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The effects of sevoflurane and desflurane on the hemodynamics and respiratory functions in laparoscopic sleeve gastrectomy
Journal of Clinical Anesthesia (2016) 35, 441–445
Original Contribution
The effects of sevoflurane and desflurane on the hemodynamics and respiratory functions in laparoscopic sleeve gastrectomy Hatice Kaya Ozdogan MD a,⁎, Suleyman Cetinkunar MD b , Faruk Karateke MD b , Sibel Cetinalp MD a , Muge Celik MD a , Sefa Ozyazici MD b a
Department of Anesthesiology and Reanimation, Adana Numune Training and Research Hospital, Adana, Turkey Department of General Surgery, Adana Numune Training and Research Hospital, Adana, Turkey
b
Received 20 December 2015; accepted 14 August 2016
Keywords: Anesthesia; Desflurane; Morbid obesity; Sevoflurane
Abstract Study objectives: Sleeve gastrectomy has been one of the most commonly performed bariatric surgery methods. The study aimed to compare the effects of 2 most commonly used inhalation anesthetics, sevoflurane and desflurane, on the peroperative hemodynamic alterations and postoperative respiratory functions in morbidly obese patients undergoing sleeve gastrectomy. Design: Nonrandomized cohort. Settings: Operating room, postoperative period. Patients: Eighty-four morbidly obese patients with a body mass index greater than 40 kg/m2 who had scheduled to undergo sleeve gastrectomy operation were prospectively included in the study. Interventions: Patients were divided into 2 groups. The maintenance of inhalation anesthesia was performed by sevoflurane in 1 group (sevoflurane group) and desflurane (desflurane group) in the other group. Measurements: Demographic features, peroperative hemodynamic alterations, and the results of preoperative and postoperative 24th hour respiratory function tests were recorded. Results: There was not any statistically significant difference between groups regarding age, sex, body mass index, anesthesia time, peroperative mean arterial pressure, arterial oxygen saturation, end-tidal carbon dioxide, and preoperative or postoperative forced expiratory volume 1/forced vital capacity ratios. Conclusion: We determined that both desflurane and sevoflurane provide similar intraoperative hemodynamic and early postoperative respiratory functions in morbidly obese patients in laparoscopic sleeve gastrectomy. Both agents can be regarded as alternatives for inhalation anesthetics in maintenance of anesthesia. © 2016 Published by Elsevier Inc.
1. Introduction Laparoscopic sleeve gastrectomy is one of the most commonly performed bariatric surgical techniques. Pneumoperitoneum ⁎ Corresponding author at: Esentepe mah. 85510 sok. 11/6 Cukurova, Adana, Turkey. Tel.: +90 532 6262266. E-mail address: [email protected] (H.K. Ozdogan). http://dx.doi.org/10.1016/j.jclinane.2016.08.028 0952-8180/© 2016 Published by Elsevier Inc.
during laparoscopic surgeries pushes the diaphragm upward, reduces thoracopulmonay compliance, decreases venous return and cardiac output, and increases vascular resistance; and in that aspect, it is the main reason of adverse pulmonary effects and hemodynamic disturbances in those patients [1,2]. It is clearly known that obesity markedly affects the cardiovascular and respiratory systems, and this also affects the operative and recovery times of the patients. Morbid obesity
442 deranges respiratory functions and may increase the risk for airway complications, sleep apnea, and hypoxia during the postoperative period [3]. Increased body mass index (BMI) was defined as an independent risk factor for postoperative pulmonary complications [4,5]. In general, short-acting anesthetic drugs are thought to be more reliable for a fast recovery in morbidly obese patients. However, physiological and pharmacological alterations associated with fat tissue in obese individuals might cause important changes in the distribution and elimination of drugs, leading to variations in pharmacokinetic effects [6]. In morbidly obese patients, because water content and blood flow per gram of fat tissue are reduced, the kinetic behavior of many drugs changes, and prediction of their effects becomes difficult. Moreover, as total body weight and duration of anesthesia increase, the patients become more prone to adverse effects [7,8]. Sevoflurane and desflurane are 2 inhalation anesthetic agents that are used in the maintenance of general anesthesia, with a low blood-gas solubility coefficient, 0.69 and 0.42, respectively, and low oil-gas partition coefficient that provide more rapid modification of the anesthetic distribution and emergence than traditional inhalation anesthetics [9,10]. The data about the intraoperative hypnotic and hemodynamic effects of these short-acting drugs in morbidly obese patients, as well as their effects on respiratory function tests, are limited. We aimed to compare the 2 most commonly used inhalation anesthetics, sevoflurane and desflurane, regarding peroperative hemodynamic alterations and postoperative respiratory function tests in morbidly obese patients who had undergone sleeve gastrectomy.
