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Hendrickx JFA, Nielsen OJ, De Hert S, De Wolf AM. The science behind banning desflurane: A narrative review. Eur J Anaesthesiol 2022; 39:818-824. [PMID: 36036420 DOI: 10.1097/eja.0000000000001739] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Potent inhaled anaesthetics are halogenated hydrocarbons with a large global warming effect. The use of fluorinated hydrocarbons (most are not anaesthetics) are being restricted but volatile anaesthetics have been exempted from legislation, until now: the EU has formulated a proposal to ban or at least severely restrict the use of desflurane starting January 2026. This narrative review addresses the implications of a politics-driven decision - without prior consultation with major stakeholders, such as the European Society of Anaesthesiology and Intensive Care (ESAIC) - on daily anaesthesia practice and reviews the potential scientific arguments that would support stopping the routine use of desflurane in anaesthetic practice. Of note, banning or severely restricting the use of one anaesthetic agent should not distract the user from sensible interventions like reducing fresh gas flows and developing technology to capture and recycle or destroy the wasted potent inhaled anaesthetics that we will continue to use. We call to join efforts to minimise our professional environmental footprint.
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Affiliation(s)
- Jan F A Hendrickx
- From the Department of Anesthesiology, Onze-Lieve-Vrouw Hospital, Aalst (JFAH), Department of Basic and Applied Medical Sciences, Ghent University, Ghent (JFAH, SDH), Department of Anesthesiology, University Hospital and Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium (JFAH), Department of Chemistry, University of Copenhagen, Copenhagen, Denmark (OJN), Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium (SDH) and Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA (AMDW)
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Sakata DJ. Carbon Dioxide as the Other Therapeutic Carrier Gas? Anesth Analg 2022; 135:60-61. [PMID: 35709445 DOI: 10.1213/ane.0000000000006012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Derek J Sakata
- From the Department of Anesthesiology, University of Utah, Salt Lake City, Utah
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Arterial and Mixed Venous Kinetics of Desflurane and Sevoflurane, Administered Simultaneously, at Three Different Global Ventilation to Perfusion Ratios in Piglets with Normal Lungs. Anesthesiology 2021; 135:1027-1041. [PMID: 34731241 DOI: 10.1097/aln.0000000000004007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previous studies have established the role of various tissue compartments in the kinetics of inhaled anesthetic uptake and elimination. The role of normal lungs in inhaled anesthetic kinetics is less understood. In juvenile pigs with normal lungs, the authors measured desflurane and sevoflurane washin and washout kinetics at three different ratios of alveolar minute ventilation to cardiac output value. The main hypothesis was that the ventilation/perfusion ratio (VA/Q) of normal lungs influences the kinetics of inhaled anesthetics. METHODS Seven healthy pigs were anesthetized with intravenous anesthetics and mechanically ventilated. Each animal was studied under three different VA/Q conditions: normal, low, and high. For each VA/Q condition, desflurane and sevoflurane were administered at a constant, subanesthetic inspired partial pressure (0.15 volume% for sevoflurane and 0.5 volume% for desflurane) for 45 min. Pulmonary arterial and systemic arterial blood samples were collected at eight time points during uptake, and then at these same times during elimination, for measurement of desflurane and sevoflurane partial pressures. The authors also assessed the effect of VA/Q on paired differences in arterial and mixed venous partial pressures. RESULTS For desflurane washin, the scaled arterial partial pressure differences between 5 and 0 min were 0.70 ± 0.10, 0.93 ± 0.08, and 0.82 ± 0.07 for the low, normal, and high VA/Q conditions (means, 95% CI). Equivalent measurements for sevoflurane were 0.55 ± 0.06, 0.77 ± 0.04, and 0.75 ± 0.08. For desflurane washout, the scaled arterial partial pressure differences between 0 and 5 min were 0.76 ± 0.04, 0.88 ± 0.02, and 0.92 ± 0.01 for the low, normal, and high VA/Q conditions. Equivalent measurements for sevoflurane were 0.79 ± 0.05, 0.85 ± 0.03, and 0.90 ± 0.03. CONCLUSIONS Kinetics of inhaled anesthetic washin and washout are substantially altered by changes in the global VA/Q ratio for normal lungs. EDITOR’S PERSPECTIVE
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Effect of Global Ventilation to Perfusion Ratio, for Normal Lungs, on Desflurane and Sevoflurane Elimination Kinetics. Anesthesiology 2021; 135:1042-1054. [PMID: 34731232 DOI: 10.1097/aln.0000000000004008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Kinetics of the uptake of inhaled anesthetics have been well studied, but the kinetics of elimination might be of more practical importance. The objective of the authors' study was to assess the effect of the overall ventilation/perfusion ratio (VA/Q), for normal lungs, on elimination kinetics of desflurane and sevoflurane. METHODS The authors developed a mathematical model of inhaled anesthetic elimination that explicitly relates the terminal washout time constant to the global lung VA/Q ratio. Assumptions and results of the model were tested with experimental data from a recent study, where desflurane and sevoflurane elimination were observed for three different VA/Q conditions: normal, low, and high. RESULTS The mathematical model predicts that the global VA/Q ratio, for normal lungs, modifies the time constant for tissue anesthetic washout throughout the entire elimination. For all three VA/Q conditions, the ratio of arterial to mixed venous anesthetic partial pressure Part/Pmv reached a constant value after 5 min of elimination, as predicted by the retention equation. The time constant corrected for incomplete lung clearance was a better predictor of late-stage kinetics than the intrinsic tissue time constant. CONCLUSIONS In addition to the well-known role of the lungs in the early phases of inhaled anesthetic washout, the lungs play a long-overlooked role in modulating the kinetics of tissue washout during the later stages of inhaled anesthetic elimination. The VA/Q ratio influences the kinetics of desflurane and sevoflurane elimination throughout the entire elimination, with more pronounced slowing of tissue washout at lower VA/Q ratios. EDITOR’S PERSPECTIVE
