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Lineburger EB, Módolo NSP, Braz LG, do Nascimento P. Minimal fresh gas flow sevoflurane anesthesia and postoperative acute kidney injury in on-pump cardiac surgery: a randomized comparative trial. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2021; 73:46-53. [PMID: 34852266 PMCID: PMC9801186 DOI: 10.1016/j.bjane.2021.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 10/29/2021] [Accepted: 11/13/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Compound A is generated by sevoflurane when it reacts with carbon dioxide absorbers with strong bases at minimal fresh gas flow (FGF) and is nephrotoxic in animals. No conclusive data has shown increased risk in humans. The aim of this study was to investigate if minimal FGF promotes an increase in the incidence of acute kidney injury (AKI) when compared to high FGF in patients undergoing on-pump cardiac surgery under sevoflurane anesthesia. METHODS Two hundred and four adult patients scheduled for on-pump cardiac surgery under sevoflurane anesthesia were randomly allocated to two groups differentiated by FGF: minimal FGF (0.5 L.min-1) or high FGF (2.0 L.min-1). Baseline creatinine measured before surgery was compared daily to values assayed on the first five postoperative days, and 24-hour urinary output was monitored, according to the KDIGO (Kidney Disease Improving Global Outcomes) guideline to define postoperative cardiac surgery-associated acute kidney injury (CSA-AKI). Creatinine measurements were also obtained 20 and 120 days after hospital discharge. RESULTS Postoperative AKI occurred in 55 patients, 26 patients (29.5%) in the minimal FGF group and 29 patients (31.5%) in the high FGF group (p = 0.774). Twenty days after discharge, 11 patients (6.1%) still had CSA-AKI and 120 days after discharge only 2 patients (1.6%) still had CSA-AKI. CONCLUSIONS When compared to high FGF, minimal FGF sevoflurane anesthesia during on-pump cardiac surgery is not associated with increased risk of postoperative AKI in this population at high risk for renal injury.
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Affiliation(s)
| | - Norma Sueli Pinheiro Módolo
- Universidade Estadual Paulista "Júlio de Mesquita Filho" (UNESP), Faculdade de Medicina de Botucatu, Departamento de Especialidades Cirúrgicas e Anestesiologia, São Paulo, SP, Brazil
| | - Leandro Gobbo Braz
- Universidade Estadual Paulista "Júlio de Mesquita Filho" (UNESP), Faculdade de Medicina de Botucatu, Departamento de Especialidades Cirúrgicas e Anestesiologia, São Paulo, SP, Brazil
| | - Paulo do Nascimento
- Universidade Estadual Paulista "Júlio de Mesquita Filho" (UNESP), Faculdade de Medicina de Botucatu, Departamento de Especialidades Cirúrgicas e Anestesiologia, São Paulo, SP, Brazil
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Derevshchikov VS, Kazakova ED, Veselovskaya JV, Yatsenko DA, Kozlov DV. Patterns of CO2 Absorption by a Calciferous Sorbent in a Flow Adsorber. RUSSIAN JOURNAL OF PHYSICAL CHEMISTRY A 2021. [DOI: 10.1134/s0036024421070098] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Derevshchikov VS, Kazakova ED. Comparative Analysis of the Chemical Composition and Sorption, Textural, and Strength Properties of Commercial Medical CO2 Sorbents. CATALYSIS IN INDUSTRY 2020. [DOI: 10.1134/s2070050420010043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Derevschikov VS, Kazakova ED, Yatsenko DA, Veselovskaya JV. Multiscale study of carbon dioxide chemisorption in the plug flow adsorber of the anesthesia machine. SEP SCI TECHNOL 2020. [DOI: 10.1080/01496395.2020.1723029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Vladimir Sergeevitch Derevschikov
- Department of Non-Traditional Catalytic Processes, Boreskov Institute of Catalysis, Novosibirsk, Russia
- Faculty of Natural Sciences, Novosibirsk State University, Novosibirsk, Russia
- Faculty of Mechanical Engineering and Technologies, Novosibirsk State Technical University, Novosibirsk, Russia
- Department of Materials and Environmental Technology, Tallinn University of Technology, Tallinn, Estonia
| | - Evgenia Dmitrievna Kazakova
- Department of Non-Traditional Catalytic Processes, Boreskov Institute of Catalysis, Novosibirsk, Russia
- Faculty of Mechanical Engineering and Technologies, Novosibirsk State Technical University, Novosibirsk, Russia
| | - Dmitry Anatolievich Yatsenko
- Department of Non-Traditional Catalytic Processes, Boreskov Institute of Catalysis, Novosibirsk, Russia
- Faculty of Natural Sciences, Novosibirsk State University, Novosibirsk, Russia
| | - Janna Vyacheslavovna Veselovskaya
- Department of Non-Traditional Catalytic Processes, Boreskov Institute of Catalysis, Novosibirsk, Russia
- Faculty of Natural Sciences, Novosibirsk State University, Novosibirsk, Russia
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Important role of calcium chloride in preventing carbon monoxide generation during desflurane degradation with alkali hydroxide-free carbon dioxide absorbents. J Anesth 2017; 31:911-914. [PMID: 28831619 DOI: 10.1007/s00540-017-2397-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 07/29/2017] [Indexed: 10/19/2022]
Abstract
We investigated whether calcium chloride (CaCl2), a supplementary additive in carbon dioxide (CO2) absorbents, could affect carbon monoxide (CO) production caused by desflurane degradation, using a Japanese alkali-free CO2 absorbent Yabashi Lime®-f (YL-f), its CaCl2-free and 1% CaCl2-added derivatives, and other commercially available alkali-free absorbents with or without CaCl2. The reaction between 1 L of desflurane gas (3-10%) and 20 g of desiccated specimen was performed in an artificial closed-circuit anesthesia system for 3 min at 20 or 40 °C. The CO concentration was measured using a gas chromatograph equipped with a semiconductor sensor detector. The systems were validated by detecting dose-dependent CO production with an alkali hydroxide-containing CO2 absorbent, Sodasorb®. Compared with YL-f, the CaCl2-free derivative caused the production of significantly more CO, while the 1% CaCl2-added derivative caused the production of a comparable amount of CO. These phenomena were confirmed using commercially available absorbents AMSORB® PLUS, an alkali-free absorbent with CaCl2, and LoFloSorb™, an alkali-free absorbent without CaCl2. These results suggest that CaCl2 plays an important role in preventing CO generation caused by desflurane degradation with alkali hydroxide-free CO2 absorbents like YL-f.
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Abstract
Exposure to carbon monoxide (CO) during general anesthesia can result from volatile anesthetic degradation by carbon dioxide absorbents and rebreathing of endogenously produced CO. Although adherence to the Anesthesia Patient Safety Foundation guidelines reduces the risk of CO poisoning, patients may still experience subtoxic CO exposure during low-flow anesthesia. The consequences of such exposures are relatively unknown. In contrast to the widely recognized toxicity of high CO concentrations, the biologic activity of low concentration CO has recently been shown to be cytoprotective. As such, low-dose CO is being explored as a novel treatment for a variety of different diseases. Here, we review the concept of anesthesia-related CO exposure, identify the sources of production, detail the mechanisms of overt CO toxicity, highlight the cellular effects of low-dose CO, and discuss the potential therapeutic role for CO as part of routine anesthetic management.
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Affiliation(s)
- Richard J Levy
- From the Department of Anesthesiology, Columbia University Medical Center, New York, New York
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Levy RJ. Carbon monoxide and anesthesia-induced neurotoxicity. Neurotoxicol Teratol 2016; 60:50-58. [PMID: 27616667 DOI: 10.1016/j.ntt.2016.09.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Revised: 08/10/2016] [Accepted: 09/06/2016] [Indexed: 10/21/2022]
Abstract
The majority of commonly used anesthetic agents induce widespread neuronal degeneration in the developing mammalian brain. Downstream, the process appears to involve activation of the oxidative stress-associated mitochondrial apoptosis pathway. Targeting this pathway could result in prevention of anesthetic toxicity in the immature brain. Carbon monoxide (CO) is a gas that exerts biological activity in the developing brain and low dose exposures have the potential to provide neuroprotection. In recent work, low concentration CO exposures limited isoflurane-induced neuronal apoptosis in a dose-dependent manner in newborn mice and modulated oxidative stress within forebrain mitochondria. Because infants and children are routinely exposed to low levels of CO during low-flow general endotracheal anesthesia, such anti-oxidant and pro-survival cellular effects are clinically relevant. Here we provide an overview of anesthesia-related CO exposure, discuss the biological activity of low concentration CO, detail the effects of CO in the brain during development, and provide evidence for CO-mediated inhibition of anesthesia-induced neurotoxicity.