2. Materials and methods Eighty-four morbidly obese patients with a BMI of greater than 40 kg/m2 undergoing sleeve gastrectomy operation in our center between March 2013 and May 2014 were prospectively included in the study. All patients were operated on by the same surgical team and by the standard antrum-preserving sleeve gastrectomy technique. Patients were nonrandomly allocated into 2 groups. Sevoflurane was used in 1 group (sevoflurane group), and desflurane (desflurane group) was the drug of choice in the other group for the maintenance of inhalation anesthesia. All patients had American Society of Anesthesiologists (ASA) grades II or III. Patients younger than 18 years; those with significant cardiopulmonary disease, or hepatic or renal dysfunctions; and chronic alcohol or narcotic drug users were excluded from the study. In preoperative period, all patients underwent a detailed history and systemic examination compromising airway examination along with routine blood tests including complete blood count; blood glucose; serum electrolytes; coagulation indices; thyroid, liver, kidney, and pulmonary function tests; and electrocardiography. All patients were premedicated by midazolam. Preoperative proton pomp inhibitors and low– molecular-weight heparin were routinely administered.
H.K. Ozdogan et al. In the operation room, 2 18G intravenous cannulas were inserted in the forearm; standard monitoring devices, including electrocardiography, heart rate (lead II), and pulse oximeter, were applied. A radial artery catheter was inserted for invasive arterial pressure monitoring. After preoxygenation for 3 minutes, anesthesia was induced with propofol 2-2.5 mg/kg intravenously. After intubation, 0.1 mg/kg vecuronium was administered, and remifentanil infusion (0.05 μg/kg per minute) was started. In the maintenance of anesthesia, oxygennitrous oxide along with sevoflurane or desflurane was used as per the group of allocation. The patients were ventilated with tidal volume and respiratory rate, which were set to maintain end-tidal carbon dioxide (ETCO2) of 30-40 mm Hg, and arterial blood gases within normal limits, using a closed circuit breathing system. Continuous monitoring of oxygen saturation (SaO2), noninvasive and invasive blood pressure, ETCO2, and electrocardiogram measurements was performed. Mean arterial blood pressure was recorded before and at induction of anesthesia, immediately after tracheal intubation, and at predetermined intervals (5, 15, and 30 minutes and at the end of the operation). Arterial blood gases and blood glucose samples were drawn as indicated. Respiratory function tests of all patients were performed before the operation and on 24th hour after operation to determine forced expiratory volume 1 (FEV1), forced vital capacity (FVC), and FEV1/FVC. Demographic features, peroperative hemodynamic alterations, and the results of preoperative and postoperative 24th hour respiratory function tests were recorded. The study was approved by the hospital's ethics committee (ANEAH.EK.2014/44, 14.08.2014), and written informed consent was obtained from all patients. Statistical analysis was performed using SPSS package (version 21, SPSS Inc., Chicago, IL) software for Windows. Data are reported as mean ± SEM. Student t test was applied to compare the hemodynamic variables and early recovery characteristics. P value b.05 was considered as statistically significant.
3. Results Demographic features including age, body mass index, as well as the duration of anesthesia, and length of hospital stay are summarized in Table 1. Among study participants, 18 (9 in sevoflurane group and 9 in desflurane group) were males, and the remaining 64 (32 in sevoflurane group and 32 in desflurane group) were female. There was not any difference between groups regarding sex. There was not any statistically significant difference between groups regarding age, BMI, and preoperative or postoperative FEV1/FVC values (Table 1). In sevoflurane group, 35 were ASA II and 7 were ASA III. On the other hand, in desflurane group, 38 were ASA II and 4 were ASA III. There was not any statistically significant difference between groups regarding ASA class (P: .27). Moreover,
Sleeve gastrectomy anesthesia Table 1
443
Demographic features of study participants. Sevoflurane group (n:42)
Age (y) ASA Anesthesia time (min) BMI (kg/m2) FEV1 preoperative FVC preoperative FEV1/FVC preoperative FEV1 postoperative FVC postoperative FEV1/FVC postoperative LOS (d)
Desflurane group (n:42)
P
mean ± SEM
Range
mean ± SEM
Range
35.03 2.35 130.0 47.23 2.92 3.29 89.14 3.05 3.40 90.84 4.87
19-51 II-III 60-235 38.86-59.78 1.71-4.83 2.00-5.30 72-100 1.60-4.85 1.69-5.50 70-100 3-8
35.74 2.32 131.0 45.81 3.03 3.47 87.08 3.09 3.49 89.08 5.63
19-52 II-III 60-330 37.82-58.64 1.54-4.83 1.59-5.43 56-100 1.56-4.90 1.72-5.52 70-100 3-17
± ± ± ± ± ± ± ± ± ± ±
1.27 0.65 6.88 0.92 0.10 0.11 1.14 0.10 0.13 1.08 0.19
± ± ± ± ± ± ± ± ± ± ±
1.42 0.38 9.29 0.80 0.11 0.13 1.48 0.14 0.15 1.17 0.29
.84 .27 .92 .092 .49 .31 .27 .80 .66 .27 .09
Abbreviations: ASA, American Society of Anesthesiologists class; BMI, body mass index; FEV1, forced expiratory volume 1; FVC, forced vital capacity; LOS, length of stay.