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Weber J, Schmidt J, Wirth S, Schumann S, Philip JH, Eberhart LHJ. Context-sensitive decrement times for inhaled anesthetics in obese patients explored with Gas Man®. J Clin Monit Comput 2021; 35:343-354. [PMID: 32067148 PMCID: PMC7943506 DOI: 10.1007/s10877-020-00477-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 01/29/2020] [Indexed: 01/24/2023]
Abstract
Anesthesia care providers and anesthesia decision support tools use mathematical pharmacokinetic models to control delivery and especially removal of anesthetics from the patient's body. However, these models are not able to reflect alterations in pharmacokinetics of volatile anesthetics caused by obesity. The primary aim of this study was to refine those models for obese patients. To investigate the effects of obesity on the elimination of desflurane, isoflurane and sevoflurane for various anesthesia durations, the Gas Man® computer simulation software was used. Four different models simulating patients with weights of 70 kg, 100 kg, 125 kg and 150 kg were constructed by increasing fat weight to the standard 70 kg model. For each modelled patient condition, the vaporizer was set to reach quickly and then maintain an alveolar concentration of 1.0 minimum alveolar concentration (MAC). Subsequently, the circuit was switched to an open (non-rebreathing) circuit model, the inspiratory anesthetic concentration was set to 0 and the time to the anesthetic decrements by 67% (awakening times), 90% (recovery times) and 95% (resolution times) in the vessel-rich tissue compartment including highly perfused tissue of the central nervous system were determined. Awakening times did not differ greatly between the simulation models. After volatile anesthesia with sevoflurane and isoflurane, awakening times were lower in the more obese simulation models. With increasing obesity, recovery and resolution times were higher. The additional adipose tissue in obese simulation models did not prolong awakening times and thus may act more like a sink for volatile anesthetics. The results of these simulations should be validated by comparing the elimination of volatile anesthetics in obese patients with data from our simulation models.
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Affiliation(s)
- Jonas Weber
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Johannes Schmidt
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Steffen Wirth
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefan Schumann
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - James H Philip
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Leopold H J Eberhart
- Department of Anaesthesiology and Intensive Care, Philipps-Universität Marburg, Marburg, Germany
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Aftab H, Fagerland MW, Gondal G, Ghanima W, Olsen MK, Nordby T. Pain and nausea after bariatric surgery with total intravenous anesthesia versus desflurane anesthesia: a double blind, randomized, controlled trial. Surg Obes Relat Dis 2019; 15:1505-1512. [DOI: 10.1016/j.soard.2019.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/26/2019] [Accepted: 05/07/2019] [Indexed: 10/26/2022]
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De Baerdemaeker A, Poelaert J, Kennedy RR, De Wolf AM, Hendrickx JFA. The effect of isocapnic hyperventilation on early recovery after remifentanil/sevoflurane anesthesia in O 2 /air: A randomized trial. Acta Anaesthesiol Scand 2019; 63:455-460. [PMID: 30397906 DOI: 10.1111/aas.13293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 10/08/2018] [Accepted: 10/11/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Isocapnic hyperventilation (ICHV) may hasten emergence from general anesthesia but remains inadequately studied. We prospectively determined emergence time after sevoflurane anesthesia of variable duration with and without ICHV. METHODS In 25 ASA I-II patients, general anesthesia was maintained with one age-adjusted MAC sevoflurane in O2 /air and target-controlled remifentanil delivery. At the start of skin closure, the remifentanil effect-site concentration was reduced to 1.5 ng/mL, any residual neuromuscular block reversed, and once the remifentanil effect-site concentration had decreased to 1.5 ng/mL, remifentanil and sevoflurane administration was stopped, and the fresh gas flow increased above minute ventilation. Patients randomly received either normoventilation (n = 13) or ICHV (doubling minute ventilation while titrating CO2 into the inspiratory limb to maintain isocapnia [n = 12]). Three early recovery end points were determined: time to proper response to verbal command; time to extubation; and time to stating one's name. RESULTS Demographics were the same in both groups. Recovery end points were reached faster in the ICHV group compared to the normoventilation group: time to proper response to verbal command was 7.6 ± 2.2 vs 9.9 ± 2.9 min (P = 0.03); time to extubation was 7.6 ± 2.6 vs 11.0 ± 2.4 min (P = 0.002); and time to stating one's name was 8.9 ± 2.8 vs 12.5 ± 2.6 min (P = 0.003). Within each group, duration of anesthesia only marginally affected the times to reach these recovery end points. CONCLUSION Isocapnic hyperventilation only had a small effect on emergence times after anesthesia, suggesting that isocapnic hyperventilation may have limited clinical benefits with modern potent inhaled anesthetics.