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Affiliation(s)
- Richard J Levy
- Department of Anesthesiology, Columbia University Medical Center, United States.
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Abstract
Sevoflurane has been available for clinical practice for about 20 years. Nowadays, its pharmacodynamic and pharmacokinetic properties together with its absence of major adverse side effects on the different organ systems have made this drug accepted worldwide as a safe and reliable anesthetic agent for clinical practice in various settings.
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Affiliation(s)
- Stefan De Hert
- Department of Anesthesiology, Ghent University Hospital, De Pintelaan 185, Ghent, B-9000, Belgium
| | - Anneliese Moerman
- Department of Anesthesiology, Ghent University Hospital, De Pintelaan 185, Ghent, B-9000, Belgium
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Abstract
A breathing system is defined as an assembly of components, which delivers gases from the anesthesia machine to the patients’ airways. When the components are arranged as a circle, it is termed a circle system. The flow of exhaled gases is unidirectional in the system. The system contains a component (absorber), which absorbs exhaled carbon dioxide and it is not necessary to give high fresh gas flows as in Mapleson systems. When the adjustable pressure limiting (APL) valve is closed and all the exhaled gases without carbon dioxide are returned to the patient, the system becomes a totally closed one. Such a circle system can be used with flows as low as 250 to 500 mL and clinically can be termed as low-flow systems. The components of the circle system can be arranged in different ways with adherence to basic rules: (1) Unidirectional valve must be present between the reservoir bag and the patient on both inspiratory and expiratory sides; (2) fresh gas must not enter the system between the expiratory unidirectional valve and the patient; and (3) the APL valve must not be placed between the patient and the inspiratory unidirectional valve. The functional analysis is explained in detail. During the function, the arrangement of components is significant only at higher fresh gas flows. With the introduction of low resistance valves, improved soda lime canisters and low dead space connectors, the use of less complicated pediatric circle systems is gaining popularity to anesthetize children. There are bidirectional flow systems with carbon dioxide absorption. The Waters to and fro system, a classic example of bidirectional flow systems with a canister to absorb carbon dioxide, is valveless and portable. It was widely used in the past and now is only of historical importance.
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Affiliation(s)
- S Parthasarathy
- Department of Anaesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
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Stuckert AN, Yang RT. CO2 capture from the atmosphere and simultaneous concentration using zeolites and amine-grafted SBA-15. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2011; 45:10257-64. [PMID: 22029835 DOI: 10.1021/es202647a] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
CO(2) capture from the atmosphere and concentration by cyclic adsorption-desorption processes are studied for the first time. New high microporosity materials, zeolite types Li-LSX and K-LSX, are compared to zeolite NaX and amine-grafted SBA-15 with low amine content. Breakthrough performance showed low silica type X (LSX) to have the most promise for application in dry conditions and capable of high space velocities of at least 63,000 h(-1), with minimal spreading of the CO(2) breakthrough curve. Amine-grafted silica was the only adsorbent able to operate in wet conditions, but at a lower space velocity of 1500 h(-1), due to slower uptake rates. The results illustrate that the uptake rate is as important as the equilibrium adsorbed amount in determining the cyclic process performance. Li-LSX was found to have double the capacity of zeolite NaX at atmospheric conditions, also higher than all other reported zeolites. It is further demonstrated that by using a combined temperature and vacuum swing cycle, the CO(2) concentration in the desorption product is >90% for all adsorbents in pellet form. This is the first report of such high CO(2) product concentrations from a single cycle, using atmospheric air.
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Affiliation(s)
- Amy Nicki Stuckert
- Department of Chemical Engineering, University of Michigan, Ann Arbor Michigan 48105, United States
| | - Ralph T Yang
- Department of Chemical Engineering, University of Michigan, Ann Arbor Michigan 48105, United States
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Nasr V, Emmanuel J, Deutsch N, Slack M, Kanter J, Ratnayaka K, Levy R. Carbon monoxide re-breathing during low-flow anaesthesia in infants and children. Br J Anaesth 2010; 105:836-41. [PMID: 20947594 DOI: 10.1093/bja/aeq271] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Carbon monoxide (CO) has been detected within anaesthesia breathing systems. One potential source in this setting is exhaled endogenous CO. We hypothesized that CO is re-breathed during low-flow anaesthesia (LFA) in infants and children. METHODS Twenty children (age 2 months-7 yr) undergoing general anaesthesia were evaluated in a prospective observation study. LFA was established for 60 min followed by high-flow anaesthesia (HFA) for the next 60 min. Exhaled and inspired CO were measured every 5 min within the breathing circuit. Carboxyhaemoglobin (COHb%) was measured at baseline, at 60 min, after LFA, and at 120 min, after HFA. RESULTS CO concentrations increased during LFA. Inspired CO peaked at 14 ppm. During HFA, exhaled CO levels remained constant whereas inspired CO decreased markedly. Exhaled and inspired CO during HFA differed significantly from LFA. The trajectory of change in exhaled and inspired CO was most closely associated with the fresh-gas flow (FGF):minute ventilation ratio. COHb% significantly increased in children <2 yr of age at 60 min after LFA and remained increased. CONCLUSIONS LFA increased exhaled and inspired CO and increased COHb% in children <2 yr of age. Thus, LFA resulted in re-breathing of exhaled CO and exposure, especially in the youngest children. Re-breathing exhaled gas during LFA could pose a risk for an acute CO exposure in patients who have elevated COHb and high baseline levels of exhaled CO. If practitioners match or exceed minute ventilation with FGF to avoid LFA, CO re-breathing can be limited.
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Affiliation(s)
- V Nasr
- Division of Anesthesiology and Pain Medicine, Children's National Medical Center, The George Washington University School of Medicine and Health Sciences, 111 Michigan Ave., NW, Washington, DC 20010, USA
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Belmabkhout Y, Serna-Guerrero R, Sayari A. Amine-bearing mesoporous silica for CO2 removal from dry and humid air. Chem Eng Sci 2010. [DOI: 10.1016/j.ces.2010.02.044] [Citation(s) in RCA: 194] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Levy RJ, Nasr VG, Rivera O, Roberts R, Slack M, Kanter JP, Ratnayaka K, Kaplan RF, McGowan FX. Detection of Carbon Monoxide During Routine Anesthetics in Infants and Children. Anesth Analg 2010; 110:747-53. [DOI: 10.1213/ane.0b013e3181cc4b9f] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Belmabkhout Y, Serna-Guerrero R, Sayari A. Adsorption of CO2-Containing Gas Mixtures over Amine-Bearing Pore-Expanded MCM-41 Silica: Application for Gas Purification. Ind Eng Chem Res 2009. [DOI: 10.1021/ie900837t] [Citation(s) in RCA: 225] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Youssef Belmabkhout
- Department of Chemistry and Department of Chemical Engineering, University of Ottawa, Ottawa, Ontario, K1N 6N5, Canada
| | - Rodrigo Serna-Guerrero
- Department of Chemistry and Department of Chemical Engineering, University of Ottawa, Ottawa, Ontario, K1N 6N5, Canada
| | - Abdelhamid Sayari
- Department of Chemistry and Department of Chemical Engineering, University of Ottawa, Ottawa, Ontario, K1N 6N5, Canada
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Effects of temperature gradient reduction in three different carbon dioxide absorbents. Eur J Anaesthesiol 2009; 26:469-74. [DOI: 10.1097/eja.0b013e328324b709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Yamakage M, Takahashi K, Takahashi M, Satoh JI, Namiki A. Performance of four carbon dioxide absorbents in experimental and clinical settings. Anaesthesia 2009; 64:287-92. [DOI: 10.1111/j.1365-2044.2008.05759.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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An evaluation of the contributions by fresh gas flow rate, carbon dioxide concentration and desflurane partial pressure to carbon monoxide concentration during low fresh gas flows to a circle anaesthetic breathing system. Eur J Anaesthesiol 2008; 25:620-6. [PMID: 18339215 DOI: 10.1017/s0265021508003918] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE Numerous in vitro studies have shown that volatile anaesthetics react with desiccated carbon dioxide (CO2) absorbents to produce carbon monoxide (CO). The effects of anaesthetic concentration, fresh gas flow rate, and the hydration of absorbent or the excretion of CO2 by patients on CO production have also been investigated. This work aims to identify the most significant one of these factors on CO concentration in a low-flow anaesthesia system, without control of the hydration of the absorbents. METHODS A simulated clinical circle anaesthetic breathing system was used to study the CO concentration under various conditions. Desflurane was used at three different concentrations. Two CO2 flow rates and three fresh gas flow rates were used. The absorbent temperatures and hydration were measured simultaneously. RESULTS Desflurane degraded to produce CO in the breathing tube, when the CO2 absorbents were not dried beforehand. In this imitation clinical low-flow setting, fresh gas flow affected the CO production more than the CO2 did (31.7% vs. 9.5%). The actual desflurane partial pressure was not a significant factor. The CO2 flow rate explained 18.2% and 54.0% of the variation of the absorbent hydration changes (%) and temperature, respectively. CONCLUSIONS In clinical practice, the CO2 production varies among patients and is uncontrollable, but markedly affects CO production. The only controllable factor is the fresh gas flow rate if the ultimate goal is to reduce the undesirable exposure of patients to CO from the breathing tube according to this bench model without counting the oxygen consumption.