there was not any statistically significant difference between groups regarding preoperative and postoperative respiratory function tests, and in addition, there was not any decrease in postoperative FEV1/FVC values in both groups compared with the preoperative values. Alterations in FEV1/FVC in preoperative and postoperative periods between groups are shown in Figs. 1 and 2. In comparison of desflurane and sevoflurane groups regarding peroperative hemodynamic alterations, there was not any statistically significant difference between groups in peroperative mean arterial pressure, arterial SaO2, and ETCO2 (Table 2). Among early complications, bleeding was reported in 2 cases, conversion to open surgery was reported in 1 case, and narrowing twisted sleeve in 1 case in desflurane group;
Fig. 1
whereas, postoperative bleeding was reported in 1 case, and stapler-associated complications were reported in 1 case in sevoflurane group. There was not any statistically significant difference between groups regarding the prevalence of complications (P: .40).
4. Discussion In this prospective nonrandomized study, we have determined that sevoflurane and desflurane provided similar intraoperative outcomes during the maintenance period. Intraoperative hemodynamic stability was compared in both
Forced expiratory volume 1/forced vital capacity in preoperative period.
444
H.K. Ozdogan et al.
Fig. 2
Forced expiratory volume 1/forced vital capacity in postoperative period.
groups, and there was not any statistically significant difference between groups regarding mean arterial pressure, arterial SaO2, and ETCO2. The present study demonstrates that, because mean arterial blood pressure was maintained within 20% of baseline values during the course of anesthesia, both sevoflurane and desflurane arrange for comparable hemodynamic stability in morbidly obese patients. Moreover, respiratory functions are preserved, and there was not any statistically significant difference between 2 groups regarding FEV1/FVC.
Table 2 Comparison of peroperative cardiovascular and respiratory values between groups.
MAP basal MAP ind MAP ins5 MAP ins15 MAP ins30 MAP end SaO2 basal SaO2 ins SaO2 end ETCO2 basal ETCO2 ins ETCO2 end
Sevoflurane group (n:42)
Desflurane group (n:42)
mean ± SEM
mean ± SEM
95.40 86.74 90.26 90.99 93.08 97.93 96.28 98.15 96.60 31.05 35.73 32.30
97.27 87.79 91.58 92.62 94.47 99.75 96.24 98.39 96.63 31.34 35.71 31.92
± ± ± ± ± ± ± ± ± ± ± ±
1.19 1.34 1.26 1.04 0.84 0.76 0.18 0.15 0.18 0.36 0.34 0.28
± ± ± ± ± ± ± ± ± ± ± ±
1.48 1.48 1.43 1.17 1.14 1.08 0.20 0.22 0.22 0.27 0.36 0.30
P
.33 .59 .49 .30 .33 .17 .89 .36 .91 .53 .98 .36
Abbreviations: ETCO2, end-tidal carbon dioxide concentration; Ind, induction; Ins, postinsufflation time interval in minutes; MAP, mean arterial pressure; SaO2, oxygen saturation.