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Affiliation(s)
| | - Jan Poelaert
- Department of Anesthesiology, VUB; University Hospital Brussels; Jette Belgium
| | - R. Ross Kennedy
- Department of Anaesthesia; Christchurch Hospital and University of Otago, Christchurch; Christchurch New Zealand
| | - Andre M. De Wolf
- Department of Anesthesiology, Feinberg School of Medicine; Northwestern University; Chicago Illinois
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Wasilczuk AZ, Maier KL, Kelz MB. The Mouse as a Model Organism for Assessing Anesthetic Sensitivity. Methods Enzymol 2018; 602:211-228. [PMID: 29588030 DOI: 10.1016/bs.mie.2018.01.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The mouse has been used in many medical fields as a powerful model to reveal the genetic basis of human physiology and disease. The past two decades have witnessed an enormous wealth of genetic and informatic resources dedicated to this humble organism. With the ongoing revolution in mapping neural circuitry governing behavior, the mouse is an ideal model organism poised to unravel the mysteries of general anesthetic action. This chapter will describe and provide guidelines for anesthetic phenotyping in the mouse including both motor-dependent and motor-independent assessments.
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Affiliation(s)
- Andrzej Z Wasilczuk
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States
| | - Kaitlyn L Maier
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States
| | - Max B Kelz
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States; Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
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Mashari A, Fedorko L, Fisher JA, Klein M, Wąsowicz M, Meineri M. High volatile anaesthetic conservation with a digital in-line vaporizer and a reflector. Acta Anaesthesiol Scand 2018; 62:177-185. [PMID: 29068042 DOI: 10.1111/aas.13017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 06/29/2017] [Accepted: 09/29/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND A volatile anaesthetic (VA) reflector can reduce VA consumption (VAC) at the cost of fine control of its delivery and CO2 accumulation. A digital in-line vaporizer and a second CO2 absorber circumvent both of these limitations. We hypothesized that the combination of a VA reflector with an in-line vaporizer would yield substantial VA conservation, independent of fresh gas flow (FGF) in a circle circuit, and provide fine control of inspired VA concentrations. METHOD Prospective observational study on six Yorkshire pigs. A secondary anaesthetic circuit consisting of a Y-piece with 2 one-way valves, an in-line vaporizer and a CO2 absorber in the inspiratory limb was connected to the patient's side of the VA reflector. The other side was connected to the Y-piece of a circle anaesthetic circuit. In six pigs, an inspired concentration of sevoflurane of 2.5% was maintained by the in-line vaporizer. We measured VAC at FGF of 1, 4 and 10 l/min. RESULTS With the secondary circuit, VAC was 55% less than with the circle system alone at FGF 1 l/min, and independent of FGF over the range of 1-10 l/min. Insertion of a CO2 absorber in the secondary circuit reduced Pet CO2 by 1.3-2.0 kpa (10-15 mmHg). CONCLUSION A secondary circuit with reflector and in-line vaporizer provides highly efficient anaesthetic delivery, independent of FGF. A second CO2 absorber was necessary to scavenge the CO2 reflected by the anaesthetic reflector. This secondary circuit may turn any open circuit ventilator into an anaesthetic delivery unit.
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Affiliation(s)
- A. Mashari
- Department of Anesthesia and Pain Management; Toronto General Hospital; University Health Network; University of Toronto; Toronto Canada
| | - L. Fedorko
- Department of Anesthesia and Pain Management; Toronto General Hospital; University Health Network; University of Toronto; Toronto Canada
- Thornhill Research Inc.; Toronto Canada
| | - J. A. Fisher
- Department of Anesthesia and Pain Management; Toronto General Hospital; University Health Network; University of Toronto; Toronto Canada
- Thornhill Research Inc.; Toronto Canada
| | - M. Klein
- Department of Engineering; Thornhill Research Inc.; Toronto Canada
| | - M. Wąsowicz
- Department of Anesthesia and Pain Management; Toronto General Hospital; University Health Network; University of Toronto; Toronto Canada
| | - M. Meineri
- Department of Anesthesia and Pain Management; Toronto General Hospital; University Health Network; University of Toronto; Toronto Canada
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Effect of Bronchoconstriction-induced Ventilation-Perfusion Mismatch on Uptake and Elimination of Isoflurane and Desflurane. Anesthesiology 2017; 127:800-812. [PMID: 28857808 DOI: 10.1097/aln.0000000000001847] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Increasing numbers of patients with obstructive lung diseases need anesthesia for surgery. These conditions are associated with pulmonary ventilation/perfusion (VA/Q) mismatch affecting kinetics of volatile anesthetics. Pure shunt might delay uptake of less soluble anesthetic agents but other forms of VA/Q scatter have not yet been examined. Volatile anesthetics with higher blood solubility would be less affected by VA/Q mismatch. We therefore compared uptake and elimination of higher soluble isoflurane and less soluble desflurane in a piglet model. METHODS Juvenile piglets (26.7 ± 1.5 kg) received either isoflurane (n = 7) or desflurane (n = 7). Arterial and mixed venous blood samples were obtained during wash-in and wash-out of volatile anesthetics before and during bronchoconstriction by methacholine inhalation (100 μg/ml). Total uptake and elimination were calculated based on partial pressure measurements by micropore membrane inlet mass spectrometry and literature-derived partition coefficients and assumed end-expired to arterial gradients to be negligible. VA/Q distribution was assessed by the multiple inert gas elimination technique. RESULTS Before methacholine inhalation, isoflurane arterial partial pressures reached 90% of final plateau within 16 min and decreased to 10% after 28 min. By methacholine nebulization, arterial uptake and elimination delayed to 35 and 44 min. Desflurane needed 4 min during wash-in and 6 min during wash-out, but with bronchoconstriction 90% of both uptake and elimination was reached within 15 min. CONCLUSIONS Inhaled methacholine induced bronchoconstriction and inhomogeneous VA/Q distribution. Solubility of inhalational anesthetics significantly influenced pharmacokinetics: higher soluble isoflurane is less affected than fairly insoluble desflurane, indicating different uptake and elimination during bronchoconstriction.