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Keijzer C, Perez RSGM, de Lange JJ. Detection of carbon monoxide production as a result of the interaction of five volatile anesthetics and desiccated sodalime with an electrochemical carbon monoxide sensor in an anesthetic circuit compared to gas chromatography. J Clin Monit Comput 2007; 21:257-64. [PMID: 17597416 DOI: 10.1007/s10877-007-9083-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2007] [Accepted: 06/08/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVES There is a continuing risk of production of toxic levels of carbon monoxide (CO) as a result of interaction of volatile anesthetics and desiccated strong base carbon dioxide absorbents like soda lime. The aim of this study is to establish the reliability of detection of CO levels by an electrochemical carbon monoxide sensor compared to gas chromatography. METHODS Completely desiccated sodalime was conducted through a circle anesthesia system connected to an artificial lung. For different rates of CO production, a low flow anesthesia with a oxygen/nitrous oxide mixture was maintained using five volatile anesthetics. For quantification of CO production, a portable gas chromatograph (GC) was connected to this setup, as well as a Bedfont EC40 electrochemical carbon monoxide sensor (ES) with a claimed reliable sensitivity of 0-200 parts per million (ppm) and a maximum detection range of more than 5500 ppm. To assess the agreement between the GC and ES measurements the intra class correlation coefficient (ICC) and the 95% limits of agreement were calculated. Bland and Altman scatterplots were made to visualize the difference between measurements. RESULTS For concentrations up to 200 ppm, no significant differences between the GC and ES mean CO measurements were found in the halothane experiments. However CO was not accurately measured at every moment during these experiments by the ES. For concentrations above 200 ppm the results of the two instruments differed significantly. The ES malfunctioned when exposed to sevoflurane and desiccated sodalime. CONCLUSIONS From these data we conclude that the ES can only be used as an indicator of CO production. When this sensor is used with sevoflurane and desiccated sodalime it is not capable of normal operation. The use of a strong base free carbon dioxide absorbent is therefore recommended.
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Affiliation(s)
- Christiaan Keijzer
- Department of Anesthesiology and Intensive Care, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, Amsterdam, The Netherlands.
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Marini F, Bellugi I, Gambi D, Pacenti M, Dugheri S, Focardi L, Tulli G. Compound A, formaldehyde and methanol concentrations during low-flow sevoflurane anaesthesia: comparison of three carbon dioxide absorbers. Acta Anaesthesiol Scand 2007; 51:625-32. [PMID: 17430327 DOI: 10.1111/j.1399-6576.2007.01278.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To determine compound A, formaldehyde and methanol concentrations in low-flow anaesthesia using different carbon dioxide absorbers. METHODS Fifteen patients scheduled for general or urological surgery were exposed to low-flow (500 ml/min) anaesthesia with sevoflurane. The patients were randomly allocated to three groups: soda lime, DrägerSorb Free or Amsorb Plus. The concentrations of compound A, formaldehyde and methanol were sampled and analysed from the limbs of the anaesthesia circuit at T30 (30 min after the start of low-flow sevoflurane anaesthesia), T90 (90 min) and T150 (150 min). The temperatures of the absorbers were measured at the same time. RESULTS Statistically significant differences (P < 0.05) were found in the production of compound A from soda lime (with the highest values), DrägerSorb Free and Amsorb Plus at each measurement time. Only traces of methanol (ranging from < 0.131 to 3.799 mg/m(3)) were measured, higher with Amsorb Plus (statistically significant differences were found only at T90). The formaldehyde values (ranging from < 0.1227 to 17.79 mcg/m(3) p.p.b.) were higher with soda lime, and the difference was statistically significant at T150 and, in the inspiratory limb only, at T90. The temperatures of the absorbers were higher for soda lime and lower for Amsorb Plus; the difference was statistically significant at T0 in the upper canister and at T30 in both canisters. CONCLUSION The concentrations of harmful products in the circuit were negligible and were lower using the new-generation absorbers. Using Amsorb Plus, the temperatures in the canisters were lower than with the other two absorbers.
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Affiliation(s)
- F Marini
- Department of Anaesthesia and Intensive Care, Nuovo Ospedale San Giovanni di Dio, Via Mannelli no. 87, 50136 Florence, Italy.
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Keijzer C, Perez RSGM, de Lange JJ. Compound A and carbon monoxide production from sevoflurane and seven different types of carbon dioxide absorbent in a patient model. Acta Anaesthesiol Scand 2007; 51:31-7. [PMID: 17096668 DOI: 10.1111/j.1399-6576.2006.01187.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The degradation of sevoflurane can lead to the production of compound A (CA) and carbon monoxide (CO) and an increase in temperature of the absorbent. CA is known to be nephrotoxic in rats. These reactions depend on the strong base and water contents of the carbon dioxide absorbent used. The purpose of this study was to measure the maximum amounts of CA and CO produced, and the temperature increase, for seven different carbon dioxide absorbents for sevoflurane containing different contents of strong bases. METHODS Seven absorbents [some free of strong bases (f)] were employed in hydrated (h) and completely desiccated (d) conditions in a patient model, using a circle anesthesia system connected to an artificial lung. Low-flow anesthesia with an oxygen-nitrous oxide mixture was maintained using 0.8% sevoflurane. For the quantification of CA and CO, a portable gas chromatograph was used. The temperature was measured inside the absorbent. RESULTS In consecutive order of CA-producing potency, Amsorb(f)(d), Drägersorb(h), Medisorb(h), lithium hydroxide(f)(d), Drägersorb(d), Medisorb(d), Spherasorb(h) and Spherasorb(d) produced small amounts of CA. Loflosorb and Superia, which are free of strong bases, did not produce any CA or CO in hydrated or desiccated conditions. Only desiccated Drägersorb, Medisorb and Spherasorb demonstrated small amounts of CO accompanied by a significant temperature increase. CONCLUSION In this patient model, we demonstrated that different types of absorbent produced small amounts of CA and CO or none at all. No relationship could be established between temperature and CA concentration.
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Affiliation(s)
- C Keijzer
- Department of Anesthesiology and Intensive Care, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands.