Recently, there have been some studies comparing the hemodynamic effects and recovery courses of sevoflurane and desflurane among morbidly obese patients. De Baerdemaeker et al. [11] studied on 50 morbidly obese patients undergoing laparoscopic gastroplasty to determine the depth of anesthesia, hemodynamic stability, and recovery time under sevoflurane or desflurane administration with inhalation boluses and reported that immediate recovery was significantly faster and overall hemodynamic controllability was better with fewer episodes of hypotension in the desflurane group. In another study, the recovery profiles in morbidly obese patients who received sevoflurane or desflurane for maintenance of anesthesia in combination with a remifentanil in laparoscopic gastric banding were compared, and the authors reported that there was not any clinically relevant difference in recovery in the postanesthesia care unit between morbidly obese patients anesthetized with desflurane or sevoflurane and that both agents resulted in satisfactory recovery [12]. In a prospective, randomized study on morbidly obese patients undergoing laparoscopic gastroplasty, it was reported that there was not any statistically significant difference between sevoflurane and desflurane groups regarding total surgical operative time, times from turning inhalation agent off to eye opening and extubation, or average length of stay in postanesthesia care unit with similar recovery characteristics [13]. Similarly, it was reported in another study that there were no differences in emergence and recovery profiles in morbidly obese patients receiving desflurane or sevoflurane, when anesthetic concentration was carefully titrated [14]. La Colla et al. [15] compared desflurane vs sevoflurane kinetics and dynamics in morbidly obese patients and their recovery profile on 28 unpremedicated patients and reported that desflurane provides
Sleeve gastrectomy anesthesia faster wash-in and wash-out than sevoflurane in morbidly obese patients, with a faster recovery. Similarly, a faster kinetic profile of desflurane and its faster wash-out from the body were found, even though midazolam was administered as premedication [16]. Although we did not compare the recovery periods, there were not any alterations between desflurane and sevoflurane regarding anesthesia time, hospital stay, and hemodynamic alterations during operation in our study. Obesity was defined as an independent risk factor for postoperative pulmonary complications [5]. On the other hand, volatile anesthetics are known to be potent bronchodilators. By both inhibition of reflex neural pathways and direct effects on airway smooth muscle cells, volatile anesthetics induce bronchodilatation [17,18]. In an animal study, it was reported that desflurane, but not sevoflurane, increased total lung resistance concomitant with a decrease in dynamic lung compliance in guinea pigs, which may be associated with antidromic tachykinin release [19]. However, in this study, we did not determine any difference in postoperative respiratory function tests between sevoflurane and desflurane groups. Because there were not any alterations compared with preoperative values, both agents were found to be reliable regarding respiratory complications. There are some limitations of this study that should be mentioned. We have evaluated the respiratory and hemodynamic effects of desflurane and sevoflurane on morbidly obese patients, but we did not compare their kinetics or level of hypnosis during operation. In addition, lack of recovery evaluation is another limitation because all these parameters might enrich the study. Absence of randomization is an additional drawback. In conclusion, we determined that both desflurane and sevoflurane provide similar intraoperative hemodynamic and early postoperative respiratory functions in morbidly obese patients in laparoscopic sleeve gastrectomy. Both agents can be regarded as alternatives for inhalation anesthetics in maintenance of anesthesia.
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following use of sevoflurane and isoflurane. Anesth Essays Res 2014;8: 150-5. Koenig SM. Pulmonary complications of obesity. Am J Med Sci 2001; 321:249-79. Brooks-Brunn JA. Predictors of postoperative pulmonary complications following abdominal surgery. Chest 1997;111:564-71. Ahmad S, Nagle A, McCarthy RJ, Fitzgerald PC, Sullivan JT, Prystowsky J. Postoperative hypoxemia in morbidly obese patients with and without obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesth Analg 2008;107:138-43. Adams JP, Murphy PG. Obesity in anaesthesia and intensive care. Br J Anaesth 2000;85:91-108. Cheymol G. Effects of obesity on pharmacokinetic implications for drug therapy. Clin Pharmacokinet 2000;39:215-31. Virtanen