Sevoflurane use in Adult and Elderly patients

1
Sevoflurane use in Adult and Elderly patients
2
Sevoflurane Clinical Profile

• Low solubility rapid induction and emergence
  greater control of anesthetic depth
• Hemodynamic stability stable heart rate and
  blood pressure minimal sympathetic nervous
  system activation
• Favorable respiratory profile nonpungent
  minimal airway irritation ideal for mask
  induction
• Safety no increased risk of hepatic or renal
  toxicity

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Recovery ProfileSevoflurane vs Isoflurane
Sevoflurane (n149)
Aldrete scores Recovery score 8 95 of
sevoflurane patients vs 81 of isoflurane
patients (p0.004) More rapid recovery of
activity (p0.001) More rapid recovery of
consciousness (p0.003)
Isoflurane (n97)
Response toCommand
plt0.05 vs isoflurane Philip et al. Anesth
Analg 199683314.
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Sevoflurane Recovery ProfileBetter than
Propofol (Outpatient Surgery)
Sevoflurane(n143)
Propofol(n143)
12
10


8
Mean Time (min)
6
4
2
Response to Commands
0
Emergence
plt0.05 vs propofol Dubin et al. Anesthesiology
199481A3.
5
Sevoflurane Recovery Profile Better than
Propofol (Inpatient Surgery)
Sevoflurane (n93) Propofol (n93)
2
0
1
8
1
6
1
4
1
2
Mean Time (min)
1
0
8
6
4
2
0
Extubation
Response toCommands

Jellish et al. Anesth Analg 199682479.
6
Heart Rate Response to Sevoflurane and
Isoflurane Elective Surgical Cases
Isoflurane (n25)
120
Sevoflurane (n50)
100
Heart Rate (beats/min)


80


60
Base-line
1
5
3-5
1-3
15
60
5

30
Pre-
Prior to End ofAnesthesia
Post-emergence
incision
Post-
Post-
intubation
incision
Emergence
Time (min)
plt0.05 vs isoflurane Ebert et al. Anesth Analg
199581S11.
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Hemodynamic Stability Blood Pressure
90 80 70 60 50
Desflurane Isoflurane Sevoflurane
Mean Arterial Pressure (mm Hg)
//
Steady State
1
2
3
4
5
7
8
9
10
11
Minutes after Anesthetic Advanced to 1.2 or 1.5
MAC
Ebert et al. Anesth Analg 199581S11.
8
Effects on Blood Pressure and Vascular
Resistance Healthy Volunteers
Isoflurane (n7)
Desflurane (n16)
Sevoflurane (n12)
100
35
80
25
Vascular Resistance (mm Hg/mL/min/100 mL)
Mean Arterial Pressure (mm Hg)
60
15


40
5
1.2
1.5
0.4
0.8
1.5
0.8
0.4
1.2
Minimum Alveolar Concentration
ConsciousBaseline
ConsciousBaseline
Minimum Alveolar Concentration
plt0.05 vs sevoflurane Adapted from Ebert et al.
Anesth Analg 199581S11.
9
Sevoflurane Cardiovascular Profile

• Hemodynamic stability during rapid titration
  superior to desflurane and halothane
• Cardiovascular safety comparable to isoflurane in
  CAD and/or hypertension
• No potentiation of arrhythmogenic effects
• No coronary steal

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Sevoflurane not associated With Fluoride
Nephrotoxicity

• No evidence of renal toxicity or dysfunction with
  prolonged sevoflurane exposure
• Sevoflurane has important metabolic differences
  from methoxyflurane
• Minimal metabolism in kidney
• More rapid elimination smaller amount
  metabolized
• Shorter duration of fluoride level increase

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Assessment of Low-flow Sevoflurane and
Isoflurane Effects on Renal Function Using
Sensitive Markers of Tubular Toxicity
Kharasch et al Anesthesiology 1997861238.

• No significant differences in renal effects
  between sevoflurane and isoflurane
• Using conventional and sensitive biomarkers of
  renal tubular function and cellular integrity
• In surgical patients undergoing low-flow
  anesthesia for ? 7 hours

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Effects of Low-flow Sevoflurane Anesthesia on
Renal Function
Comparison With High-flow Sevoflurane
Anesthesiaand Low-flow Isoflurane Anesthesia
Bito et al Anesthesiology 1997861231.

