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Neghab M, Amiri F, Soleimani E, Yousefinejad S, Hassanzadeh J. Toxic responses of the liver and kidneys following occupational exposure to anesthetic gases. EXCLI JOURNAL 2020; 19:418-429. [PMID: 32327960 PMCID: PMC7174577 DOI: 10.17179/excli2019-1911] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 03/19/2020] [Indexed: 12/20/2022]
Abstract
This study was undertaken to determine whether exposure of operating room personnel to inhalation anesthetics, including nitrous oxide, isoflurane, and sevoflurane was associated with any hepatotoxic or nephrotoxic changes. Fifty-two operating room personnel and 52 non-exposed subjects were studied. A questionnaire pertaining to demographic characteristics and medical history of participants was completed. Fasting blood samples were taken from all subjects to measure the functional parameters of kidneys and liver. Biological monitoring was also performed to detect the urinary concentration of IAs. Urinary concentrations of nitrous oxide, isoflurane, and sevoflurane were found to be 175.8 ± 77.52, 4.95 ± 3.43, and 15.0 3± 16.06 ppm, respectively. The mean levels of alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, gamma-glutamyltransferase, Alpha-glutathione-S-transferase, as well as the serum levels of kidney injury molecule-1, creatinine and calcium were significantly higher in the exposed group. Statistically significant associations were observed between exposure to inhalation anesthetics and the mean levels of aspartate aminotransferase, alanine aminotransferase, and gamma-glutamyltransferase, serum creatinine, kidney injury molecule-1, and calcium. Under the exposure scenario described in the present study, occupational exposure to inhalation anesthetics was associated with subtle, subclinical, pre-pathologic changes in the parameters of liver and kidneys. Additionally, Alpha-glutathione-S-transferase and kidney injury molecule-1 were found to be sensitive markers for early detection of subclinical changes in the parameters of kidney and liver function in subjects who are exposed to inhalation anesthetics.
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Affiliation(s)
- Masoud Neghab
- Department of Occupational Health Engineering, Research Center for Health Sciences, Institute of Health, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Amiri
- Department of Occupational Health Engineering, Social Determinants in Health Promotion Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Esmaeel Soleimani
- Department of Occupational Health Engineering, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Saeed Yousefinejad
- Department of Occupational Health Engineering, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Jafar Hassanzadeh
- Department of Clinical Epidemiology, School of Health, Shiraz University of MedicalSciences, Shiraz, Iran
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Zhu Y, Xiao X, Li G, Bu J, Zhou W, Zhou S. Isoflurane anesthesia induces liver injury by regulating the expression of insulin-like growth factor 1. Exp Ther Med 2017; 13:1608-1613. [PMID: 28413517 DOI: 10.3892/etm.2017.4157] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 12/09/2016] [Indexed: 12/20/2022] Open
Abstract
It has been suggested that isoflurane may cause perioperative liver injury. However, the mechanism of its action remains unknown. The purpose of the present study was to determine this possible mechanism. Sprague-Dawley rats were randomly assigned into one of three groups (all n=12): Control group (exposed to mock anesthesia), isoflurane group (exposed to 2% isoflurane for 90 min), and isoflurane + insulin-like growth factor 1 (IGF-1) group (exposed to 2% isoflurane for 90 min and then treated with IGF-1). Reverse transcription-quantitative polymerase chain reaction (RT-qPCR) and western blotting were conducted to determine the levels of expression of IGF-1 and its receptor IGF-R. Liver necrosis was assessed by histological examination. TUNEL assay was performed to determine the apoptosis of hepatic cells. In addition, the levels of the proteins caspase-3 and B-cell lymphoma-extra large (Bcl-xL) were measured. Compared with the control group, levels of IGF-1 and IGF-1R mRNA and protein were significantly decreased following exposure to isoflurane (all P<0.05). The necrosis rate and liver apoptosis were significantly increased in the group treated with isoflurane alone compared with the control group (P<0.05), but were significantly decreased compared with the isoflurane group following application of IGF-1 (P<0.05). Additionally, isoflurane exposure significantly increased levels of caspase-3 compared with the control group (P<0.05), but decreased levels of Bcl-xL (P<0.05). By contrast, application of IGF-1 reversed these changes. The present study therefore suggests that isoflurane induces liver injury in part by regulating the expression of IGF-1 and that application of IGF-1 may protect against liver injury induced by isoflurane exposure.