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Kanaya A, Kuratani N, Nakata Y, Yamauchi M. Factors affecting extubation time following pediatric ambulatory surgery: an analysis using electronic anesthesia records from an academic university hospital. JA Clin Rep 2017; 3:38. [PMID: 29457082 PMCID: PMC5804621 DOI: 10.1186/s40981-017-0108-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 07/17/2017] [Indexed: 11/10/2022] Open
Abstract
Background In pediatric general anesthesia, our goal should be quicker extubation to facilitate rapid turnover in the operating room without compromising on safety and quality of anesthesia. Although many studies have focused on improving safety and pursuing a higher quality of recovery, factors related to anesthesia emergence remain unclear. We must, therefore, identify factors that influence the process of emergence from general anesthesia in children. Findings We retrospectively examined 148 children (aged 1–6 years, American Society of Anesthesiologists physical status: 1–2) who had undergone <2 h of ambulatory surgery. Clinical measures included time from the end of surgery to extubation (extubation time), age, height, weight, surgical time, mean indirect blood pressure during surgery, mean heart rate during surgery, mean end-tidal carbon dioxide during surgery (mETCO2), mean body temperature during surgery (mBT), and total amount of fentanyl. Anesthetic procedures involved sevoflurane or propofol. Multiple regression analysis revealed that mETCO2 (p < 0.01) and mBT (p < 0.01) were independent clinical factors associated with extubation time following pediatric ambulatory surgery. Conclusions This study of 148 pediatric patients demonstrated that anesthesia emergence may be associated with mBT and mETCO2 following pediatric ambulatory surgery. These results show that perioperative vital signs are important in the prevention of delayed emergence for pediatric patients.
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Affiliation(s)
- Akihiro Kanaya
- 1Department of Anesthesiology and Perioperative Medicine, Tohoku University School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan
| | - Norifumi Kuratani
- 1Department of Anesthesiology and Perioperative Medicine, Tohoku University School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan.,2Department of Anesthesia, Saitama Children's Medical Center, Saitama, Japan
| | - Yoshinori Nakata
- 3Department of Anesthesia, Teikyo University Hospital, Teikyo University Graduate School of Public Health, Tokyo, Japan
| | - Masanori Yamauchi
- 1Department of Anesthesiology and Perioperative Medicine, Tohoku University School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan
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Intravenous 15% isoflurane lipid nanoemulsion for general anesthesia in dogs. Vet Anaesth Analg 2017; 44:219-227. [DOI: 10.1016/j.vaa.2016.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 01/25/2016] [Accepted: 02/15/2016] [Indexed: 11/24/2022]
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Gonzales C, Yoshihara HAI, Dilek N, Leignadier J, Irving M, Mieville P, Helm L, Michielin O, Schwitter J. In-Vivo Detection and Tracking of T Cells in Various Organs in a Melanoma Tumor Model by 19F-Fluorine MRS/MRI. PLoS One 2016; 11:e0164557. [PMID: 27736925 PMCID: PMC5063406 DOI: 10.1371/journal.pone.0164557] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 09/02/2016] [Indexed: 12/18/2022] Open
Abstract
Background 19F-MRI and 19F-MRS can identify specific cell types after in-vitro or in-vivo 19F-labeling. Knowledge on the potential to track in-vitro 19F-labeled immune cells in tumor models by 19F-MRI/MRS is scarce. Aim To study 19F-based MR techniques for in-vivo tracking of adoptively transferred immune cells after in-vitro 19F-labeling, i.e. to detect and monitor their migration non-invasively in melanoma-bearing mice. Methods Splenocytes (SP) were labeled in-vitro with a perfluorocarbon (PFC) and IV-injected into non-tumor bearing mice. In-vitro PFC-labeled ovalbumin (OVA)-specific T cells from the T cell receptor-transgenic line OT-1, activated with anti-CD3 and anti-CD28 antibodies (Tact) or OVA-peptide pulsed antigen presenting cells (TOVA-act), were injected into B16 OVA melanoma-bearing mice. The distribution of the 19F-labelled donor cells was determined in-vivo by 19F-MRI/MRS. In-vivo 19F-MRI/MRS results were confirmed by ex-vivo 19F-NMR and flow cytometry. Results SP, Tact, and TOVA-act were successfully PFC-labeled in-vitro yielding 3x1011-1.4x1012 19F-atoms/cell in the 3 groups. Adoptively transferred 19F-labeled SP, TOVA-act, and Tact were detected by coil-localized 19F-MRS in the chest, abdomen, and left flank in most animals (corresponding to lungs, livers, and spleens, respectively, with highest signal-to-noise for SP vs TOVA-act and Tact, p<0.009 for both). SP and Tact were successfully imaged by 19F-MRI (n = 3; liver). These in-vivo data were confirmed by ex-vivo high-resolution 19F-NMR-spectroscopy. By flow cytometric analysis, however, TOVA-act tended to be more abundant versus SP and Tact (liver: p = 0.1313; lungs: p = 0.1073; spleen: p = 0.109). Unlike 19F-MRI/MRS, flow cytometry also identified transferred immune cells (SP, Tact, and TOVA-act) in the tumors. Conclusion SP, Tact, and TOVA-act were successfully PFC-labeled in-vitro and detected in-vivo by non-invasive 19F-MRS/MRI in liver, lung, and spleen. The portion of 19F-labeled T cells in the adoptively transferred cell populations was insufficient for 19F-MRS/MRI detection in the tumor. While OVA-peptide-activated T cells (TOVA-act) showed highest infiltration into all organs, SP were detected more reliably by 19F-MRS/MRI, most likely explained by cell division of TOVA-act after injection, which dilutes the 19F content in the T cell-infiltrated organs. Non-dividing 19F-labeled cell species appear most promising to be tracked by 19F-MRS/MRI.
