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      Duration effect of desflurane anesthesia and its awakening time and arterial concentration in gynecologic patients

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          Abstract

          OBJECTIVES:

          To determine the awakening arterial blood concentration of desflurane and its relationship with the end-tidal concentration during emergence from various durations of general anesthesia.

          METHOD:

          In total, 42 American Society of Anesthesiologists physical status class I-II female patients undergoing elective gynecologic surgery were enrolled. General anesthesia was maintained with fixed 6% inspiratory desflurane in 6 l min -1 oxygen until shutoff of the vaporizer at the end of surgery. One milliliter of arterial blood was obtained for desflurane concentration determination by gas chromatography at 20 and 10 minutes before and 0, 5, 10, 15, and 20 minutes after the discontinuation of desflurane and at the time of eye opening upon verbal command, defined as awakening. Concentrations of inspiratory and end-tidal desflurane were simultaneously detected by an infrared analyzer.

          RESULTS:

          The mean arterial blood concentration of desflurane was 1.20% at awakening, which correlated with the awakening end-tidal concentration of 0.96%. The mean time from the discontinuation of desflurane to eye opening was 5.2 minutes (SD = 1.6, range 3-10), which was not associated with the duration of anesthesia (60-256 minutes), total fentanyl dose, or body mass index (BMI).

          CONCLUSIONS:

          The mean awakening arterial blood concentration of desflurane was 1.20%. The time to awakening was independent of anesthetic duration within four hours. Using well-assisted ventilation, the end-tidal concentration of desflurane was proven to represent the arterial blood concentration during elimination and could be a clinically feasible predictor of emergence from general anesthesia.

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          Most cited references68

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          Age, minimum alveolar anesthetic concentration, and minimum alveolar anesthetic concentration-awake.

          E I Eger (2001)
          Two defining effects of inhaled anesthetics (immobility in the face of noxious stimulation, and absence of memory) correlate with the end-tidal concentrations of the anesthetics. Such defining effects are characterized as MAC (the concentration producing immobility in 50% of patients subjected to a noxious stimulus) and MAC-Awake (the concentration suppressing appropriate response to command in 50% of patients; memory is usually lost at MAC-Awake). If the concentrations are monitored and corrected for the effects of age and temperature, the concentrations may be displayed as multiples of MAC for a standard age, usually 40 yr. This article provides an algorithm that might be used to produce such a display, including provision of an estimate of the effect of nitrous oxide. Two defining effects of inhaled anesthetics (immobility in the face of noxious stimulation, and absence of memory) correlate with the end-tidal concentrations of the anesthetics. Thus, these defining effects may be monitored and the results displayed if the concentrations are known and corrected for the effects of age and temperature.
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            Statistical modeling of average and variability of time to extubation for meta-analysis comparing desflurane to sevoflurane.

            The recovery profile of an ideal anesthetic or technique would be fast (e.g., mean of 5 min from end of surgery to extubation) with little variability (e.g., always 4-7 min). We used anesthesia information management system (AIMS) data to learn how to model the time from end of surgery to extubation. We applied that knowledge for meta-analyses of trials comparing extubation times after use of desflurane and sevoflurane. AIMS data studied were 32,792 cases performed by 95 surgeons that included tracheal intubation and extubation in the operating room (OR) and use of volatile anesthetic(s). Meta-analysis included the 29 randomized controlled trials through 2008 comparing extubation times with desflurane and sevoflurane. Percentage differences in means and standard deviations were studied using random effects meta-analysis and a Bayesian method. Times to extubation were better fit by (skewed) Weibull distributions than by (symmetric) normal distributions. Drug choice had nearly equally proportional effects on the means and standard deviations of extubation times, as shown by unchanged coefficients of variation (P > 0.10 for 26 of 29 studies) and nonsignificant pooled difference in the coefficient of variation (sevoflurane--desflurane = -1%, 95% confidence interval [CI] -3% to 1%, P = 0.22). Applying these findings, desflurane reduced the mean extubation time by 25% (95% CI 17%-32%, P 15 min. These cases averaged 4.9 min longer times from out of the OR to the start of surgery of the surgeon's next case (95% CI 2.7-7.1 min, P < 0.0001). Reduction in the means and standard deviations by 20%-25% would likely reduce incidences of these prolonged extubation times by 71%-82% (95% CI 68%-84%). Desflurane reduces the average extubation time and the variability of extubation time by 20%-25% relative to sevoflurane. The principal economic value of these end points is their reductions of direct (labor) costs of OR time. However, reductions in intangible costs of prolonged extubation are real, being associated with subsequent delays. Reductions in the average and variance of times to extubation can be interpreted and monitored in terms of corresponding expected 75% reductions in the incidences of prolonged extubation times by using desflurane relative to sevoflurane.
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              Effect of increased body mass index and anaesthetic duration on recovery of protective airway reflexes after sevoflurane vs desflurane.