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Affiliation(s)
- Yingxian Zhu
- Department of Anesthesiology, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong 519000, P.R. China
| | - Xiaoyu Xiao
- Department of Anesthesiology, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong 519000, P.R. China
| | - Guowei Li
- Department of Orthopaedics II, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong 519000, P.R. China
| | - Juyuan Bu
- Department of General Surgery I, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong 519000, P.R. China
| | - Wenying Zhou
- Department of Center Laboratory, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong 519000, P.R. China
| | - Shaopeng Zhou
- Department of Anesthesiology, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong 519000, P.R. China
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Safari S, Motavaf M, Seyed Siamdoust SA, Alavian SM. Hepatotoxicity of halogenated inhalational anesthetics. IRANIAN RED CRESCENT MEDICAL JOURNAL 2014; 16:e20153. [PMID: 25593732 PMCID: PMC4270648 DOI: 10.5812/ircmj.20153] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Revised: 08/18/2014] [Accepted: 07/31/2014] [Indexed: 12/17/2022]
Abstract
Context: Halogenated inhalational anesthetics are currently the most common drugs used for the induction and maintenance of general anesthesia. Postoperative hepatic injury has been reported after exposure to these agents. Based on much evidence, mechanism of liver toxicity is more likely to be immunoallergic. The objective of this review study was to assess available studies on hepatotoxicity of these anesthetics. Evidence Acquisition: We searched PubMed, Google Scholar, Scopus, Index Copernicus, EBSCO and the Cochrane Database using the following keywords: “inhalational Anesthetics” and “liver injury”; “inhalational anesthetics” and “hepatotoxicity”; “volatile anesthetics” and “liver injury”; “volatile anesthetics” and hepatotoxicity for the period of 1966 to 2013. Fifty two studies were included in this work. Results: All halogenated inhalational anesthetics are associated with liver injury. Halothane, enflurane, isoflurane and desflurane are metabolized through the metabolic pathway involving cytochrome P-450 2E1 (CYP2E1) and produce trifluoroacetylated components; some of which may be immunogenic. The severity of hepatotoxicity is associated with the degree by which they undergo hepatic metabolism by this cytochrome. However, liver toxicity is highly unlikely from sevoflurane as is not metabolized to trifluoroacetyl compounds. Conclusions: Hepatotoxicity of halogenated inhalational anesthetics has been well documented in available literature. Halothane-induced liver injury was extensively acknowledged; however, the next generation halogenated anesthetics have different molecular structures and associated with less hepatotoxicity. Although anesthesia-induced hepatitis is not a common occurrence, we must consider the association between this disorder and the use of halogenated anesthetics.
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Affiliation(s)
- Saeid Safari
- Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, IR Iran
| | - Mahsa Motavaf
- Department of Genetics, Faculty of Biological Sciences, Tarbiat Modares University, Tehran, IR Iran
- Department of Molecular Hepatology, Middle East Liver Disease Center, Tehran, IR Iran
| | | | - Seyed Moayed Alavian
- Department of Molecular Hepatology, Middle East Liver Disease Center, Tehran, IR Iran
- Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
- Corresponding Author: Seyed Moayed Alavian, Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah University of Medical Sciences and Tehran Hepatitis Center, Tehran, IR Iran. Tel: +98-2188945186, Fax: +98-2188945188, E-mail:
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Kusuma HR, Venkataramana NK, Rao SA, Naik AL, Gangadhara D, Venkatesh KH. Fulminant hepatic failure after repeated exposure to isoflurane. Indian J Anaesth 2011; 55:290-2. [PMID: 21808406 PMCID: PMC3141158 DOI: 10.4103/0019-5049.82696] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Inhalational agents are used routinely for maintenance of anaesthesia. Post anaesthesia hepatic failure has been documented following exposure to halothane. However, there are very few reports of such complications following isoflurane anaesthesia. A 6-year-old child developed fulminant hepatic failure 2 days following craniotomy under general anaesthesia. There was no evidence of viral, autoimmune, or metabolic causes of hepatitis. No other medications known to cause hepatitis, except low dose paracetamol, were administered. The clinical and histological picture of our case is similar to that of halothane hepatitis, which has a significant mortality rate. We report this as a possible fulminant hepatic failure resulting from exposure to isoflurane anaesthesia.