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Affiliation(s)
- Christine Gonzales
- Division of Cardiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Hikari A. I. Yoshihara
- Division of Cardiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Institute of Physics of Biological Systems, Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Nahzli Dilek
- Molecular Modeling Group, Swiss Institute of Bioinformatics (SIB), Lausanne, Switzerland
- Ludwig Branch for Cancer Research of the University of Lausanne, Epalinges, Switzerland
| | - Julie Leignadier
- Ludwig Branch for Cancer Research of the University of Lausanne, Epalinges, Switzerland
| | - Melita Irving
- Ludwig Branch for Cancer Research of the University of Lausanne, Epalinges, Switzerland
| | - Pascal Mieville
- Institut des Sciences et Ingénierie Chimiques, Ecole Polytechnique Fédérale de Lausanne (EPFL), Batochime, Lausanne, Switzerland
| | - Lothar Helm
- Institut des Sciences et Ingénierie Chimiques, Ecole Polytechnique Fédérale de Lausanne (EPFL), Batochime, Lausanne, Switzerland
| | - Olivier Michielin
- Molecular Modeling Group, Swiss Institute of Bioinformatics (SIB), Lausanne, Switzerland
- Ludwig Branch for Cancer Research of the University of Lausanne, Epalinges, Switzerland
- Department of Oncology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Juerg Schwitter
- Division of Cardiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Cardiac Magnetic Resonance Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- * E-mail:
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Bronchoconstriction induced by inhaled methacholine delays desflurane uptake and elimination in a piglet model. Respir Physiol Neurobiol 2015; 220:88-94. [PMID: 26440992 DOI: 10.1016/j.resp.2015.09.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 09/22/2015] [Accepted: 09/27/2015] [Indexed: 12/11/2022]
Abstract
Bronchoconstriction is a hallmark of asthma and impairs gas exchange. We hypothesized that pharmacokinetics of volatile anesthetics would be affected by bronchoconstriction. Ventilation/perfusion (VA/Q) ratios and pharmacokinetics of desflurane in both healthy state and during inhalational administration of methacholine (MCh) to double peak airway pressure were studied in a piglet model. In piglets, MCh administration by inhalation (100 μg/ml, n=6) increased respiratory resistance, impaired VA/Q distribution, increased shunt, and decreased paO2 in all animals. The uptake and elimination of desflurane in arterial blood was delayed by nebulization of MCh, as determined by Micropore Membrane Inlet Mass Spectrometry (wash-in time to P50, healthy vs. inhalation: 0.5 min vs. 1.1 min, to P90: 4.0 min vs. 14.8 min). Volatile elimination was accordingly delayed. Inhaled methacholine induced severe bronchoconstriction and marked inhomogeneous VA/Q distribution in pigs, which is similar to findings in human asthma exacerbation. Furthermore, MCh-induced bronchoconstriction delayed both uptake and elimination of desflurane. These findings might be considered when administering inhalational anesthesia to asthmatic patients.
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Katznelson R, Fisher JA. Fast wake-up time in obese patients: Which anesthetic is best? Can J Anaesth 2015; 62:847-51. [PMID: 26041690 DOI: 10.1007/s12630-015-0406-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 05/15/2015] [Indexed: 12/13/2022] Open
Affiliation(s)
- Rita Katznelson
- Department of Anesthesia and Pain Management, University Health Network, University of Toronto, 200 Elizabeth Street, EN3, Toronto, ON, M5G 2C4, Canada,
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van Heeswijk RB, Pellegrin M, Flögel U, Gonzales C, Aubert JF, Mazzolai L, Schwitter J, Stuber M. Fluorine MR Imaging of Inflammation in Atherosclerotic Plaque in Vivo. Radiology 2015; 275:421-9. [DOI: 10.1148/radiol.14141371] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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17
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Valente ACS, Brosnan RJ, Guedes AGP. Desflurane and sevoflurane elimination kinetics and recovery quality in horses. Am J Vet Res 2015; 76:201-7. [DOI: 10.2460/ajvr.76.3.201] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Kleine S, Hofmeister E, Egan K. Multivariable analysis of anesthetic factors associated with time to extubation in dogs. Res Vet Sci 2014; 97:592-6. [PMID: 25443592 DOI: 10.1016/j.rvsc.2014.09.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 09/09/2014] [Accepted: 09/15/2014] [Indexed: 01/21/2023]
Abstract
The purpose of this study was to identify factors that prolong the time to extubation in dogs. Anesthetic records of 900 dogs at a university teaching hospital were searched. Multiple linear regression was used to compare independent predictors (patient demographics, anesthetic and intraoperative variables) with the dependent variable (time to extubation). Induction with propofol (P < 0.025) was associated with a shorter time to extubation, while premedication with acepromazine (P = 0.000) was associated with a longer time to extubation. Time to extubation was increased by 0.311 minutes for every kilogram increase in body weight (P = 0.000), 5.924 minutes for every 1 °C loss in body temperature (P = 0.0000), and by 0.096 minutes for every 1 minute increase in anesthetic duration (P = 0.000). Anesthetic variables, which can be manipulated by the anesthetist, include choice of premedication and induction drugs, hypothermia, and duration of anesthesia.