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Coppens MJ, Versichelen LFM, Rolly G, Mortier EP, Struys MMRF. The mechanisms of carbon monoxide production by inhalational agents. Anaesthesia 2006; 61:462-8. [PMID: 16674622 DOI: 10.1111/j.1365-2044.2006.04536.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Carbon monoxide can be formed when volatile anaesthetic agents such as desflurane and sevoflurane are used with anaesthetic breathing systems containing carbon dioxide absorbents. This review describes the possible chemical processes involved and summarises the experimental and clinical evidence for the generation of carbon monoxide. We emphasise the different conditions that were used in the experimental work, and explain some of the features of the clinical reports. Finally, we provide guidelines for the prevention and detection of this complication.
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Affiliation(s)
- M J Coppens
- Department of Anaesthesia, Ghent University Hospital, De Pintelaan 185, b-9000, Ghent, Belgium.
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Sakai EM, Connolly LA, Klauck JA. Inhalation Anesthesiology and Volatile Liquid Anesthetics: Focus on Isoflurane, Desflurane, and Sevoflurane. Pharmacotherapy 2005; 25:1773-88. [PMID: 16305297 DOI: 10.1592/phco.2005.25.12.1773] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Clinical pharmacists rarely are involved in the selection and dosing of anesthetic agents. However, when practicing evidence-based medicine in a cost-conscious health care system, optimizing drug therapy is imperative in all areas. Thus, we provide general information on anesthesiology, including the different types of breathing systems and the components of anesthesia machines. Modern inhalation anesthetics that are predominantly used in clinical practice include one gas--nitrous oxide--and new volatile liquid agents--isoflurane, desflurane, and sevoflurane. Desflurane and sevoflurane are the low-soluble inhalation anesthetics, and they offer some clinical advantages over isoflurane, such as fast induction and faster recovery with long procedures. However, efficient use of isoflurane can match the speed of induction and recovery of the other agents in certain cases. In addition, the patient characteristics, duration and type of procedure, type of breathing system, and efficiency in monitoring must be considered when selecting the most optimal therapy for each patient. Maximizing the clinical advantages of these agents while minimizing the waste of an institution's operating room and pharmacy budget requires an understanding of the characteristics, pharmacokinetics, and pharmacodynamics of these anesthetic agents and the collaborated effort from both the anesthesia and pharmacy departments. An anesthetic agent algorithm is provided as a sample decision-process tree for selecting among isoflurane, desflurane, and sevoflurane.
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Affiliation(s)
- Eileen M Sakai
- Department of Pharmacy, Froedtert Memorial Lutheran Hospital, and the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
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Abstract
Even when anaesthesia does not represent a major part of the expense of a given surgical operation, reducing costs is not negligible because the large number of patients passing through a department of anaesthesia accounts for a huge annual budget. Volatile anaesthetics contribute 20% of the drug expenses in anaesthesia, coming just behind the myorelaxants; however, the cost of halogenated agents has potential for savings because a significant part of the delivered amount is wasted when a non- or partial-rebreathing system is used. The cost of inhaled agents is related to more than the amount taken up; it also depends on their market prices, their relative potencies, the amount of vapour released per millilitre of liquid, and last but not least the fresh-gas flow rate (FGF) delivered to the vaporizer--the most important factor determining the cost of anaesthesia. Poorly soluble agents like desflurane and sevoflurane facilitate the control of low-flow anaesthesia and reduce the duration of temporary high-flow phases to rapidly wash in or adjust the circuit gas concentrations. Modelling low-flow or minimal-flow anaesthesia will help anaesthetists to understand the kinetics of inhaled agents in those circumstances and to design their own clinical protocols. The monitoring facilities present on modern anaesthesia machines should convince clinicians that low- or even minimal-flow anaesthesia would not jeopardize the safety of their patients. Cost containment requires primarily a decrease in FGFs, but it may also be influenced by a rational use of the available halogenated agents. Isoflurane, the cheapest generic agent, might be advantageous for maintenance of anaesthesia of less than 3 hours. Sevoflurane is the agent of choice for inhalational induction and might also be used for maintenance. Desflurane might be preferred for long anaesthetics where rapid recovery will generate savings in the PACU.
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Affiliation(s)
- I Odin
- University Hospital of Limoges, France
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Laster MJ, Eger EI. Temperatures in soda lime during degradation of desflurane, isoflurane, and sevoflurane by desiccated soda lime. Anesth Analg 2005; 101:753-757. [PMID: 16115987 DOI: 10.1213/01.ane.0000166953.89536.ed] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Rarely, fire and patient injury result from the degradation of sevoflurane by desiccated Baralyme. The present investigation sought to determine whether high temperatures also arose with sevoflurane use in the presence of desiccated soda lime. We desiccated soda lime by directing a 10 L/min flow of oxygen through fresh absorbent. Using 1140 +/- 30 g (mean +/- sd) of this desiccated absorbent, we filled a single standard absorber canister placed in a standard anesthetic circuit to which we directed a 6 L/min flow of oxygen containing 1.5 minimum alveolar concentration (MAC) desflurane or sevoflurane, or 3.0 MAC desflurane, isoflurane, or sevoflurane (with and without concurrent delivery of 200 mL/min carbon dioxide). In an additional test, 2 canisters (rather than a single canister) containing desiccated absorbent were used and 3.0 MAC sevoflurane was applied. A 3-L reservoir bag served as a surrogate lung, and we ventilated this lung with a minute ventilation of 10 L/min. With desflurane at 1.5 MAC or 3.0 MAC or isoflurane at 3.0 MAC temperatures increased in 20 to 40 min to a peak of 30 degrees C to 45 degrees C and then declined. With 1.5 or 3.0 MAC sevoflurane, temperatures increased to approximately 90 degrees C, after which temperatures declined. Concurrent delivery of carbon dioxide and sevoflurane did not increase the peak temperatures reached. The use of 2 canisters increased the duration but not the peak of increased temperature reached with 3.0 MAC sevoflurane. No fires resulted from degradation of any anesthetic.
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Affiliation(s)
- Michael J Laster
- From the Department of Anesthesia and Perioperative Care, University of California, San Francisco, California
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Keijzer C, Perez RSGM, de Lange JJ. Carbon monoxide production from desflurane and six types of carbon dioxide absorbents in a patient model. Acta Anaesthesiol Scand 2005; 49:815-8. [PMID: 15954965 DOI: 10.1111/j.1399-6576.2005.00690.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Desflurane is known to produce high concentrations of carbon monoxide (CO) in desiccated sodalime or Baralyme (Allied Healthcare Products, St. Louis, MO). Desiccated absorbents without strong bases like potassium hydroxide or sodium hydroxide are reported to produce less or no CO at all. The purpose of this study is to compare the concentration of CO in an anesthesia circuit for desflurane with six different types of completely desiccated CO(2) absorbents with less strong bases than sodalime. METHODS A patient model was simulated using a circle anesthesia system connected to an artificial lung. Completely desiccated CO(2) absorbent (950 g) was used in this system. A low flow anesthesia (500 ml min(-1)) was maintained using desflurane. For immediate quantification of CO production a portable gas chromatograph was used. RESULTS Peak concentrations of CO were very high in Medisorb (Datex-Ohmeda, Hoevelaken, The Netherlands) and Spherasorb (Intersurgical, Uden, The Netherlands) (13317 and 9045 p.p.m., respectively). It was lower with Loflosorb (Intersurgical, Uden, The Netherlands) and Superia (Datex-Ohmeda, Hoevelaken, The Netherlands) (524 and 31 p.p.m., respectively). Amsorb (Armstrong, Coleraine, N. Ireland) and lithium hydroxide produced no CO at all. CONCLUSION Medisorb and Spherasorb are capable of producing large concentrations of CO when desiccated. Loflosorb and Superia produce far less CO under the same conditions. Amsorb and lithium hydroxide should be considered safe when desiccated.
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Affiliation(s)
- C Keijzer
- Department of Anesthesiology, VU University Medical Center, Amsterdam, the Netherlands.
