by the ethics board at Xiang'an Hospital of Xiamen University (XAHLL2019003). The results of this study will be published in a peer-review journal and presented at national conferences as poster or oral presentations. Participants wishing to know the results of this study will be contacted directly on data publication.

TRIAL REGISTRATION NUMBER

ChiCTR2000031087.

Oxidative and pro-inflammatory lung injury induced by desflurane inhalation in rats and the protective effect of rutin

BACKGROUND

Desflurane is a mainstay of general inhaled anesthetics with a methyl ethyl ether structure and is widely used in clinical practice. It has been reported to induce inflammation and lipid peroxidation in rat pulmonary parenchyma, to increase alveolar macrophages, and to cause peribronchial infiltration and edema. Rutin, a flavonoid vitamin P1, is known to have biological properties including acting as an antioxidant, an anti-inflammatory, and an inhibitor of bronchoalveolar polymorphonuclear leukocyte (PNL) infiltration.

OBJECTIVES

The aim of this study is to examine the effects of rutin on desflurane-induced pulmonary injury using biochemical and histopathological methods.

MATERIAL AND METHODS

The rats were divided into 3 groups (n = 6 each): healthy control (HC), rutin+desflurane-treated (DRT) and desflurane-only (DSF). Briefly, 50 mg/kg of rutin was given orally to the DRT group and an equal volume of normal saline was given to the DSF and HC groups. After 1 h, anesthesia was induced and maintained in the DRT and DSF groups for 2 h. After the rats had been sacrificed, the lungs were removed. Malondialdehyde (MDA), total glutathione (GSH), tumor necrosis factor alpha (TNF-α), and nuclear factor kappa B (NF-κB) levels were measured in the excised lung tissue. The removed tissues were also fixed in 10% formalin, and the obtained sections were stained with hematoxylin and eosin (H&E) and evaluated under light microscopy. The biochemical and histopathological results of the DRT group were compared with those obtained from the DSF and HC groups.

RESULTS

Desflurane increased MDA, TNF-α and NF-κB, and decreased GSH in lung tissue. The PNL infiltration, alveolar macrophages, hemorrhage, alveolar damage, and edema were observed in the lung tissue of the DSF group. Rutin was histopathologically shown to protect lung tissue from oxidative stress by preventing an increase in oxidant parameters and a decrease in antioxidants.

CONCLUSIONS

The results suggest that rutin may be useful in the treatment of desflurane-associated lung injury.

Comparison of minimal-flow sevoflurane versus desflurane anesthesia: randomized clinical trial

BACKGROUND AND OBJECTIVES

Minimal-flow anesthesia provides various advantages, such as reduced environmental pollution, proper humidification and warming of anesthetic gases, and reduced costs. The aim of this study was to compare the cost-effectiveness of minimal-flow sevoflurane and desflurane anesthesia and their effects on hemodynamics, postoperative recovery, respiratory parameters, and liver and kidney functions.

METHODS

A total of 60 ASA I-II patients aged 18-70 years who underwent posterior spinal instrumentation were included in the study. The patients were divided into Group S (sevoflurane) and Group D (desflurane). After anesthesia induction, the gas flow was initiated at a rate of 4 L.min^-1 using a concentration of 8% in Group D and 3.5% in Group S, and the time to reach 0.8 MAC was recorded. The gas flow was then switched to minimal flow. Patient hemodynamic and respiratory parameters, body temperatures and arterial blood gas levels were recorded. The integrated pulmonary index (IPI) was monitored postoperatively. Biochemical findings were recorded 12 hours after the operation. The amount of bleeding and blood transfused, and the costs involved were calculated.

RESULTS

The patients' demographic characteristics, duration of surgery, hemodynamic parameters, IPI values, body temperatures, and arterial blood gas levels were similar at all time points. Biochemical findings, amount of bleeding and amount of blood transfused were similar between the two groups. The mean cost was lower in Group S than in Group D (p = 0.007).

CONCLUSION

The study found no significant difference in terms of reliability between minimal-flow sevoflurane and desflurane anesthesia. Furthermore, the procedure was found to be more cost-effective for Group S than for Group D.

Comparison of isoflurane, sevoflurane, and desflurane as inhalant anesthetics in prairie rattlesnakes (Crotalus viridis)

OBJECTIVE

To characterize induction and recovery characteristics of 3 commonly used inhalant anesthetics in prairie rattlesnakes (Crotalus viridis): isoflurane, sevoflurane, and desflurane.