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Affiliation(s)
- Stephanie Kleine
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA 30605, USA.
| | - Erik Hofmeister
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA 30605, USA
| | - Katrina Egan
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA 30605, USA
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de la Matta-Martín M, López-Herrera D, Luis-Navarro JC, López-Romero JL. Effects of inhalational anaesthesia with low tidal volume ventilation on end-tidal sevoflurane and carbon dioxide concentrations: prospective randomized study. ACTA ACUST UNITED AC 2013; 61:78-86. [PMID: 24373754 DOI: 10.1016/j.redar.2013.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 05/26/2013] [Accepted: 06/04/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We investigated how ventilation with low tidal volumes affects the pharmacokinetics of sevoflurane uptake during the first minutes of inhaled anaesthesia. METHODS Forty-eight patients scheduled for lung resection were randomly assigned to three groups. Patients in group 1, 2 and 3 received 3% sevoflurane for 3 min via face mask and controlled ventilation with a tidal volume of 2.2, 8 and 12 ml kg(-1), respectively (Phase 1). After tracheal intubation (Phase 2), 3% sevoflurane was supplied for 2 min using a tidal volume of 8 ml kg(-1) (Phase 3). RESULTS End-tidal sevoflurane concentrations were significantly higher in group 1 at the end of phase 1 and lower at the end of phase 2 than in the other groups as follows: median of 2.5%, 2.2% and 2.3% in phase 1 for groups 1, 2 and 3, respectively (P<0.001); and 1.7%, 2.1% and 2.0% in phase 2, respectively (P<0.001). End-tidal carbon dioxide values in group 1 were significantly lower at the end of phase 1 and higher at the end of phase 2 than in the other groups as follows: median of 16.5, 31 and 29.5 mm Hg in phase 1 for groups 1, 2 and 3, respectively (P<0.001); and 46.2, 36 and 33.5 mm Hg in phase 2, respectively (P<0.001). CONCLUSION When sevoflurane is administered with tidal volume approximating the airway dead space volume, end-tidal sevoflurane and end-tidal carbon dioxide may not correctly reflect the concentration of these gases in the alveoli, leading to misinterpretation of expired gas data.
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Affiliation(s)
- M de la Matta-Martín
- Anesthesia Department, General Hospital, Hospital Universitario Virgen del Rocío, Sevilla, Spain.
| | - D López-Herrera
- Anesthesia Department, General Hospital, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - J C Luis-Navarro
- Anesthesia Department, General Hospital, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - J L López-Romero
- Anesthesia Department, General Hospital, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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Abstract
This article establishes the basic mathematical models and the principles and assumptions used for inert gas transfer within body tissues-first, for a single compartment model and then for a multicompartment model. From these, and other more complex mathematical models, the transport of inert gases between lungs, blood, and other tissues is derived and compared to known experimental studies in both animals and humans. Some aspects of airway and lung transfer are particularly important to the uptake and elimination of inert gases, and these aspects of gas transport in tissues are briefly described. The most frequently used inert gases are those that are administered in anesthesia, and the specific issues relating to the uptake, transport, and elimination of these gases and vapors are dealt with in some detail showing how their transfer depends on various physical and chemical attributes, particularly their solubilities in blood and different tissues. Absorption characteristics of inert gases from within gas cavities or tissue bubbles are described, and the effects other inhaled gas mixtures have on the composition of these gas cavities are discussed. Very brief consideration is given to the effects of hyper- and hypobaric conditions on inert gas transport.
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Affiliation(s)
- A Barry Baker
- Department of Anaesthesia, University of Sydney, NSW, Australia.
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21
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Saikia P. Dose sparing of opioids and anaesthetics with pre-operative dexmedetomidine. Indian J Anaesth 2013; 57:93. [PMID: 23716784 PMCID: PMC3658355 DOI: 10.4103/0019-5049.108589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Priyam Saikia
- Department of Anaesthesiology and Critical Care, Gauhati Medical College and Hospital, Guwahati, Assam, India
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Abstract
Inhaled agents represent an important and useful class of drugs for equine anesthesia. This article reviews the ether-type anesthetics in contemporary use, their uptake and elimination, their mechanisms of action, and their desirable and undesirable effects in horses.
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Affiliation(s)
- Robert J Brosnan
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, One Shields Avenue, Davis, CA 95616, USA.