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Keijzer C, Perez RSGM, De Lange JJ. Carbon monoxide production from five volatile anesthetics in dry sodalime in a patient model: halothane and sevoflurane do produce carbon monoxide; temperature is a poor predictor of carbon monoxide production. BMC Anesthesiol 2005; 5:6. [PMID: 15932634 PMCID: PMC1164401 DOI: 10.1186/1471-2253-5-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2004] [Accepted: 06/02/2005] [Indexed: 11/24/2022] Open
Abstract
Background Desflurane and enflurane have been reported to produce substantial amounts of carbon monoxide (CO) in desiccated sodalime. Isoflurane is said to produce less CO and sevoflurane and halothane should produce no CO at all. The purpose of this study is to measure the maximum amounts of CO production for all modern volatile anesthetics, with completely dry sodalime. We also tried to establish a relationship between CO production and temperature increase inside the sodalime. Methods A patient model was simulated using a circle anesthesia system connected to an artificial lung. Completely desiccated sodalime (950 grams) was used in this system. A low flow anesthesia (500 ml/min) was maintained using nitrous oxide with desflurane, enflurane, isoflurane, halothane or sevoflurane. For immediate quantification of CO production a portable gas chromatograph was used. Temperature was measured within the sodalime container. Results Peak concentrations of CO were very high with desflurane and enflurane (14262 and 10654 ppm respectively). It was lower with isoflurane (2512 ppm). We also measured small concentrations of CO for sevoflurane and halothane. No significant temperature increases were detected with high CO productions. Conclusion All modern volatile anesthetics produce CO in desiccated sodalime. Sodalime temperature increase is a poor predictor of CO production.
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Affiliation(s)
- Christiaan Keijzer
- Department of anesthesiology, VU University medical center, Amsterdam, The Netherlands
| | - Roberto SGM Perez
- Department of anesthesiology, VU University medical center, Amsterdam, The Netherlands
| | - Jaap J De Lange
- Department of anesthesiology, VU University medical center, Amsterdam, The Netherlands
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Boller M, Moens Y, Kästner SBN, Bettschart-Wolfensberger R. Closed system anaesthesia in dogs using liquid sevoflurane injection; evaluation of the square-root-of-time model and the influence of CO 2 absorbent. Vet Anaesth Analg 2005; 32:168-77. [PMID: 15877663 DOI: 10.1111/j.1467-2995.2005.00193.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine whether predictable alveolar concentrations of sevoflurane are reliably produced in dogs when liquid sevoflurane is injected into closed circuit breathing systems, as calculated by Lowe's square-root-of-time anaesthetic uptake model, and to confirm the validity of the model using soda lime and calcium hydroxide lime. STUDY DESIGN Prospective clinical study. ANIMALS Eleven healthy dogs with a mean body mass of 34 +/- 9 kg scheduled for pelvic limb orthopaedic surgery. MATERIALS AND METHODS Following pre-anaesthetic medication, anaesthesia was induced with propofol and maintained with sevoflurane in a closed circle system. Epidural anaesthesia was performed with morphine and bupivacaine. Liquid sevoflurane was injected into the circuit by syringe, using dosages and time intervals derived from Lowe's square-root-of-time anaesthetic uptake model. The target alveolar concentration chosen was 1.1 x MAC (2.6% end-tidal sevoflurane). Either soda lime (group S; n = 6) or calcium hydroxide lime (Amsorb; group A; n = 5) were used for CO(2) absorption. Sevoflurane concentration and the respiratory gas composition were measured with an infrared gas analyser. RESULTS End-tidal sevoflurane concentrations were close to the predicted value of 2.6% at 9 minutes (2.53 +/- 0.1% group S; 2.60 +/- 0.26% group A) and 16 minutes (2.55 +/- 0.30 group S; 2.52 +/- 0.28% group A) but declined thereafter to reach 50% (group S) and 64% (group A) of the predicted value at 121 minutes. There was a constant trend towards higher end-tidal sevoflurane concentrations in group A but the difference was not statistically significant. CONCLUSIONS The square-root-of-time model leads to significantly lower alveolar concentrations than expected, suggesting that the rate of sevoflurane uptake in dogs declines less rapidly than predicted. The use of Amsorb tends to reduce the deviation from predicted concentrations. CLINICAL RELEVANCE The model used in this study provided only an approximate guide to the volume of liquid sevoflurane required. Consequently, the definitive dose schedule must be based on measured anaesthetic concentrations and clinical monitoring.
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Affiliation(s)
- Manuel Boller
- Anaesthesia Section, Vetsuisse Faculty, University of Zurich, Switzerland.
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30
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Abstract
Rarely, fire and patient injury have resulted from the degradation of sevoflurane by desiccated carbon dioxide absorbent. Desiccated absorbent also can degrade desflurane and isoflurane, and in the present investigation we sought to determine whether a danger of fire also arose with their use in the presence of desiccated absorbent. Baralyme was desiccated by heating and directing a 10 L/min flow of oxygen through the absorbent. Approximately 1200 g of this desiccated absorbent was used to fill a standard absorber placed in a standard anesthetic circuit to which we directed a 6 L/min flow of oxygen containing 1.5 or 3.0 MAC desflurane, isoflurane, or sevoflurane. A 3-L reservoir bag served as a surrogate lung, and we ventilated this lung with a minute ventilation of 10 L/min. With desflurane or isoflurane, at both 1.5 MAC and 3.0 MAC, temperatures increased in 30 to 70 min to a peak of approximately 100 degrees C and then decreased. With 1.5 MAC sevoflurane (3.0 MAC was not studied), temperatures increased to over 200 degrees C, and in 2 of 5 studies, flames appeared in the anesthetic circuit. In a separate study, we found that concurrent delivery of carbon dioxide and desflurane did not increase peak temperatures. We conclude that the interaction of desflurane or isoflurane with desiccated absorbent is not likely to produce the conflagrations possible with sevoflurane.
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Affiliation(s)
- Michael Laster
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, California
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Struys MMRF, Bouche MPLA, Rolly G, Vandevivere YDI, Dyzers D, Goeteyn W, Versichelen LFM, Van Bocxlaer JFP, Mortier EP. Production of compound A and carbon monoxide in circle systems: an in vitro comparison of two carbon dioxide absorbents. Anaesthesia 2004; 59:584-9. [PMID: 15144299 DOI: 10.1111/j.1365-2044.2004.03704.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Two new generation carbon dioxide absorbents, DrägerSorb Free and Amsorb Plus, were studied in vitro for formation of compound A or carbon monoxide, during minimal gas flow (500 ml x min(-1)) with sevoflurane or desflurane. Compound A was assessed by gas chromatography/mass spectrometry and carbon monoxide with continuous infrared spectrometry. Fresh and dehydrated absorbents were studied. Mean (SD) time till exhaustion (inspiratory carbon dioxide concentration >or= 1 kPa) with fresh absorbents was longer with DrägerSorb Free (1233 (55) min) than with Amsorb Plus (1025 (55) min; p < 0.01). For both absorbents, values of compound A were < 1 ppm and therefore below clinically significant levels, but were up to 0.25 ppm higher with DrägerSorb Free than with Amsorb Plus. Using dehydrated absorbents, values of compound A were about 50% lower than with fresh absorbents and were identical for DrägerSorb Free and Amsorb Plus. With dehydrated absorbents, no detectable carbon monoxide was found with desflurane.
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Affiliation(s)
- M M R F Struys
- Department of Anaesthesia, Ghent University Hospital, Ghent, Belgium.
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Yamakage M, Yoshida SI, Iwasaki S, Mizu-Uchi M, Namiki A. The Type of Carbon Dioxide Absorbent has no Relation to the Concentration of Carbon Monoxide in the Breathing Circuit during Low-flow Isoflurane Anaesthesia in Smoking and Non-smoking Subjects. Anaesth Intensive Care 2004; 32:230-5. [PMID: 15957721 DOI: 10.1177/0310057x0403200211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The present study was designed to investigate the concentrations of carbon monoxide (CO) in the anaesthetic circuit and of arterial carboxyhaemoglobin (COHb) during low-flow isoflurane anaesthesia in smoking and non-smoking subjects using three kinds of cardon dioxide (CO2) absorbent. Thirty smoking and 30 non-smoking subjects were selected for this study, and these two groups were each divided into three groups according to the type of CO2absorbent used (Wakolime™A, Drägersorb™Free, and Amsorb™). Anaesthesia was maintained with 1.0% isoflurane and nitrous oxide (1.0l min–1)/oxygen (1.0l min–1). Concentrations of CO in the inspired breathing circuit and concentrations of arterial COHb were measured at 0, 1, 2, 3, and 4 hours after exposure to isoflurane. In the smoking groups there were no significant differences in CO concentrations in the circuit between the groups and the CO concentrations did not change significantly during the study period. There were also no significant differences in the arterial COHb values between the groups and the COHb concentrations remained constant. There was a significant linear correlation between the concentrations of CO and COHb (r=0.86, n=30, P<0.001). In the nonsmoking groups all of the parameters remained constant at low levels that were independent of the type of CO2absorbents tested. The major source for increased intraoperative CO exposure is related to the patient's smoking status, and the type of CO2absorbent used has no relation to an increase in CO concentration in the breathing circuit.
