Comparison of hemodynamic parameters and recovery characteristics between sevoflurane and desflurane in patients undergoing day care gynecological laparoscopic surgery.
Day care anesthesia is as old as the anesthesia itself but contributes to a greater proportion of overall surgeries carried out today than 15 years ago. This is because of the availability of new minimally invasive surgical techniques and addition of new short acting and rapidly metabolized anesthetic agents. Very high-risk patients and major surgical procedures can now be carried out safely because of the precision in monitoring and advanced surgical techniques.  One of the major factors that determine speed of recovery from anesthesia is the choice of anesthetic technique. General anesthesia is the most commonly used technique in day care setup. An ideal general anesthetic should provide smooth and rapid induction, optimal operating conditions, and rapid recovery with minimal side effects such as nausea, vomiting, bleeding, and postoperative pain. Inhaled anesthetics allow rapid emergence from anesthesia because of easy titrability with inherent neuromuscular blocking effects that make them more suitable for day care anesthesia.  The availability of less soluble inhalation anesthetics such as sevoflurane and desflurane has made us rethink about the selection of volatile anesthetics for outpatient surgical procedures. Given the low blood/gas partition coefficient of sevoflurane and desflurane, faster emergence from anesthesia is expected compared to traditional inhalation anesthetics.  Sevoflurane, a volatile anesthetic agent, is a halogenated methyl propyl ether. It is nonirritant, noninflammable, and produces bronchodilatation. It has rapid induction due to low blood/gas partition coefficient. It can be used for inhalational induction. [4,5] It produces dose-dependent cardiovascular and respiratory depression. Sevoflurane does not activate the sympathetic nervous system.  Desflurane is a fluorinated methyl ethyl ether. It has a pungent odor, is irritable to the respiratory tract, and is noninflammable. Low solubility of desflurane in blood and body tissues leads to rapid induction and recovery. It does not predispose to ventricular arrhythmias. [4,5] Maintenance characteristics can be assessed by various monitoring techniques, which include electrocardiogram, oxygen saturation, noninvasive mean arterial pressure (MAP), heart rate, and ETCO2. The advent of rapid and short-acting drugs for induction and maintenance of anesthesia has facilitated early recovery following day care surgery.
The objective of this study was to compare intraoperative hemodynamic profile of desflurane and sevoflurane as maintenance anesthetic in patients undergoing day care gynecological laparoscopic surgery and to compare early and intermediate emergence characteristics with desflurane and sevoflurane in day care gynecological laparoscopic surgery patients.
Materials and Methods
This was a prospective randomized single-blind study that was conducted by the Department of Anesthesiology at Krishna Institute of Medical Science, Secunderabad, India, during the period of January 2010 to May 2011 in patients undergoing day care gynecological laparoscopic surgery, laparoscopic hysteroscopy. The study was approved by the hospital ethics committee.
Design of Study
After obtaining ethics committee approval, patients were thoroughly explained regarding the nature of the study and a written informed consent was obtained from all the patients.
A total of 100 female patients belonging to the American Society of Anesthesiologists (ASA) grade I or II, scheduled to undergo day care laparoscopic gynecological surgery were recruited for the study. Patients were randomized into two groups to receive either desflurane (group D; n = 50) or sevoflurane (group S; n = 50) for maintenance of anesthesia.
Patients were randomly divided into 2 groups of 50 each by a computer-generated randomization sheet.
* Group I (D): Anesthesia was induced using propofol and maintained with 60% [N.sub.2]O in [O.sub.2] and desflurane.
* Group II (S): Anesthesia was induced using ropofol and maintained with 60% [N.sub.2]O in [O.sub.2] and sevoflurane.
Inclusion criteria were as follows: (1) patients undergoing elective surgery under general anesthesia, (2) surgery lasting more than 30 min or less than 90 min, (3) age group between 18 and 60 years, and (4) ASA I and ASA II.