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De Wolf AM, Van Zundert TC, De Cooman S, Hendrickx JF. Theoretical effect of hyperventilation on speed of recovery and risk of rehypnotization following recovery - a GasMan® simulation. BMC Anesthesiol 2012; 12:22. [PMID: 22989260 PMCID: PMC3502091 DOI: 10.1186/1471-2253-12-22] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Accepted: 09/13/2012] [Indexed: 11/21/2022] Open
Abstract
Background Hyperventilation may be used to hasten recovery from general anesthesia with potent inhaled anesthetics. However, its effect may be less pronounced with the newer, less soluble agents, and it may result in rehypnotization if subsequent hypoventilation occurs because more residual anesthetic will be available in the body for redistribution to the central nervous system. We used GasMan® simulations to examine these issues. Methods One MAC of isoflurane, sevoflurane, or desflurane was administered to a fictitious 70 kg patient for 8 h with normoventilation (alveolar minute ventilation [VA] 5 L.min-1), resulting in full saturation of the vessel rich group (VRG) and >95% saturation of the muscle group. After 8 h, agent administration was stopped, and fresh gas flow was increased to 10 L.min-1 to avoid rebreathing. At that same time, we continued with one simulation where normoventilation was maintained, while in a second simulation hyperventilation was instituted (10 L.min-1). We determined the time needed for the partial pressure in the VRG (FVRG; representing the central nervous system) to reach 0.3 MAC (MACawake). After reaching MACawake in the VRG, several degrees of hypoventilation were instituted (VA of 2.5, 1.5, 1, and 0.5 L.min-1) to determine whether FVRG would increase above 0.3 MAC(= rehypnotization). Results Time to reach 0.3 MAC in the VRG with normoventilation was 14 min 42 s with isoflurane, 9 min 12 s with sevoflurane, and 6 min 12 s with desflurane. Hyperventilation reduced these recovery times by 30, 18, and 13% for isoflurane, sevoflurane, and desflurane, respectively. Rehypnotization was observed with VA of 0.5 L.min-1 with desflurane, 0.5 and 1 L.min-1 with sevoflurane, and 0.5, 1, 1.5, and 2.5 L.min-1 with isoflurane. Only with isoflurane did initial hyperventilation slightly increase the risk of rehypnotization. Conclusions These GasMan® simulations confirm that the use of hyperventilation to hasten recovery is marginally beneficial with the newer, less soluble agents. In addition, subsequent hypoventilation results in rehypnotization only with more soluble agents, unless hypoventilation is severe. Also, initial hyperventilation does not increase the risk of rehypnotization with less soluble agents when subsequent hypoventilation occurs. Well-controlled clinical studies are required to validate these simulations.
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Affiliation(s)
- Andre M De Wolf
- Department of Anesthesiology, Feinberg School of Medicine, Northwestern University Medical School, 251 East Huron, Chicago, IL, 60611-3053, USA.
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Perilli V, Vitale F, Modesti C, Ciocchetti P, Sacco T, Sollazzi L. Carbon dioxide elimination pattern in morbidly obese patients undergoing laparoscopic surgery. Surg Obes Relat Dis 2012; 8:590-4. [DOI: 10.1016/j.soard.2011.06.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 06/17/2011] [Accepted: 06/22/2011] [Indexed: 10/18/2022]
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van Heeswijk RB, Pilloud Y, Flögel U, Schwitter J, Stuber M. Fluorine-19 magnetic resonance angiography of the mouse. PLoS One 2012; 7:e42236. [PMID: 22848749 PMCID: PMC3407132 DOI: 10.1371/journal.pone.0042236] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Accepted: 07/04/2012] [Indexed: 11/30/2022] Open
Abstract
Purpose To implement and characterize a fluorine-19 (19F) magnetic resonance imaging (MRI) technique and to test the hypothesis that the 19F MRI signal in steady state after intravenous injection of a perfluoro-15-crown-5 ether (PCE) emulsion may be exploited for angiography in a pre-clinical in vivo animal study. Materials and Methods In vitro at 9.4T, the detection limit of the PCE emulsion at a scan time of 10 min/slice was determined, after which the T1 and T2 of PCE in venous blood were measured. Permission from the local animal use committee was obtained for all animal experiments. 12 µl/g of PCE emulsion was intravenously injected in 11 mice. Gradient echo 1H and 19F images were obtained at identical anatomical levels. Signal-to-noise (SNR) and contrast-to-noise (CNR) ratios were determined for 33 vessels in both the 19F and 1H images, which was followed by vessel tracking to determine the vessel conspicuity for both modalities. Results In vitro, the detection limit was ∼400 µM, while the 19F T1 and T2 were 1350±40 and 25±2 ms. The 19F MR angiograms selectively visualized the vasculature (and the liver parenchyma over time) while precisely coregistering with the 1H images. Due to the lower SNR of 19F compared to 1H (17±8 vs. 83±49, p<0.001), the 19F CNR was also lower at 15±8 vs. 52±35 (p<0.001). Vessel tracking demonstrated a significantly higher vessel sharpness in the 19F images (66±11 vs. 56±12, p = 0.002). Conclusion 19F magnetic resonance angiography of intravenously administered perfluorocarbon emulsions is feasible for a selective and exclusive visualization of the vasculature in vivo.
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Affiliation(s)
- Ruud B van Heeswijk
- Department of Radiology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland.
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Abstract
Data from the NHS Information Centre reveals that more than one in three adults (36.9%) is overweight. In addition, almost a quarter of adults (24% of men and 25% of women aged 16 or over) are obese, with their need for treatment placing a growing burden on the NHS (The NHS Information Centre 2010). Given these proportions, and that an increasing number of morbidly obese patients are undergoing weight loss surgery and procedures related to obesity, it is an opportune time to review the perioperative care of morbidly obese patients.