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Affiliation(s)
- M Yamakage
- Department of Anesthesiology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
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Knolle E, Linert W, Gilly H. The color change in CO2 absorbents on drying: an in vitro study using moisture analysis. Anesth Analg 2003; 97:151-5, table of contents. [PMID: 12818958 DOI: 10.1213/01.ane.0000066264.64544.dc] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Alkali hydroxide-free absorbents change color markedly when they dry, whereas absorbents containing alkali hydroxides do not. We investigated whether this observation can be explained by the weaker hygroscopic properties of pure calcium hydroxide compared with alkali hydroxides. Samples of the alkali hydroxide-free absorbents Amsorb or Superia and samples of these two absorbents with 1% or 3% NaOH or 3% KOH added were dried in a moisture analyzer at 105 degrees C to determine their moisture content and to assess the color of the samples during drying (each group, n = 5). Additionally, we repeated the experiments with pulverized samples of Baralyme and Spherasorb, which contain approximately 4% KOH and 1% NaOH, respectively. Amsorb and Superia changed color long before they were dry. After the addition of 1% NaOH, and as with the Spherasorb samples, the drying time required for a color change was longer, and the intensity of the resulting violet was less. This effect was even stronger when 3% NaOH was added. The samples with added KOH and the Baralyme did not change color at all on drying. We conclude that the differences in color change on drying in absorbents with varying NaOH or KOH content cannot be explained by larger water retention because of the hygroscopic properties of the alkali hydroxides. IMPLICATIONS In an in vitro study, the moisture content and color change on drying were determined in samples of Amsorb or Superia and in the same absorbents with added NaOH or KOH. With increasing concentrations of alkali hydroxide, a delay in the color change upon drying was observed. However, the moisture content did not change.
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Affiliation(s)
- Erich Knolle
- Department of Anesthesiology and General Intensive Care (B), University of Vienna, Austria.
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Tempia A, Olivei MC, Calza E, Lambert H, Scotti L, Orlando E, Livigni S, Guglielmotti E. The anesthetic conserving device compared with conventional circle system used under different flow conditions for inhaled anesthesia. Anesth Analg 2003; 96:1056-1061. [PMID: 12651660 DOI: 10.1213/01.ane.0000050558.89090.95] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
UNLABELLED The Anesthetic Conserving Device (ACD) is a high-flow anesthesia system closed to volatile anesthetics only. We compared the ACD with a circle system under different fresh gas flow (FGF) conditions. Eighty-one patients undergoing major surgery were randomly allocated to receive sevoflurane from a circle circuit combined either with the ACD placed at the Y-piece (n = 41) or with a vaporizer (n = 40). The FGF was set to 8 L/min in the ACD system, where the circle circuit served as a nonrebreather. In the conventional circle system without ACD, the vaporizer was supplied with 1-, 1.5-, 3-, and 6-L/min FGFs. We compared the ACD with the circle system under the four FGFs in terms of sevoflurane dosing, sevoflurane consumption, humidification efficiency, and environmental pollution. The ACD and the low-flow circle system (1.5- and 1-L/min FGFs) resulted in the smallest sevoflurane consumption. The increase in inspired sevoflurane concentration was faster with the circle system than with the ACD only with FGFs > or =3 L/min. The removal of ACD from the circuit allowed the fastest washout of sevoflurane. Respiratory gas humidification was always adequate. Sevoflurane ambient concentration with the ACD was 1-70 ppb. The ACD is a valid and simple alternative to low-flow systems. IMPLICATIONS The Anesthetic Conserving Device (ACD) is a new device for anesthetic vapor delivery. We demonstrated that the ACD reduces anesthetic consumption and environmental pollution similarly to a low-flow circle system, offering advantages such as simplicity, no toxicity from compounds produced in the absorber, and potential cost savings.
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Affiliation(s)
- Augusto Tempia
- *Istituto di Anestesia e Rianimazione Ospedale San Luigi, Orbassano, Italy; Servizio di Anestesia †A e ‡B, Ospedale San Giovanni Bosco, Torino, Italy; §Istituto di Anestesia e Rianimazione Ospedale San Giovanni Battista, Torino, Italy; and ∥Hudson RCI, Upplands Väsby, Sweden
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Abstract
The halogenated inhalational anaesthetics halothane, enflurane, isoflurane and desflurane can produce metabolic hepatocellular injury in humans to a variable extent. During metabolism of these anaesthetics, tissue acetylation occurs due to the formation of reactive intermediates. Proteins modified by acetylation may constitute neo-antigens with a potential for triggering an antibody-mediated immune response. The likelihood of suffering post-operative immune hepatitis depends on the amount of the anaesthetic metabolized and is thereby considerably less with enflurane, isoflurane or desflurane compared with halothane. Plasma inorganic fluoride concentrations are regularly increased after sevoflurane. Elevated inorganic fluoride concentrations have been associated with nephrotoxicity following methoxyflurane anaesthesia but not after sevoflurane. Another source of concern is the products of degradation from reactions with carbon dioxide absorbents. Most important is compound A, which has been shown to exhibit nephrotoxicity in rodents. However, no significant changes in renal function parameters have been reported in surgical patients.
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Affiliation(s)
- Florian M Reichle
- Department of Anaesthesiology, University of Munich, Marchioninistrasse 15, 81377 Munich, Germany.
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Baum JA, Woehlck HJ. Interaction of inhalational anaesthetics with CO2 absorbents. Best Pract Res Clin Anaesthesiol 2003; 17:63-76. [PMID: 12751549 DOI: 10.1053/bean.2003.0269] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We review the currently available carbon dioxide absorbents: sodium hydroxide lime (=soda lime), barium hydroxide lime, potassium-hydroxide-free soda lime, calcium hydroxide lime and non-caustic lime. In general, all of these carbon dioxide absorbents are liable to react with inhalational anaesthetics. However, there is a decreasing reactivity of the different absorbents with inhalational anaesthetics: barium hydroxide lime >> soda lime > potassium-hydroxide-free soda lime > calcium hydroxide lime and non-caustic lime. Gaseous compounds generated by the reaction of the anaesthetics with desiccated absorbents are those that threaten patients. All measures are comprehensively described to--as far as possible--prevent any accidental drying out of the absorbent. Whether or not compound A, a gaseous compound formed by the reaction of sevoflurane with normally hydrated absorbents, is still a matter of concern is discussed. Even after very high loading with this compound, during long-lasting low-flow sevoflurane anaesthesias, no clinical or laboratory signs of renal impairment were observed in any of the surgical patients. Finally, guidelines for the judicious use of different absorbents are given.
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Affiliation(s)
- Jan A Baum
- Department of Anaesthesia, Hospital St Elisabeth-Stift, Lindenstrasse 3-7, D-49401 Domme, Germany.