              Increased BMI may increase the body's capacity to store potent inhaled anaesthetics, more so with more soluble agents. Accordingly, we asked whether increased BMI and longer anaesthesia prolonged airway reflex recovery. We measured time from anaesthetic discontinuation until first response to command (T1); from response to command until ability to swallow (T2); and from anaesthetic discontinuation to recovery of ability to swallow (T3) in 120 patients within three BMI ranges (18-24, 25-29, and >or=30 kg m(-2)). All received sevoflurane or desflurane, delivered via an LMA. T1 and T3 after sevoflurane exceeded T1 and T3 after desflurane: 6.6 (sd 4.2) vs 4.0 (1.9) min (P or=30 kg m(-2) were less often able to swallow 2 min after response to command than were those with BMI 18-24 or 25-29 kg m(-2) (3/20 vs 10/20 or 9/20, P<0.05). Each sevoflurane MAC-hour delayed T3 by 4.5 min (268 s) (R=0.46, P<0.001) whereas each desflurane MAC-hour delayed T3 by 0.2 min (16 s) (R=0.10, P=0.44). Prolonged sevoflurane administration and greater BMI delay airway reflex recovery. The contribution of BMI to this delay is more pronounced after sevoflurane than desflurane.
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                Author and article information

                Journal
                Clinics (Sao Paulo)
                Clinics (Sao Paulo)
                Clinics
                Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
                1807-5932
                1980-5322
                October 2013
                : 68
                : 10
                : 1305-1311
                Affiliations
                [I ]Tri-Service General Hospital/National Defense Medical Center, Department of Anesthesiology, Taipei, Taiwan.
                [II ]Tri-Service General Hospital/National Defense Medical Center, Departments of Obstetrics and Gynecology, Taipei, Taiwan.
                [III ]National Defense Medical Center, Graduate Institute of Medical Science, Taipei, Taiwan.
                [IV ]National Defense Medical Center, School of Public Health, Taipei, Taiwan.
                [V ]Taipei Veterans General Hospital/National Defense Medical Center, Department of Anesthesiology, Taipei, Taiwan.
                Author notes

                Lin TC, Lu CC, and Hsu HC performed this clinical study and drafted the manuscript. Lee MS performed the statistical analysis. Ho ST conceived the study and provided laboratory support to measure the blood desflurane concentration. Wu GJ participated in the study design and coordination. All authors read and approved the final version of the manuscript.

                E-mail: stho@ 123456vghtpe.gov.tw Tel.: 886-2-28757155
                Article
                cln_68p1305
                10.6061/clinics/2013(10)03
                3798610
                24212836
                a28e9b69-07b6-49dc-9f82-034a1ba0cc18
                Copyright © 2013 Hospital das Clínicas da FMUSP

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 17 December 2012
                : 25 February 2013
                : 9 May 2013
                Page count
                Pages: 7
                Categories
                Clinical Science

                Medicine
                desflurane,arterial blood,end-tidal,awakening
                Medicine
                desflurane, arterial blood, end-tidal, awakening

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