Exclusion criteria were as follows: (1) emergency surgery under general anesthesia; (2) surgery lasting less than 30 min or more than 90 min; (3) age below 18 years and above 60 years; (4) ASA III and ASA IV; (5) patients with significant cardiopulmonary, respiratory, hepatic, renal, endocrinal, neurological, psychiatric, and metabolic diseases;, (6) patients on central nervous system depressants and sedatives; (7) patients with allergy to any drug; (8) drug abuse; (9) pregnant/breastfeeding women; and (10) women who have undergone recent anesthesia (within the previous 7 days).
A study population of 50 patients for each group was determined to have 99% power at a = 0.05 (two-tailed) to detect a difference of 10% in the time to early recovery with desflurane group compared to sevoflurane group. Data are expressed as mean [+ or -] SD. Statistical analysis of data among the groups was done by Student's t-test for independent samples and for categorical value Fisher's exact test has been applied. For nonparametric data, Mann-Whitney U-test was used, p < 0.05 has been considered as statistically significant. SPSS 17 statistics package has been used for analysis.
A total of 100 patients were recruited for the study and 50 patients were allocated in each group. There was no premature study withdrawal due to failure of surgery to proceed as planned or the development of complications hindering the assessment of study variables. All demographic parameters such as age, weight, and height were compared in both the groups and all parameters were statistically insignificant as shown in Figure 1.
The mean duration of surgery in the groups of desflurane and sevoflurane was 38.90 and 41.30 min, respectively. There was no statistical difference in desflurane and sevoflurane groups. Intraoperative changes in heart rate and mean arterial blood pressure of desflurane and sevoflurane groups are summarized in Tables 1 and 2, respectively. The groups did not differ in blood pressure (systolic, diastolic, and mean) or heart rate throughout the surgery. During the maintenance period, heart rate [Table 1] and MAP [Table 2] were satisfactorily maintained within 20% of baseline values with both anesthetics.
The time from administration of reversal agent to response to painful stimuli, to eye opening, to verbal commands, and spontaneous eye opening were significantly shorter in patients given desflurane than in patients given sevoflurane (p = 0.000). For a given duration of anesthesia, emergence from anesthesia was significantly faster in desflurane group as compared to sevoflurane group as shown in Table 3.
Early recovery as assessed by modified Aldrete score was compared in both the groups. Patients given desflurane achieved modified Aldrete score of 9 significantly faster than patients given sevoflurane. Postanesthesia discharge scoring system (PADSS) for time to home readiness is compared in both the groups. The two groups were comparable with respect to time to achieve PADSS of 9 or above, the difference being insignificant. Both the groups were compared for postoperative incidence of nausea, vomiting, drowsiness, respiratory distress, laryngospasm, sore throat, and headache. There was no difference in both the groups as far as the incidence of these complications is concerned.
Emergence and early recovery from anesthesia was faster with desflurane compared to sevoflurane. However, intermediate recovery time, including time to discharge, was similar after desflurane and sevoflurane. As doses of the adjuvant drugs were similar in the two groups, differences in later recovery times may have been masked by the use of these supplemental drugs (e.g., opioid analgesics).