• Compound A concentration and exposure times
  during low-flow sevoflurane no clinically
  significant effects on renal function
• No significant effects on renal function with
• Low-flow sevoflurane (1 L/min)
• High-flow sevoflurane (6-10 L/min) compared with
  low-flow isoflurane (1 L/min)

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More Over

• Sevoflurane like the other halogenated vapors
  presents
• Antinociceptive properties
• Matute E et al. ASA 2001. Hollmann MW et al.
  Anesth Analg 2001.
• Cardioprotective properties
• kashimoto S et coll J Anesth 1989 Takahata et
  coll Acta Anaesthesiol Scand 1995 Preckel B et
  coll. Br J Anaesth 1998 De Hert SG et coll.
  Anesthesiology 2002
• Neuroprotective properties (?)

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Sevoflurane Respiratory Profile

• Nonpungent
• Minimal airway irritation
• No increase in airway secretions
• No cough reflex or laryngospasm

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Sevoflurane and Bronchodilation
Goff et al. Anesthesiology 2000.
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Sevoflurane Suitable for Mask Induction

• Smooth, rapid induction and predictable recovery
• Rapid adjustment of anesthetic depth
• Patient acceptance
• Nonpungent odor
• No pain on injection
• Spontaneous ventilation maintained
• Ideal for difficult airway
• Neuromuscular blockade avoided
• Cost savings

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Absence dAcreté 100 des patients tolèrent le
sévoflurane
TerRiet al. B.J.A 2000
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Mask induction

• Why ?
• How ?
• For whom ?
• At what price ?
• How to learn ?

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Mask induction

• Why ?
• How ?
• For whom ?
• At what price ?
• How to learn ?

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IV Induction and maintenance with isoflurane
propofol
propofol
FGF 8 L/min, Vapo 4
FGF 2 L/min, vapo 4
Fi
isoflurane
GasMan et Mediq Simulator simulations
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Sevoflurane for induction and maintenance
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Hemodynamics during inductionSevoflurane vs
Propofol
125
110
95
Sevoflurane
MAP (mmHg)
Propofol
80
65
n102 Age 1885 years
50
1
2
3
4
5
Time (minutes)
Thwaites et al. Br J Anaesth 199778356.
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Respiratory effects during inductionSevoflurane
vs Propofol
Sevoflurane (n51)
70
Propofol (n51)
60
50
40
Incidence ()
30

20

10
plt0.01 vs propofol p0.03 vs propofol
0
Apnea
Post-inductionCoughing
Thwaites et al. Br J Anaesth 199778356.
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Sevoflurane Mask Induction Rapid Induction and
Intubation
8
Loss of Lid-lash Reflex Acceptable
ETT/LMA Insertion
7
6
5
Mean Time (min)
4
3
2
1
0
Sevo/N2OLMA
Sevo/O2 ETT
Sevo/N2OETT
ETT endotracheal tube LMA laryngeal mask
airway Muzi et al. Anesthesiology 199685536.
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Sevoflurane for Mask Induction

• Rapid induction
• Few hemodynamic effects
• Low risk of airway complications
• Spontaneous ventilation maintained
• Ideal for difficult airway
• Neuromuscular blockade can be avoided
• Avoids IV access problems/needle phobia
• Well accepted by patients
• Nonpungent odor
• Minimal respiratory irritation

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Mask induction

• Why ?
• How ?
• For whom ?
• At what price ?
• How to learn it ?

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Mask induction with sevoflurane HOW?