KA, Lönnroth P, Parkkola R, Peltoniemi P, Asola M, Viljanen T, et al. Glucose uptake and perfusion in subcutaneous and visceral adipose tissue during insulin stimulation in nonobese and obese humans. J Clin Endocrinol Metab 2002;87:3902-10. Dupont J, Tavernier B, Ghosez Y, Durinck L, Thevenot A, MoktadirChalons N, et al. Recovery after anaesthesia for pulmonary surgery: desflurane, sevoflurane and isoflurane. Br J Anaesth 1999;82:355-9. Juvin P, Vadam C, Malek L, Dupont H, Marmuse JP, Desmonts JM. Postoperative recovery after desflurane, propofol, or isoflurane anaesthesia among morbidly obese patients: a prospective randomized study. Anesth Analg 2000;91:714-9. De Baerdemaeker LE, Struys MM, Jacobs S, Den Blauwen NM, Bossuyt GR, Pattyn P, et al. Optimization of desflurane administration in morbidly obese patients: a comparison with sevoflurane using an ‘inhalation bolus’ technique. Br J Anaesth 2003;91:638-50. De Baerdemaeker LE, Jacobs S, Den Blauwen NM, Pattyn P, Herregods LL, Mortier EP. Postoperative results after desflurane or sevoflurane combined with remifentanil in morbidly obese patients. Obes Surg 2006;16:728-33. Vallejo MC, Sah N, Phelps AL, O'Donnell J, Romeo RC. Desflurane versus sevoflurane for laparoscopic gastroplasty in morbidly obese patients. J Clin Anesth 2007;19:3-8. Arain SR, Barth CD, Shankar H, Ebert TJ. Choice of volatile anesthetic for the morbidly obese patient: sevoflurane or desflurane. J Clin Anesth 2005;17:413-9. La Colla L, Albertin A, La Colla G, Mangano A. Faster wash-out and recovery for desflurane vs sevoflurane in morbidly obese patients when no premedication is used. Br J Anaesth 2007;99:353-8. Strum EM, Szenohradszki J, Kaufman WA, Anthone GJ, Manz IL, Lumb PD. Emergence and recovery characteristics of desflurane versus sevoflurane in morbidly obese adult surgical patients: a prospective, randomized study. Anesth Analg 2004;99:1848-53. Rooke GA, Choi JH, Bishop MJ. The effect of isoflurane, halothane, sevoflurane, and thiopental/nitrous oxide on respiratory system resistance after tracheal intubation. Anesthesiology 1997;86:1294-9. Volta CA, Alvisi V, Petrini S, Zardi S, Marangoni E, Ragazzi R, et al. The effect of volatile anesthetics on respiratory system resistance in patients with chronic obstructive pulmonary disease. Anesth Analg 2005;100:348-53. Satoh JI, Yamakage M, Kobayashi T, Tohse N, Watanabe H, Namiki A. Desflurane but not sevoflurane can increase lung resistance via tachykinin pathways. Br J Anaesth 2009;102:704-13.
Original Contribution
The effects of sevoflurane and desflurane on the hemodynamics and respiratory functions in laparoscopic sleeve gastrectomy Hatice Kaya Ozdogan MD a,⁎, Suleyman Cetinkunar MD b , Faruk Karateke MD b , Sibel Cetinalp MD a , Muge Celik MD a , Sefa Ozyazici MD b a
Department of Anesthesiology and Reanimation, Adana Numune Training and Research Hospital, Adana, Turkey Department of General Surgery, Adana Numune Training and Research Hospital, Adana, Turkey
b
Received 20 December 2015; accepted 14 August 2016
Keywords: Anesthesia; Desflurane; Morbid obesity; Sevoflurane
Abstract Study objectives: Sleeve gastrectomy has been one of the most commonly performed bariatric surgery methods. The study aimed to compare the effects of 2 most commonly used inhalation anesthetics, sevoflurane and desflurane, on the peroperative hemodynamic alterations and postoperative respiratory functions in morbidly obese patients undergoing sleeve gastrectomy. Design: Nonrandomized cohort. Settings: Operating room, postoperative period. Patients: Eighty-four morbidly obese patients with a body mass index greater than 40 kg/m2 who had scheduled to undergo sleeve gastrectomy operation were prospectively included in the study. Interventions: Patients were divided into 2 groups. The maintenance of inhalation anesthesia was performed by sevoflurane in 1 group (sevoflurane group) and desflurane (desflurane group) in the other group. Measurements: Demographic features, peroperative hemodynamic alterations, and the results of preoperative and postoperative 24th hour respiratory function tests were recorded. Results: There was not any statistically significant difference between groups regarding age, sex, body mass index, anesthesia time, peroperative mean arterial pressure, arterial oxygen saturation, end-tidal carbon dioxide, and preoperative or postoperative forced expiratory volume 1/forced vital capacity ratios. Conclusion: We determined that both desflurane and sevoflurane provide similar intraoperative hemodynamic and early postoperative respiratory functions in morbidly obese patients in laparoscopic sleeve gastrectomy. Both agents can be regarded as alternatives for inhalation anesthetics in maintenance of anesthesia. © 2016 Published by Elsevier Inc.