ANIMALS

12 healthy adult prairie rattlesnakes.

PROCEDURES

In a randomized crossover design, snakes underwent anesthetic induction with 5% isoflurane, 8% sevoflurane, or 18% desflurane, with a washout period of ≥ 7 days between anesthetic events. Anesthetic depth parameters were recorded throughout induction and recovery, including time to loss and return of righting reflex, muscle tone, ability to intubate, response to pressure, and time to return to spontaneous respiration. Every 5 minutes throughout the anesthetic procedures, heart rate, respiratory rate, and percentage expired anesthetic gas were recorded.

RESULTS

No snakes died during the study. Sevoflurane anesthesia resulted in anesthetic gas avoidance behavior in snakes during induction and had the significantly longest recovery time to extubation and time to return of pressure response, compared with the other inhalant anesthetics. Anesthesia with isoflurane resulted in a significantly longer time to return of righting reflex, compared with sevoflurane or desflurane. No significant difference was noted in time to loss of pressure response among the 3 anesthetic gases. Desflurane anesthesia resulted in the significantly quickest loss of righting reflex among the anesthetic protocols; despite this, 4 of 12 desflurane anesthetized snakes did not achieve an anesthetic plane deep enough for intubation.

CONCLUSIONS AND CLINICAL RELEVANCE

Isoflurane and sevoflurane, but not desflurane, inhalation anesthesia resulted in consistent and predictable loss of righting reflex and induction of anesthesia deep enough to allow intubation in snakes.

The effect of desflurane on retinal angiogenesis in a mouse model of oxygen-induced retinopathy

PURPOSE

Retinopathy of prematurity (ROP) is an ocular disorder that primarily occurs in premature infants and is the most common cause of vision impairment. This study examined the effect of desflurane on angiogenesis in a mouse model of oxygen-induced retinopathy (OIR).

METHODS

Mice were randomly allocated to the control (C), ROP control (R_c), or ROP with desflurane exposure (R_d) group. To induce ROP, 7-day-old mice were exposed to 75% oxygen in a chamber for 5 days [postnatal days (P) 7-12], and thereafter returned to room air. Age-matched mice exposed to room air formed the C group. The R_d group was exposed to 8% desflurane for 2 h on P12, P13, and P14 with 40% oxygen. To observe changes in angiogenesis of the retina, mice were sacrificed at P16.

RESULTS

The ratio of avascular area/total retinal area was not changed significantly in the R_d group, compared to the R_c group. The expression of endothelial growth factor A (VEGF-A) and hypoxia inducible factor-1α (HIF-1α) in the R_d group and R_c group was not significantly different.

CONCLUSIONS

Desflurane does not have a significant influence on retinal angiogenesis via HIF-1α and VEGF-A expression in the OIR mouse model. However, these findings are not directly applicable to premature infants, and it is thus necessary to perform further studies to determine the effect of desflurane on angiogenesis.

Development of a prototype anti-pollution filter for volatile anesthetics

INTRODUCTION

The use of volatile agents during cardiopulmonary bypass allows a "single drug anesthesia" and is associated with reduced peak postoperative troponin levels. Connecting the exhaust systems to the oxygenator's gas outlet port is mandatory and allows to prevent operating room (but not atmospheric) pollution by volatile agents. The aim of this study was to create a prototype filter for volatile agents and to test its adsorption efficacy during an ex-vivo simulated conventional cardiopulmonary bypass test.

METHODS

We carried out bench tests to conceive a prototype filter that could prevent room and environment pollution without damaging membrane oxygenators. We performed the tests at the Engineering Center for Circulatory Assistance Laboratory, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil. Bench tests included simulation of integral adsorption tests, filter dimensions and design, flow versus pressure curve, sizing, and tightness.

RESULTS

Calgon AT 410 was the best kind of activated charcoal granules for adsorption of sevoflurane, isoflurane, and desflurane. Filter dimension tests showed that a chamber of 30-cm width over 10-cm diameter filled with 200 g of the Calgon AT410 granules was the minimum required to fully adsorb sevoflurane for 90 min. Adsorption tests showed that the prototype filter fully adsorbed isoflurane in 100 ± 2.3 min, sevoflurane in 95 ± 3.4 min, and desflurane in 95 ± 4.3 min.

CONCLUSION

The new version of our prototype filter adsorbed most of the volatile anesthetics agents during an ex-vivo simulated conventional cardiopulmonary bypass test.