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Kobayashi S, Bito H, Obata Y, Katoh T, Sato S. Compound A concentration in the circle absorber system during low-flow sevoflurane anesthesia: comparison of Drägersorb Free, Amsorb, and Sodasorb II. J Clin Anesth 2003; 15:33-7. [PMID: 12657409 DOI: 10.1016/s0952-8180(02)00478-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE To determine compound A concentrations in a low-flow circuit containing Drägersorb Free (Dräger, Lübeck, Germany), Amsorb (Armstrong, Coleraine, Northern Ireland), and Sodasorb II (W. R. Grace, Lexington, MA). DESIGN Randomized study. SETTING Hamamatsu University Hospital. PATIENTS 24 ASA physical status I and II patients scheduled for general anesthesia greater than 3 hours' duration. INTERVENTIONS Patients were allocated to three groups of eight patients each to receive either using either Drägersorb Free, Amsorb, or Sodasorb II. Immediately before anesthesia induction, 1 kg of fresh absorbent was placed in the anesthesia canister. Anesthesia was maintained with sevoflurane (end-tidal concentration 1% to 3%) in oxygen and nitrous oxide (FIO(2) > 0.3) at a total flow of 1 L/min. MEASUREMENTS Inspiratory compound A concentration in the circuit was measured once every hour. MAIN RESULTS Maximum compound A concentrations for Drägersorb Free, Amsorb, and Sodasorb II were 2.4 +/- 0.8 (mean +/- SD) ppm, 3.1 +/- 0.5 ppm, and 28.0 +/- 10.0 ppm (p < 0.01 vs. Drägersorb Free and Amsorb). Concentrations with Drägersorb Free and Amsorb remained at less than 4 ppm throughout the study. CONCLUSIONS Because compound A concentrations in the circuit with Drägersorb Free and Amsorb were negligible, sevoflurane can be used at a fresh gas flow of 1 L/min with these two absorbents.
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Affiliation(s)
- Shunji Kobayashi
- Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, Japan.
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Krause T, Scholz J, Jansen L, Boettcher H, Koch C, Wappler F, Schulte am Esch J. Sevoflurane anaesthesia does not induce the formation of sister chromatid exchanges in peripheral blood lymphocytes of children. Br J Anaesth 2003; 90:233-5. [PMID: 12538381 DOI: 10.1093/bja/aeg030] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Compound A, a degradation product of sevoflurane, has been demonstrated to induce sister chromatid exchanges (SCE) in Chinese hamster ovary cells in vitro as a marker for possible genotoxicity. We investigated the formation of SCE in mitogen-stimulated T-lymphocytes of 40 children undergoing sevoflurane anaesthesia for minor surgical procedures. METHODS Anaesthesia was induced by inhalation of up to 8% sevoflurane and maintained at 2.5-3% in oxygen/nitrous oxide (65/35%) at a fresh gas flow of 3 litre min(-1). Soda lime (humidity 12-15%) was used as a carbon dioxide absorbent. Blood was drawn directly before induction and after termination of anaesthesia. Twenty-five second division metaphases of mitogen-stimulated T-lymphocytes per blood sample were screened for SCE rates using standard techniques. RESULTS Average duration of anaesthesia was 49.6 (SD 24.0) min. Before anaesthesia induction, 7.93 (1.23) SCE per metaphase were determined. After sevoflurane anaesthesia [1.40 (0.77) MAC h] 7.92 (1.19) SCE per metaphase were observed. Additionally, no differences were evident between male or female children. CONCLUSION Short-term administration of sevoflurane anaesthesia did not induce SCE in T-lymphocytes of children. No indication for a possible genotoxic effect has been observed.
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Affiliation(s)
- T Krause
- Christian-Albrechts-University Kiel, Brunswiker Strasse 10, D-24105 Kiel, Germany.
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Bouche MPLA, Versichelen LFM, Struys MMRF, Van Bocxlaer JFP, De Leenheer AP, Mortier EP, Rolly G. No compound a formation with Superia during minimal-flow sevoflurane anesthesia: a comparison with Sofnolime. Anesth Analg 2002; 95:1680-5, table of contents. [PMID: 12456439 DOI: 10.1097/00000539-200212000-00039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED There is concern about the toxicity of Compound (Co) A. Absorbents differ in the production of Co A during minimal-flow sevoflurane anesthesia. Strong alkali-free Amsorb does not produce Co A. It was our aim to study Superia, another new NaOH- and KOH-free CO(2) absorbent, in minimal-flow anesthesia, compared with KOH-free Sofnolime. After Ethics Committee approval, 14 consenting adult patients were included randomly by using Superia or Sofnolime as the CO(2) absorbent in the compact 750-mL canister of an ADU ventilator. After propofol and remifentanil administration, sevoflurane was given in oxygen and air (500 mL/min; fraction of inspired oxygen, 0.4), aiming at an end-tidal concentration of 2.3%-2.5%; ventilation aimed for 33-35 mm Hg PETCO(2). Compound A inspired (Co A(insp)) and expired (Co A(exp)) samples were taken for analysis, and canister temperatures were measured for 150 min. Statistical analysis was performed with the Friedman test or the Mann-Whitney U-test where appropriate. Correction for multiple testing was used. In the Superia group, no significant amount of Co A was formed, whereas in the Sofnolime group, maximum median (range) inspiratory values of 25 ppm (16 ppm) were found. The intergroup difference was P < 0.05. No difference was noticed between the two groups for the canister CO(2) absorbent temperature. IMPLICATIONS During minimal-flow 2.3%-2.5% end-tidal sevoflurane, no compound A (Co A) is formed with the NaOH- and KOH-free CO(2) absorbent Superia. Although Co A values with KOH-free Sofnolime are still within reported safe limits, Superia is definitely an alternative for safe clinical practice.
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Affiliation(s)
- Marie-Paule L A Bouche
- Faculty of Pharmaceutical Sciences, Laboratory of Medical Biochemistry and Clinical Analysis, Ghent, Belgium
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Knolle E, Heinze G, Gilly H. Small carbon monoxide formation in absorbents does not correlate with small carbon dioxide absorption. Anesth Analg 2002; 95:650-5, table of contents. [PMID: 12198054 DOI: 10.1097/00000539-200209000-00029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED In this study we sought to determine whether an absorbent in which little carbon monoxide (CO) forms has a correspondingly small capacity to absorb carbon dioxide (CO(2)). Completely dried samples (600 g) of Baralyme (A), Drägersorb 800 (B), Drägersorb 800 Plus (C), Intersorb (D), Spherasorb (E), LoFloSorb (F), Superia (G), and Amsorb (H) were exposed to a flow of 0.5% (A-H; n = 4-5) and 4% isoflurane (F-H; n = 3) in pure oxygen at 5 L/min for 60 min. Downstream CO concentration, temperature, and isoflurane concentration were recorded every 60 s to calculate CO formation and isoflurane loss. The CO(2) absorption capacity of each brand was determined by passing 5.1% CO(2) in oxygen (flow, 250 mL/min) through untreated samples (30 g; n = 5) until the outlet CO(2) concentration reached 0.5%. CO formation was largest in absorbents containing potassium hydroxide (A and B) and negligible in absorbents not containing any alkali hydroxide (F-H). The outlet temperature correlated with CO formation, but the isoflurane loss did not. The duration of CO(2) absorption also did not correlate with CO formation. We conclude that absorbents that allow only very little CO formation are not necessarily poor CO(2) absorbents. IMPLICATIONS In an in vitro study, carbon dioxide (CO(2)) absorption capacity and possible carbon monoxide (CO) formation were tested in different absorbent brands. Absorbents with very small CO formation are not necessarily poor CO(2) absorbents.
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Affiliation(s)
- Erich Knolle
- Department of Anesthesiology and General Intensive Care (B), University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
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Knolle E, Heinze G, Gilly H. Small Carbon Monoxide Formation in Absorbents Does Not Correlate with Small Carbon Dioxide Absorption. Anesth Analg 2002. [DOI: 10.1213/00000539-200209000-00029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Di Filippo A, Marini F, Pacenti M, Dugheri S, Focardi L, Novelli GP. Sevoflurane low-flow anaesthesia: best strategy to reduce Compound A concentration. Acta Anaesthesiol Scand 2002; 46:1017-20. [PMID: 12190805 DOI: 10.1034/j.1399-6576.2002.460815.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND To define the best strategy to reduce Compound A production in Sevoflurane low-flow anaesthesia by experiments in vitro and in vivo of different absorbers and different anaesthesia machines. METHODS In vitro Compound A has been measured at 45 degrees C in vitro following Sevoflurane interactions with potassium hydroxide, sodium hydroxide, soda lime, Dragersorb 800 Plus and Amsorb, a new absorber that does not contain sodium or potassium hydroxide. In vivo Compound A concentration in the anaesthesia circuit (inspiratory branch) has been measured using an indirect sampling method through absorber vials (SKC) with active coal granules, during low flows (500 ml/min) general anaesthesia using soda lime, Dragersorb 800 Plus or Amsorb as absorber. Compound A was also measured during low flows (500 ml/min) general anaesthesia using as carbon dioxide absorber soda lime with different anaesthesia machines. RESULTS In vitro at 45 degrees C Compound A concentration with soda lime and Dragersorb 800 Plus was about 10 times higher than with Amsorb. In vivo the Compound A concentrations in the inspiratory branch of the circuit were lower in the group with Amsorb. CONCLUSION The Compound A production is minimal with Amsorb as carbon dioxide absorber.