1. Introduction Laparoscopic sleeve gastrectomy is one of the most commonly performed bariatric surgical techniques. Pneumoperitoneum ⁎ Corresponding author at: Esentepe mah. 85510 sok. 11/6 Cukurova, Adana, Turkey. Tel.: +90 532 6262266. E-mail address: [email protected] (H.K. Ozdogan). http://dx.doi.org/10.1016/j.jclinane.2016.08.028 0952-8180/© 2016 Published by Elsevier Inc.
during laparoscopic surgeries pushes the diaphragm upward, reduces thoracopulmonay compliance, decreases venous return and cardiac output, and increases vascular resistance; and in that aspect, it is the main reason of adverse pulmonary effects and hemodynamic disturbances in those patients [1,2]. It is clearly known that obesity markedly affects the cardiovascular and respiratory systems, and this also affects the operative and recovery times of the patients. Morbid obesity
442 deranges respiratory functions and may increase the risk for airway complications, sleep apnea, and hypoxia during the postoperative period [3]. Increased body mass index (BMI) was defined as an independent risk factor for postoperative pulmonary complications [4,5]. In general, short-acting anesthetic drugs are thought to be more reliable for a fast recovery in morbidly obese patients. However, physiological and pharmacological alterations associated with fat tissue in obese individuals might cause important changes in the distribution and elimination of drugs, leading to variations in pharmacokinetic effects [6]. In morbidly obese patients, because water content and blood flow per gram of fat tissue are reduced, the kinetic behavior of many drugs changes, and prediction of their effects becomes difficult. Moreover, as total body weight and duration of anesthesia increase, the patients become more prone to adverse effects [7,8]. Sevoflurane and desflurane are 2 inhalation anesthetic agents that are used in the maintenance of general anesthesia, with a low blood-gas solubility coefficient, 0.69 and 0.42, respectively, and low oil-gas partition coefficient that provide more rapid modification of the anesthetic distribution and emergence than traditional inhalation anesthetics [9,10]. The data about the intraoperative hypnotic and hemodynamic effects of these short-acting drugs in morbidly obese patients, as well as their effects on respiratory function tests, are limited. We aimed to compare the 2 most commonly used inhalation anesthetics, sevoflurane and desflurane, regarding peroperative hemodynamic alterations and postoperative respiratory function tests in morbidly obese patients who had undergone sleeve gastrectomy.
2. Materials and methods Eighty-four morbidly obese patients with a BMI of greater than 40 kg/m2 undergoing sleeve gastrectomy operation in our center between March 2013 and May 2014 were prospectively included in the study. All patients were operated on by the same surgical team and by the standard antrum-preserving sleeve gastrectomy technique. Patients were nonrandomly allocated into 2 groups. Sevoflurane was used in 1 group (sevoflurane group), and desflurane (desflurane group) was the drug of choice in the other group for the maintenance of inhalation anesthesia. All patients had American Society of Anesthesiologists (ASA) grades II or III. Patients younger than 18 years; those with significant cardiopulmonary disease, or hepatic or renal dysfunctions; and chronic alcohol or narcotic drug users were excluded from the study. In preoperative period, all patients underwent a detailed history and systemic examination compromising airway examination along with routine blood tests including complete blood count; blood glucose; serum electrolytes; coagulation indices; thyroid, liver, kidney, and pulmonary function tests; and electrocardiography. All patients were premedicated by midazolam. Preoperative proton pomp inhibitors and low– molecular-weight heparin were routinely administered.
H.K. Ozdogan et al. In the operation room, 2 18G intravenous cannulas were inserted in the forearm; standard monitoring devices, including electrocardiography, heart rate (lead II), and pulse oximeter, were applied. A radial artery catheter was inserted for invasive arterial pressure monitoring. After preoxygenation for 3 minutes, anesthesia was induced with propofol 2-2.5 mg/kg intravenously. After intubation, 0.1 mg/kg vecuronium was administered, and remifentanil infusion (0.05 μg/kg per minute) was started. In the maintenance of anesthesia, oxygennitrous oxide along with sevoflurane or desflurane was used as per the group of allocation. The patients were ventilated with tidal volume and respiratory rate, which were set to maintain end-tidal carbon dioxide (ETCO2) of 30-40 mm Hg, and arterial blood gases within normal limits, using a closed circuit breathing system. Continuous monitoring of oxygen saturation (SaO2), noninvasive and invasive blood pressure, ETCO2, and electrocardiogram measurements was performed. Mean arterial blood pressure was recorded before and at induction of anesthesia, immediately after tracheal intubation, and at predetermined intervals (5, 15, and 30 minutes and at the end of the operation). Arterial blood gases and blood glucose samples were drawn as indicated. Respiratory function tests of all patients were performed before the operation and on 24th hour after operation to determine forced expiratory volume 1 (FEV1), forced vital capacity (FVC), and FEV1/FVC. Demographic features, peroperative hemodynamic alterations, and the results of preoperative and postoperative 24th hour respiratory function tests were recorded. The study was approved by the hospital's ethics committee (ANEAH.EK.2014/44, 14.08.2014), and written informed consent was obtained from all patients. Statistical analysis was performed using SPSS package (version 21, SPSS Inc., Chicago, IL) software for Windows. Data are reported as mean ± SEM. Student t test was applied to compare the hemodynamic variables and early recovery characteristics. P value b.05 was considered as statistically significant.