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Affiliation(s)
- Halemani R Kusuma
- Department of Anaesthesiology & Critical Care, BGS Global Hospitals, Bangalore, Karnataka, India
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Bastos EM, Neto MS, Alves MTS, Garcia EB, Santos RA, Heink T, Pereira JB, Ferreira LM. Histologic analysis of zafirlukast's effect on capsule formation around silicone implants. Aesthetic Plast Surg 2007; 31:559-65. [PMID: 17576504 DOI: 10.1007/s00266-006-0257-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The most common complication experienced by patients who have undergone mammary implant surgery is capsular contracture. This matter concerns physicians and patients, but to date, there is no effective way to avoid this complication. Surgical intervention usually is required. In 2002, the use of zafirlukast, a leukotriene inhibitor (a drug used for asthma treatment), was reported for the treatment of capsular contracture, with good results. METHODS For this study, 30 female Wistar rats were used. These animals received two silicone implants each: one with a smooth surface and one with a textured surface. All the animals received daily intraperitoneal injections for 90 days and were divided as follows: control group (C) receiving only saline solution, experimental group 1 (E-I) receiving 1.25 mg/kg/day of zafirlukast, and experimental group 2 (E-II) receiving 5 mg/kg/day of zafirlukast. Histologic analysis used hematoxilin and eosin to verify vessels, capsule thickness, and inflammatory cells. Immunoistochemical analysis with smooth muscle anti-actin antibody was used for myofibroblast verification. Picro-Sirius under polarized light was used for collagen analysis. RESULTS Textured implant experimental groups presented smaller numbers of vessels, thinner capsules, lower collagen density, and smaller numbers of mastocytes and eosinophils than the control group. No significant differences were found in smooth surface implants, as compared with the control group. CONCLUSION Zafirlukast reduced the occurrence of factors directly and indirectly connected with capsular contracture.
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Affiliation(s)
- Erika M Bastos
- Division of Plastic Surgery, Department of Surgery, Federal University of São Paulo, Escola Paulista de Medicina, Rua Napoleão de Barros, 715, 4o andar HSP, Vila Clementino, 04024-002, São Paulo, SP, Brazil.
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Nishiyama T, Fujimoto T, Hanaoka K. A comparison of liver function after hepatectomy in cirrhotic patients between sevoflurane and isoflurane in anesthesia with nitrous oxide and epidural block. Anesth Analg 2004; 98:990-993. [PMID: 15041586 DOI: 10.1213/01.ane.0000104581.22295.fb] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
UNLABELLED In this study, we compared postoperative liver function in patients with liver cirrhosis between isoflurane and sevoflurane anesthesia with nitrous oxide (N(2)O) and epidural block. Forty cirrhotic patients with Child-Pugh Grade A, aged 40 to 70 yr, scheduled for liver segmentectomy, had anesthesia induced with midazolam 0.1 mg/kg and fentanyl 4 micro g/kg. For maintenance, intermittent epidural administration of 1.5% lidocaine 4 to 6 mL and sevoflurane (sevoflurane group) or isoflurane (isoflurane group) with N(2)O 3 L/min in oxygen 3 L/min was used. Aspartate aminotransferase, alanine aminotransferase, total bilirubin, alkaline phosphatase, choline esterase, albumin, prothrombin time, and platelet count were measured before and 1, 3, and 7 days after surgery. Aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase increased significantly, with the peaks at 3 days after surgery in both groups. The increases in these variables were significantly larger in the isoflurane group than those in the sevoflurane group. No patient developed hepatic failure. All increases in liver enzymes were small and of questionable clinical relevance. Whether sevoflurane might be a better anesthetic when combined with N(2)O and epidural block for cirrhotic patients than isoflurane with respect to liver damage remains to be determined. IMPLICATIONS In cirrhotic patients with Child-Pugh Grade A, isoflurane induced more of an increase in serum concentrations of liver enzymes after surgery than sevoflurane when combined with nitrous oxide and epidural block. However, the increases were small, and there was no clinical liver damage.