• Techniques of ventilation
• Inhaled concentrations
• Target cerebral concentrations
• Associations
• Practical aspects
• How to decrease the CV effects

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Two techniques of ventilation

• Vital Capacity
• Patient exhales to residual volume
• Mask applied and patient inhales a vital capacity
  breath
• Patient holds breath as long as possible
• Tidal Breathing

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Vital Capacity vs Tidal Breathing Induction With
Sevoflurane
Faster Induction
Other Advantages
Vital Capacity (n19)

• Significantly fewer induction-related
  complications
• Less coughing
• Less involuntary movement

TidalBreathing(n16)
0
2
0
4
0
6
0
Mean Time (sec)
plt0.05 vs tidal breathing Yurino, Kimura.
Anesthesia 199550308.
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Vital capacity vs Tidal breathing self (PCI)

• 124 patients (VCI or PCI)
• Sevo 8, FGF 4L/min
• Laryngeal mask
• Insertion
• 3,4 min PCI
• 3,3 min VCI
• Laryngospasm, SaO2, Hemodynamics no difference

Yogendran S et al Can J Anaesth 2005
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Inhaled concentrations

• Use high concentration (7-8) until loss of
  consciousness
• Then, adapt the concentration (FGF or vaporizator
  concentration) according to the patients and the
  purposes of induction

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Associations

• Premedication
• N2O
• Opioids
• Myorelaxants

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Sevoflurane Mask Induction Effect of
Premedication
Loss of Lid-lash Reflex Acceptable
Tracheal Intubating Conditions
5
4
3
ET50 (min)
2
1
0
Fentanyl Midazolam
Midazolam
Fentanyl
Sevoflurane exposure time required for 50 of
subjects to achieve endpoint Muzi et al. Anesth
Analg 1997851143.
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Katoh T et al. Anesthesiology 1999.
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Time to maximal brain concentration after bolus
100
80
60
Conc max. in the brain
40
20
0
0
2
4
6
8
10
Time after bolus (min)
Minto et al. Anesthesiology, 1997
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Which target cerebral concentration?

• For endotracheal intubation without opioids
• 4-4.5
• Kimura et coll, Anesth Analg 1994
• Yurino, Anaesthesia 1995
• For endotracheal intubation with opioids
• 2.08-2.5
• Katoh, Br J Anaesth 1999
• Cros et coll, Anesthesia 2000
• For Laryngeal mask insertion
• 1.6 - 2
• Kah, Anesth Analg 1999 88 908-12
• Tanaka, Anaesthesia 1999 54 1155-60

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FGF
Gas Man
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Fraction insp
Fraction exp
Concentration site
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Inhalational induction in practice

• Premedication possible but must not depress the
  ventilation
• Except precise case, venous access before
  induction
• Begin with high concentrations (priming high
  FGF)
• Vital capacity or at least 2 - 3 large
  inspirations
• Good installation hose, arm, balloon reservoir
• Except in case of difficult intubation, associate
  an opioid
• myorelaxants are not mandatory for the intubation
  but could be associated
• No manual ventilation if apnea within 1 minute
• Effective ventilation (curve of capnigraphy),
  (PSV Banchereau F et al. Eur J Anaesth Nov 2005)
• Cannula possible after 1,5 min
• Wait for a cerebral concentration of 2MAC without
  opioid and of 1MAC if associated with an opioid
• Switch off the vaporizator FGF during intubation

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Sevoflurane concentration in the circuit
FGF 8 L/min Priming/ FGF 4L/min No priming/
4L/min Priming/FGF 1L/min No priming/ 1L/min
Minutes
Gas Man
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INDUCTION with SEVOFLURANE

• Several techniques are possible.
• They result from the association of
• the technique of induction (VC or CV)
• the Fresh gaz flow
• the association with N2O and\or opioid and\or
  myorelaxant
• The choice of a technique has to take into
  account goals
• Preservation of spontaneous ventilation
• Decrease of hemodynamic effects.

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How to decrease the cardio vascular effects ?

• Take into account the MAC
• Decrease quickly the concentrations
• Maintain a fresh gas flow during intubation
• Beware on the too strong doses of opioids

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Sevoflurane Minimum Alveolar Concentration (MAC)
by Age
MAC in O2 ()
MAC in 65 N2O/35 O2 ()
Age
0 - 1 mo
3.3
-
1 - lt 6 mo
3.0
-
6 mo - lt 3 yr
2.8
2.0

3 - 12 yr
2.5
-
25 yr
2.6
1.4
40 yr
2.1
1.1
60 yr
1.7
0.9
80 yr
1.4
0.7
Neonates are full-term gestational age. MAC in
premature infants has not been determined
60 N2O/40 O2 was used in patients aged 1 - lt 3
years

Data on file, Abbott Laboratories Inc.