3. Results Demographic features including age, body mass index, as well as the duration of anesthesia, and length of hospital stay are summarized in Table 1. Among study participants, 18 (9 in sevoflurane group and 9 in desflurane group) were males, and the remaining 64 (32 in sevoflurane group and 32 in desflurane group) were female. There was not any difference between groups regarding sex. There was not any statistically significant difference between groups regarding age, BMI, and preoperative or postoperative FEV1/FVC values (Table 1). In sevoflurane group, 35 were ASA II and 7 were ASA III. On the other hand, in desflurane group, 38 were ASA II and 4 were ASA III. There was not any statistically significant difference between groups regarding ASA class (P: .27). Moreover,
Sleeve gastrectomy anesthesia Table 1
443
Demographic features of study participants. Sevoflurane group (n:42)
Age (y) ASA Anesthesia time (min) BMI (kg/m2) FEV1 preoperative FVC preoperative FEV1/FVC preoperative FEV1 postoperative FVC postoperative FEV1/FVC postoperative LOS (d)
Desflurane group (n:42)
P
mean ± SEM
Range
mean ± SEM
Range
35.03 2.35 130.0 47.23 2.92 3.29 89.14 3.05 3.40 90.84 4.87
19-51 II-III 60-235 38.86-59.78 1.71-4.83 2.00-5.30 72-100 1.60-4.85 1.69-5.50 70-100 3-8
35.74 2.32 131.0 45.81 3.03 3.47 87.08 3.09 3.49 89.08 5.63
19-52 II-III 60-330 37.82-58.64 1.54-4.83 1.59-5.43 56-100 1.56-4.90 1.72-5.52 70-100 3-17
± ± ± ± ± ± ± ± ± ± ±
1.27 0.65 6.88 0.92 0.10 0.11 1.14 0.10 0.13 1.08 0.19
± ± ± ± ± ± ± ± ± ± ±
1.42 0.38 9.29 0.80 0.11 0.13 1.48 0.14 0.15 1.17 0.29
.84 .27 .92 .092 .49 .31 .27 .80 .66 .27 .09
Abbreviations: ASA, American Society of Anesthesiologists class; BMI, body mass index; FEV1, forced expiratory volume 1; FVC, forced vital capacity; LOS, length of stay.
there was not any statistically significant difference between groups regarding preoperative and postoperative respiratory function tests, and in addition, there was not any decrease in postoperative FEV1/FVC values in both groups compared with the preoperative values. Alterations in FEV1/FVC in preoperative and postoperative periods between groups are shown in Figs. 1 and 2. In comparison of desflurane and sevoflurane groups regarding peroperative hemodynamic alterations, there was not any statistically significant difference between groups in peroperative mean arterial pressure, arterial SaO2, and ETCO2 (Table 2). Among early complications, bleeding was reported in 2 cases, conversion to open surgery was reported in 1 case, and narrowing twisted sleeve in 1 case in desflurane group;
Fig. 1
whereas, postoperative bleeding was reported in 1 case, and stapler-associated complications were reported in 1 case in sevoflurane group. There was not any statistically significant difference between groups regarding the prevalence of complications (P: .40).
4. Discussion In this prospective nonrandomized study, we have determined that sevoflurane and desflurane provided similar intraoperative outcomes during the maintenance period. Intraoperative hemodynamic stability was compared in both
Forced expiratory volume 1/forced vital capacity in preoperative period.
444
H.K. Ozdogan et al.
Fig. 2
Forced expiratory volume 1/forced vital capacity in postoperative period.
groups, and there was not any statistically significant difference between groups regarding mean arterial pressure, arterial SaO2, and ETCO2. The present study demonstrates that, because mean arterial blood pressure was maintained within 20% of baseline values during the course of anesthesia, both sevoflurane and desflurane arrange for comparable hemodynamic stability in morbidly obese patients. Moreover, respiratory functions are preserved, and there was not any statistically significant difference between 2 groups regarding FEV1/FVC.