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Affiliation(s)
- Tomoki Nishiyama
- Department of Anesthesiology, The University of Tokyo, Tokyo, Japan
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Malnick SDH, Mahlab K, Borchardt J, Sokolowski N, Attali M. Acute cholestatic hepatitis after exposure to isoflurane. Ann Pharmacother 2002; 36:261-3. [PMID: 11847945 DOI: 10.1345/aph.1a009] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To report a case of acute cholestatic hepatitis following exposure to the inhalational anesthetic isoflurane. CASE SUMMARY A 70-year-old healthy woman from Iraq developed acute cholestatic hepatitis 3 weeks following repair of the right rotator cuff under general anesthesia. There was no evidence for viral, autoimmune, or metabolic causes of hepatitis. No other medications were involved except for dipyrone for analgesia. The alanine aminotransferase was elevated to a peak concentration of 1533 U/L and the serum bilirubin reached a peak of 17.0 mg/dL. There was slow improvement over 4 months. Accidental reexposure by the patient to dipyrone was uneventful. DISCUSSION The clinical and histologic picture of this case resembles halothane hepatitis, which has a significant mortality rate. CONCLUSIONS Isoflurane, a common anesthetic agent, can cause severe cholestatic hepatitis.
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Affiliation(s)
- Stephen D H Malnick
- Department of Internal Medicine C, Kaplan Medical Center, Rehovot 76100, Israel.
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Wissing H, Kuhn I. The effect of desflurane on liver function markers in infants and children. Report of a study and a pertinent case report. Acta Anaesthesiol Scand 2000; 44:1149-53. [PMID: 11028739 DOI: 10.1034/j.1399-6576.2000.440920.x] [Citation(s) in RCA: 5] [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 In an open-labelled clinical trial, the effect of desflurane anaesthesia on liver function markers in paediatric patients was monitored. METHODS Fifty infants and children, 37 male, scheduled for elective cleft plate surgery were included in the study. Median age was 0.57 (0.25-5.45) years (range), mean desflurane exposure was 2.29 +/- 0.75 MAC-h. Function markers were determined within 24 h prior to and within 24-48 h after anaesthesia. Complete data sets were available for total bilirubin 29, aspartate aminotransferase (ASAT) 36, alanine aminotransferase (ALAT) 35, and for alkaline phosphatase (AP) 28. Pre- and postanaesthetic function tests were compared by means of Wilcoxon's matched-pairs test. RESULTS Only for AP could a statistically significant reduction of the postanaesthetic values be observed, while the other parameters showed no significant changes. Postanaesthetic ASAT and ALAT were clearly reduced in three children who had unspecific highly elevated preanaesthetic values. After the study, this observation could be repeated in at least one child, who received a further anaesthesia with desflurane within 3 months. CONCLUSION The data suggest that desflurane does not affect excretory or structural liver integrity in infants and children.
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Affiliation(s)
- H Wissing
- Department of Anaesthesiology, Johann Wolfgang Goethe University Hospital, Frankfurt am Main, Germany.
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Sergi C, Jundt K, Seipp S, Goeser T, Theilmann L, Otto G, Otto HF, Hofmann WJ. The distribution of HBV, HCV and HGV among livers with fulminant hepatic failure of different aetiology. J Hepatol 1998; 29:861-71. [PMID: 9875631 DOI: 10.1016/s0168-8278(98)80112-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND/AIMS The aim of the study was to assess the impact factor of HCV and HGV in fulminant hepatic failure. METHODS The 5'-untranslated regions of HCV RNA and HGV RNA and a segment of the core antigen sequence of HBV were amplified after extracting the nucleic acids from snap-frozen tissue aliquots from explanted livers of 26 consecutive patients undergoing orthotopic liver transplantation for fulminant hepatic failure preoperatively diagnosed as either autoimmune (n=2), HAV/HBV (n=8), toxic (n=4) or aetiologically unknown (n=12). RESULTS HCV RNA was detected in five of 26 (19.2%) livers with fulminant hepatic failure. All five HCV RNA-positive livers belonged to the group of non-toxic, non-autoimmune liver failure (n=20), three of them were found in the group of liver failure with unknown aetiology (n=12) and two in the group of HBV-associated liver failure (n=7), making an HCV incidence of 25%, 25% and 28.6%, in the different groups, respectively. HGV RNA was detected in 10 of 17 (58.8%) explants and in all four groups of fulminant hepatic failure as defined preoperatively. HBV DNA was identified in six livers of 26 patients (23.1%) with fulminant hepatic failure. Neither HCV RNA nor HBV DNA was detected in the livers of patients with toxic or autoimmune fulminant hepatic failure. CONCLUSIONS These results indicate that HBV and HCV, but not HGV, play an aetiologic role in fulminant hepatic failure. HCV-positive cases were concentrated either in the group of otherwise unexplained fulminant hepatic failure or in the group of HBV fulminant hepatic failure. HGV-positive cases, on the other hand, were found within all four preoperatively defined groups, indicating a role as cofactor rather than as single aetiologic agent.