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Affiliation(s)
- A Di Filippo
- Department of Medical and Surgical Critical Care, University of Florence, Italy.
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Abstract
Sevoflurane and desflurane have important advantages over isoflurane and halothane. Disadvantages, which the clinician should keep in mind, include the degradation of both agents by soda lime under certain circumstances during closed circuit anaesthesia. As a result compound A and carbon monoxide (CO) may be generated in soda lime canisters and may be inhaled by patients. The extent to which this constitutes a significant problem during routine anaesthesia in humans is not clear. Recent developments in absorbent technology have the potential to reduce any hazard to negligible proportions. Other undesirable properties of the newer inhalation agents include agitation with sevoflurane in children and cardiovascular and airway effects with desflurane.
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Affiliation(s)
- A Bedi
- Department of Anaesthetics and Intensive Care Medicine, The Queen's University of Belfast, Belfast, UK.
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45
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Higuchi H, Adachi Y, Arimura S, Kanno M, Satoh T. The carbon dioxide absorption capacity of Amsorb is half that of soda lime. Anesth Analg 2001; 93:221-5. [PMID: 11429370 DOI: 10.1097/00000539-200107000-00044] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED A new CO(2) absorbent, Amsorb (A), which does not contain monovalent bases, is ideal because it does not degrade volatile anesthetics to either Compound A (from sevoflurane) or carbon monoxide (from desflurane, enflurane, or isoflurane). The CO(2) absorption capacity of A, however, has not been investigated under clinical conditions. In this study, we compared the longevity (time to exhaustion) and CO(2) absorption capacity (the volume of CO(2) absorbed before CO(2) rebreathing occurs) of A under low-flow anesthesia (1 L/min) with those of two soda lime absorbents-Medisorb (M) and Sodasorb (S)-by using a 750-mL ADU canister and a 1350-mL Aestiva 3000 canister. In the study with the ADU canister, the longevity of A was 213 +/- 71 min, significantly less than those of M (445 +/- 125; P < 0.01) and S (503 +/- 89; P < 0.001). The CO(2) absorption capacity (L/100 g absorbent) of A was 5.5 +/- 1.2, significantly less than those of M (10.7 +/- 1.7) and S (12.1 +/- 1.8; P < 0.001). In the study with the Aestiva 3000 canister, the longevity of A was 218 +/- 61 min, significantly less than those of M (538 +/- 136) and S (528 +/- 103; P < 0.001). The CO(2) absorption capacity (L/100 g absorbent) of A was 7.6 +/- 1.6, significantly less than those of M (14.4 +/- 1.8) and S (14.8 +/- 2.3; P < 0.001). These results indicate that the CO(2) absorption capacity of A is half that of M or S and that the difference in the CO(2) absorption capacity between A and M or S is almost constant, regardless of the canister design. IMPLICATIONS The CO(2) absorption capacity of Amsorb is half that of Medisorb and Sodasorb under clinical low-flow (1 L/min) anesthesia with either a 750-mL Ohmeda ADU compact or a 1350-mL Ohmeda Aestiva 3000 canister.
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Affiliation(s)
- H Higuchi
- Department of Anesthesia, Self Defense Force Central Hospital, Tokyo, Japan.
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Bedi A, Gallagher AC, Fee JP, Murray JM. The in vitro performance of carbon dioxide absorbents with and without strong alkali apparatus. Anaesthesia 2001; 56:546-50. [PMID: 11412160 DOI: 10.1046/j.1365-2044.2001.01985.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report the in vitro longevity of a conventional soda lime carbon dioxide absorbent and an absorbent free from strong alkali (Amsorb). Although the times taken to breakthrough of carbon dioxide (> 0.5%) within an in vitro low flow breathing system were shorter with the alkali-free absorbent, we found that the size and shape of the absorbent container was the major factor in determining the efficiency of the carbon dioxide absorbents.
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Affiliation(s)
- A Bedi
- Department of Anaesthetics and Intensive Care Medicine, The Queen's University of Belfast, Whitla Medical Building, 97 Lisburn Road, Belfast BT9 6HP, UK.
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Composition of CO2 Absorbents. Anesth Analg 2001. [DOI: 10.1097/00000539-200105000-00058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Yamakage M, Kimura A, Chen X, Tsujiguchi N, Kamada Y, Namiki A. Production of compound A under low-flow anesthesia is affected by type of anesthetic machine. Can J Anaesth 2001; 48:435-8. [PMID: 11394509 DOI: 10.1007/bf03028304] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
PURPOSE The purpose was to compare the concentrations of compound A in inspired gas breathed by patients produced by different types of anesthetic machines under prolonged sevoflurane low-flow anesthesia. METHODS The anesthetic machines tested were Excel 210 SE (Datex-Ohmeda, Louisville, CO), Cicero (Dräger, Lübeck, Germany), and AS/3 ADU (Datex-Ohmeda, Louisville, CO). Anesthesia expected to last more than four hours was maintained with 2.0% sevoflurane and nitrous oxide (0.5 L x min(-1))/oxygen (0.5 L x min(-1)). The concentrations of compound A, obtained from the inspiratory limb of the circle system, were measured using a gas chromatograph. RESULTS When Excel and Cicero were used, concentrations of compound A increased steadily from the baseline values to 28 and 29 (mean) ppm, respectively, at two hours after exposure to sevoflurane and became constant. There was no significant difference between the concentrations of compound A produced by these anesthetic machines. In contrast, the new anesthetic machine AS/3 was associated with lower concentrations of compound A (6 ppm at one hour, P <0.05 compared with Excel and Cicero), and the concentration did not change significantly thereafter. CONCLUSION In spite of the use of a conventional carbon dioxide (CO2) absorbent with strong bases, the anesthetic machine AS/3 with a small volume of canister/soda lime (900 ml/700 ml) produced lower concentrations of compound A than those produced by the other machines.
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Affiliation(s)
- M Yamakage
- Department of Anesthesiology, Sapporo Medical University School of Medicine, Hokkaido, Japan.
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Delgado-Herrera L, Ostroff RD, Rogers SA. Sevoflurance: approaching the ideal inhalational anesthetic. a pharmacologic, pharmacoeconomic, and clinical review. CNS DRUG REVIEWS 2001; 7:48-120. [PMID: 11420572 PMCID: PMC6741648 DOI: 10.1111/j.1527-3458.2001.tb00190.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Sevoflurane is a safe and versatile inhalational anesthetic compared with currently available agents. Sevoflurane is useful in adults and children for both induction and maintenance of anesthesia in inpatient and outpatient surgery. Of all currently used anesthetics, the physical, pharmacodynamic, and pharmacokinetic properties of sevoflurane come closest to that of the ideal anesthetic (200). These characteristics include inherent stability, low flammability, non-pungent odor, lack of irritation to airway passages, low blood:gas solubility allowing rapid induction of and emergence from anesthesia, minimal cardiovascular and respiratory side effects, minimal end-organ effects, minimal effect on cerebral blood flow, low reactivity with other drugs, and a vapor pressure and boiling point that enables delivery using standard vaporization techniques. As a result, sevoflurane has become one of the most widely used agents in its class.
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Affiliation(s)
- L Delgado-Herrera
- Abbott Laboratories, Hospital Products Division, 200 Abbott Park Road, Abbott Park, IL 60064, USA.
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