Table 2 Comparison of peroperative cardiovascular and respiratory values between groups.
MAP basal MAP ind MAP ins5 MAP ins15 MAP ins30 MAP end SaO2 basal SaO2 ins SaO2 end ETCO2 basal ETCO2 ins ETCO2 end
Sevoflurane group (n:42)
Desflurane group (n:42)
mean ± SEM
mean ± SEM
95.40 86.74 90.26 90.99 93.08 97.93 96.28 98.15 96.60 31.05 35.73 32.30
97.27 87.79 91.58 92.62 94.47 99.75 96.24 98.39 96.63 31.34 35.71 31.92
± ± ± ± ± ± ± ± ± ± ± ±
1.19 1.34 1.26 1.04 0.84 0.76 0.18 0.15 0.18 0.36 0.34 0.28
± ± ± ± ± ± ± ± ± ± ± ±
1.48 1.48 1.43 1.17 1.14 1.08 0.20 0.22 0.22 0.27 0.36 0.30
P
.33 .59 .49 .30 .33 .17 .89 .36 .91 .53 .98 .36
Abbreviations: ETCO2, end-tidal carbon dioxide concentration; Ind, induction; Ins, postinsufflation time interval in minutes; MAP, mean arterial pressure; SaO2, oxygen saturation.
Recently, there have been some studies comparing the hemodynamic effects and recovery courses of sevoflurane and desflurane among morbidly obese patients. De Baerdemaeker et al. [11] studied on 50 morbidly obese patients undergoing laparoscopic gastroplasty to determine the depth of anesthesia, hemodynamic stability, and recovery time under sevoflurane or desflurane administration with inhalation boluses and reported that immediate recovery was significantly faster and overall hemodynamic controllability was better with fewer episodes of hypotension in the desflurane group. In another study, the recovery profiles in morbidly obese patients who received sevoflurane or desflurane for maintenance of anesthesia in combination with a remifentanil in laparoscopic gastric banding were compared, and the authors reported that there was not any clinically relevant difference in recovery in the postanesthesia care unit between morbidly obese patients anesthetized with desflurane or sevoflurane and that both agents resulted in satisfactory recovery [12]. In a prospective, randomized study on morbidly obese patients undergoing laparoscopic gastroplasty, it was reported that there was not any statistically significant difference between sevoflurane and desflurane groups regarding total surgical operative time, times from turning inhalation agent off to eye opening and extubation, or average length of stay in postanesthesia care unit with similar recovery characteristics [13]. Similarly, it was reported in another study that there were no differences in emergence and recovery profiles in morbidly obese patients receiving desflurane or sevoflurane, when anesthetic concentration was carefully titrated [14]. La Colla et al. [15] compared desflurane vs sevoflurane kinetics and dynamics in morbidly obese patients and their recovery profile on 28 unpremedicated patients and reported that desflurane provides
Sleeve gastrectomy anesthesia faster wash-in and wash-out than sevoflurane in morbidly obese patients, with a faster recovery. Similarly, a faster kinetic profile of desflurane and its faster wash-out from the body were found, even though midazolam was administered as premedication [16]. Although we did not compare the recovery periods, there were not any alterations between desflurane and sevoflurane regarding anesthesia time, hospital stay, and hemodynamic alterations during operation in our study. Obesity was defined as an independent risk factor for postoperative pulmonary complications [5]. On the other hand, volatile anesthetics are known to be potent bronchodilators. By both inhibition of reflex neural pathways and direct effects on airway smooth muscle cells, volatile anesthetics induce bronchodilatation [17,18]. In an animal study, it was reported that desflurane, but not sevoflurane, increased total lung resistance concomitant with a decrease in dynamic lung compliance in guinea pigs, which may be associated with antidromic tachykinin release [19]. However, in this study, we did not determine any difference in postoperative respiratory function tests between sevoflurane and desflurane groups. Because there were not any alterations compared with preoperative values, both agents were found to be reliable regarding respiratory complications. There are some limitations of this study that should be mentioned. We have evaluated the respiratory and hemodynamic effects of desflurane and sevoflurane on morbidly obese patients, but we did not compare their kinetics or level of hypnosis during operation. In addition, lack of recovery evaluation is another limitation because all these parameters might enrich the study. Absence of randomization is an additional drawback. In conclusion, we determined that both desflurane and sevoflurane provide similar intraoperative hemodynamic and early postoperative respiratory functions in morbidly obese patients in laparoscopic sleeve gastrectomy. Both agents can be regarded as alternatives for inhalation anesthetics in maintenance of anesthesia.
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