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Affiliation(s)
- C Sergi
- Institute of Pathology, University of Heidelberg, Germany
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Abstract
This report is of a case of a previously fit 65-year-old woman who developed postoperative liver dysfunction following an anaesthetic involving isoflurane. Biliary ultrasound demonstrated gallstones. However, serum antibodies to trifluoroacetylated proteins were detected, suggesting that immune sensitisation to the anaesthetic could have contributed to the impaired liver function.
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Affiliation(s)
- D J Meldrum
- Department of Anaesthesia, Hinchingbrooke Hospital, Huntingdon, UK
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Nishiyama T, Yokoyama T, Hanaoka K. Liver function after sevoflurane or isoflurane anaesthesia in neurosurgical patients. Can J Anaesth 1998; 45:753-6. [PMID: 9793665 DOI: 10.1007/bf03012146] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Although both sevoflurane and isoflurane are thought to be less hepatotoxic than halothane or enflurane, recent case reports have described liver injury after sevoflurane or isoflurane anaesthesia. There are no studies comparing liver function after sevoflurane or isoflurane anaesthesia. The purpose of this study was to compare serum liver enzyme concentrations in patients receiving either sevoflurane or isoflurane anaesthesia prospectively. METHODS Ninety patients scheduled for elective neurosurgery were studied. Serum concentrations of aspartame aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin (TBil), alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GTP), and lactate dehydrogenase (LDH) were measured before and, 1, 2, 3, 7, and 14 days after either sevoflurane (45 patients) or isoflurane (45 patients) anaesthesia. RESULTS AST, ALT and GTP increased peaking seven days after anaesthesia, especially in the isoflurane group. The numbers of patients with abnormal values in AST and ALT were not different in the isoflurane from that in the sevoflurane group. The increase in TBil peaked one day after anaesthesia in both groups. CONCLUSION Even in a small number of patients, isoflurane induced an elevation of serum levels of liver enzymes more frequently than did sevoflurane three to 14 days after anaesthesia.
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Affiliation(s)
- T Nishiyama
- Department of Anesthesiology, University of Tokyo, Japan
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Nishiyama T, Yokoyama T, Hanaoka K. Liver and renal function after repeated sevoflurane or isoflurane anaesthesia. Can J Anaesth 1998; 45:789-93. [PMID: 9793670 DOI: 10.1007/bf03012151] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To compare retrospectively liver and renal function after repeated exposure (twice) to sevoflurane or isoflurane. METHODS Sixty patients were studied for liver and renal function after repeated exposure within 30 to 180 days to sevoflurane (30 patients) or isoflurane (30 patients). Serum concentrations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin (TBil), alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GTP), blood urea nitrogen (BUN) and creatinine (Cr) were measured before and, 1, 3, 7, and 14 days after surgery. Qualitative analyses of urinary protein and glucose were done 1, 3, and 7 days after surgery. RESULTS The number of patients with abnormal values in AST, ALT and GTP was larger in the isoflurane than in the sevoflurane group. BUN and Cr were within normal range after anaesthesia in either group. Renal excretion of protein and glucose increased one and three days after anaesthesia with no difference between the anaesthetics. None of the variables showed differences between the first and second anaesthesia after either anaesthetic. CONCLUSION Repeat exposure to sevoflurane or isoflurane within 30 to 180 days had no additional risk of increasing serum concentration of liver enzymes or increasing urinary excretion of protein and glucose compared with the first exposure to the same anaesthetic.
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Affiliation(s)
- T Nishiyama
- Department of Anesthesiology, University of Tokyo
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