Desflurane offered an advantage over sevoflurane with respect to early recovery end points (i.e., emergence from anesthesia). However, the intermediate recovery end points (readiness for home discharge) did not differ significantly between the two anesthetic groups. The current findings are consistent with previously published comparative study conducted by Heavner et al.  demonstrating that the faster emergence from desflurane (versus sevoflurane) anesthesia failed to lead to an earlier discharge from hospital after both outpatient and inpatient surgical procedures. It also suggested that sevoflurane and desflurane provided similar intraoperative conditions during the maintenance period. Although early recovery was faster with desflurane, there was no difference in the intermediate recovery end points. Kim et al.  also found that late recovery profiles and incidences of postoperative side effects were similar after desflurane and sevoflurane. It also showed that regardless of the duration of anesthesia, elimination was faster and recovery was quicker for inhaled anesthetic desflurane than for the inhaled anesthetic sevoflurane. The study conducted by Vallejo et al.  showed that despite the faster initial recovery with desflurane, no significant differences were found between the two volatile anesthetics in the later recovery period. Findings of the present study are consistent with the earlier reported data of faster early recovery with desflurane compared to sevoflurane. White et al.  studied the hemodynamics, emergence, and recovery characteristics of sevoflurane with those of desflurane in nitrous oxide anesthesia and concluded that the groups did not differ in these hemodynamic measures. Findings in our study are also similar. As a result of the lower solubility of desflurane compared with sevoflurane in blood and lean tissues, one might expect to find differences in the intermediate and late recovery end points when these two anesthetics are used for longer surgical procedures. However, studies have found that only early recovery was faster with desflurane compared to sevoflurane even when the duration of surgery exceeded 2 h. [3,11] Furthermore, the recovery of psychomotor and cognitive function after desflurane and sevoflurane were similar after the first 30-45 min in both younger patients undergoing day care surgery and older patients undergoing more prolonged general anesthesia for inpatient procedures. Yet, even these studies accept the possibility that the difference in intermediate recovery and cognitive function recovery might not have been detected due to lack of sensitivity and selectivity of digit-symbol substitution test and mini-mental state test used in these studies. Intraoperative cardiovascular stability was easily achieved with both sevoflurane and desflurane, with MAP - mean arterial Pressure and HR - heart rate maintained within [+ or -] 20% of baseline values during the entire maintenance period. The cardiovascular stability during the maintenance period and the lack of any difference between the two groups were predictable, as the study was designed to maintain MAP within 20% of the baseline values by varying the inspired concentration of the volatile anesthetics. In our study, we found that both desflurane and sevoflurane group had rapid recovery. There was a significant difference in the emergence and early recovery between the two groups. The early recovery was faster with desflurane compared to sevoflurane. Although there was difference in intermediate recovery time, the magnitude of the difference was small and insignificant. This was despite stepwise reduction of anesthetic concentration was not allowed toward the end of the procedure, which is a common clinical practice. One explanation for this small magnitude of difference could be residual effects of drugs used for premedication, opiates, and muscle relaxants, which could have interfaced with the anesthetic agents. Because of the greater pungency and airway irritant properties of desflurane, sevoflurane has been called "the ideal agent for adult day-case anesthesia." Previous studies comparing desflurane and sevoflurane when administered for minor outpatient surgical procedures using an laryngeal mask airway for airway management have reported a low incidence of respiratory complications and no significant differences between the two volatile anesthetics. [12-14] Our study also found no difference in the incidence of respiratory complications between the two groups. Perhaps this could be attributed to propofol used for induction. It is also possible that the use of fentanyl during the intraoperative period may have minimized the difference between the airway responses to desflurane and sevoflurane. The incidence of other postoperative complications (postoperative nausea and vomiting, headache, drowsiness) was also similar in both the groups.
This study can be criticized because the design did not permit a double-blind comparison of the two volatile anesthetics. However, all patients were undergoing identical procedure. In addition a cost analysis with the use of the two agents was not a part of this study. The cost saving due to lesser use of opioids, muscle relaxants, carrier gases, and early discharge from the postanesthesia care unit could impinge on the decision regarding use of either sevoflurane or desflurane in a day care setting.
We concluded from the study that desflurane anesthesia produces faster emergence and early recovery from anesthesia compared to sevoflurane anesthesia. Time to home readiness is similar with both agents. Intraoperative hemodynamic parameters are similar in both desflurane and sevoflurane anesthesia. Both the agents produce similar incidence of postoperative complications. Because of the greater pungency and airway irritant properties of desflurane, sevoflurane has been called "the ideal agent for adult day-case anesthesia."
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How to cite this article: Patel M, Parmar N. Comparison of hemodynamic parameters and recovery characteristics between sevoflurane and desflurane in patients undergoing day care gynecological laparoscopic surgery. Int J Med Sci Public Health 2016;5:1412-1416
Source of Support: Nil, Conflict of Interest: None declared.
Mayur Patel (1), Neelam Parmar (2)
(1) Department of Anesthesia, Tristar Hospital, Surat, Gujarat, India.
(2) Department of Anesthesiology, Government Medical College, Surat, Gujarat, India.
Correspondence to: Mayur Patel, E-mail: email@example.com
Received August 24, 2015. Accepted October 27, 2015.
Table 1: Hemodynamic (heart rate) Heart rate Desflurane Sevoflurane (beats/min) group group p Preoperative 81.58 (10.025) 83.98 (10.790) 0.252 Induction 85.32 (12.891) 83.54 (10.752) 0.455 At intubation 82.36 (12.116) 84.34 (13.514) 0.442 Immediately after 92.02 (12.290) 89.26 (13.521) 0.288 intubation 2 min 88.96 (11.150) 87.32 (13.942) 0.517 3 min 83.64 (10.883) 82.94 (11.883) 0.759 4 min 78.54 (11.433) 79.70 (11.182) 0.609 5 min 75.56 (11.207) 77.44 (11.418) 0.408 10 min 73.00 (11.053) 73.58 (11.720) 0.800 15 min 73.08 (11.130) 74.42 (11.009) 0.546 20 min 72.90 (10.403) 75.72 (10.958) 0.190 30 min 72.16 (10.001) 74.38 (8.051) 0.224 45 min 74.54 (9.671) 77.38 (9.005) 0.132 60 min 76.24 (7.968) 79.14 (8.804) 0.087 Table 2: Hemodynamic (mean arterial pressure [MAP]) MAP (mm Hg) Desflurane group Sevoflurane group P Preoperative 89.013 (9.371) 89.160 (7.891) 0.933 Induction 89.98 (8.823) 89.31 (10.933) 0.723 At intubation 78.01 (12.111) 76.65 (9.874) 0.538 Immediately after 89.43 (11.083) 86.59 (11.576) 0..189 intubation 2 min 86.85 (11.723) 83.71 (10.404) 0.160 3 min 79.007 (10.220) 82.16 (11.175) 0.144 4 min 80.56 (9.822) 82.68 (13.411) 0.369 5 min 80.360 (9.406) 84.333 (11.605) 0.063 10 min 90.82 (7.482) 91.26 (10.515) 0.810 15 min 91.56 (7.941) 92.953 (9.791) 0.436 20 min 89.733 (7.770) 92.953 (9.791) 0.072 30 min 91.307 (9.670) 91.767 (12.023) 0.833 45 min 92.47 (7.609) 93.80 (8.549) 0.414 60 min 93.63 (5.974) 94.09 (8.596) 0.757 Table 3: Time to recovery in both groups Time to recovery (min) Desflurane Sevoflurane p group group Response to painful stimuli 2.75 (1.411) 4.02 (1.767) 0.000 Response to verbal commands 3.48 (1.488) 5.04 (1.616) 0.000 Spontaneous eye opening 4.18 (1.548) 6.80 (2.259) 0.000 Stating name 5.34 (1.944) 7.62 (2.079) 0.000 Date of birth 5.56 (1.955) 8.00 (2.399) 0.000 Place of stay 5.66 (1.955) 8.16 (2.289) 0.000 Squeeze fingers 6.76 (2.016) 9.36 (2.038) 0.000 Lift limb 7.14 (2.250) 10.08 (1.947) 0.000 Figure 1: Comparison of age, weight, and height between the two groups. Desflurane Sevoflurane Age (yrs) 33.2 30.36 Weight (Kg) 58.72 57.2 Height (cm) 154.58 155.19 Note: Table made from bar graph.
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|Title Annotation:||Research Article|
|Author:||Patel, Mayur; Parmar, Neelam|
|Publication:||International Journal of Medical Science and Public Health|
|Date:||Jul 1, 2016|
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