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Affiliation(s)
- Sammy Al-Benna
- St Bartholomew's Hospital, West Smithfield, London, ECIA 7BE.
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Katznelson R, Van Rensburg A, Friedman Z, Wasowicz M, Djaiani GN, Fedorko L, Minkovich L, Fisher JA. Isocapnic hyperpnoea shortens postanesthetic care unit stay after isoflurane anesthesia. Anesth Analg 2010; 111:403-8. [PMID: 20495141 DOI: 10.1213/ane.0b013e3181e2475c] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND We conducted a prospective controlled clinical trial of the effect of isocapnic hyperpnoea (IH) on the times-to-recovery milestones in the operating room (OR) and postanesthetic care unit (PACU) after 1.5 to 3 hours of isoflurane anesthesia. METHODS Thirty ASA grade I-III patients undergoing elective gynecological surgery were randomized at the end of surgery to either IH or the conventional recovery (control). Six patients with duration of anesthesia of <90 minutes were excluded from the analysis. The anesthesia protocol included propofol, fentanyl, morphine, rocuronium, and isoflurane in air/O(2). Unpaired t tests and analyses of variance were used to test for differences in times-to-recovery indicators between the two groups. RESULTS The durations of anesthesia in IH and control groups were 140.8 + or - 32.7 and 142 + or - 55.6 minutes, respectively (P = 0.99). The time to extubation was much shorter in the IH group than in the control group (6.6 + or - 1.6 (SD) vs. 13. 6 + or - 3.9 minutes, respectively; P < 0.01). The IH group also had shorter times to eye opening (5.8 + or - 1.3 vs. 13.7 + or - 4.5 minutes; P < 0.01), eligibility for leaving the OR (8.0 + or - 1.7 vs. 17.4 + or - 6.1 minutes; P < 0.01), and eligibility for PACU discharge (74.0 + or - 16.5 vs. 94.5 + or - 14.7 minutes; P < 0.01). There were no differences in other indicators of recovery. CONCLUSION IH accelerates recovery after 1.5 to 3 hours of isoflurane anesthesia and shortens OR and PACU stay.
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Affiliation(s)
- Rita Katznelson
- Department of Anesthesia, Toronto General Hospital, Eaton North 3-453, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada.
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Schrey A, Kinnunen I, Kalliokoski K, Minn H, Grénman R, Vahlberg T, Niemi T, Suominen E, Aitasalo K. Perfusion in free breast reconstruction flap zones assessed with positron emission tomography. Microsurgery 2010; 30:430-6. [DOI: 10.1002/micr.20770] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Mellish JAE, Tuomi PA, Hindle AG, Horning M. Chemical immobilization of Weddell seals (Leptonychotes weddellii) by ketamine/midazolam combination. Vet Anaesth Analg 2010; 37:123-31. [DOI: 10.1111/j.1467-2995.2009.00517.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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McKay RE, Malhotra A, Cakmakkaya OS, Hall KT, McKay WR, Apfel CC. Effect of increased body mass index and anaesthetic duration on recovery of protective airway reflexes after sevoflurane vs desflurane. Br J Anaesth 2009; 104:175-82. [PMID: 20037150 DOI: 10.1093/bja/aep374] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Increased BMI may increase the body's capacity to store potent inhaled anaesthetics, more so with more soluble agents. Accordingly, we asked whether increased BMI and longer anaesthesia prolonged airway reflex recovery. METHODS We measured time from anaesthetic discontinuation until first response to command (T1); from response to command until ability to swallow (T2); and from anaesthetic discontinuation to recovery of ability to swallow (T3) in 120 patients within three BMI ranges (18-24, 25-29, and >or=30 kg m(-2)). All received sevoflurane or desflurane, delivered via an LMA. RESULTS T1 and T3 after sevoflurane exceeded T1 and T3 after desflurane: 6.6 (sd 4.2) vs 4.0 (1.9) min (P<0.001), and 14.1 (sd 8.3) vs 6.1 (2.0) min (P<0.0001). T3 correlated more strongly with BMI after sevoflurane (28 s per kg m(-2), P=0.02) than desflurane (7 s per kg m(-2), P=0.03). Regarding T2, patients receiving sevoflurane with BMI >or=30 kg m(-2) were less often able to swallow 2 min after response to command than were those with BMI 18-24 or 25-29 kg m(-2) (3/20 vs 10/20 or 9/20, P<0.05). Each sevoflurane MAC-hour delayed T3 by 4.5 min (268 s) (R=0.46, P<0.001) whereas each desflurane MAC-hour delayed T3 by 0.2 min (16 s) (R=0.10, P=0.44). CONCLUSIONS Prolonged sevoflurane administration and greater BMI delay airway reflex recovery. The contribution of BMI to this delay is more pronounced after sevoflurane than desflurane.
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Affiliation(s)
- R E McKay
- Department of Anaesthesia and Perioperative Care, C-450, University of California San Francisco, San Francisco, CA 94143-0648, USA.
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Van Zundert T, Brebels A, Hendrickx J, Carette R, De Cooman S, Gatt S, De Wolf A. Derivation and Prospective Testing of a Two-step Sevoflurane-O2-N2O Low Fresh Gas Flow Sequence. Anaesth Intensive Care 2009; 37:911-7. [DOI: 10.1177/0310057x0903700608] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Simple vaporiser setting (FD) and fresh gas flow (FGF) sequences make the practice of low-flow anaesthesia not only possible but also easy to achieve. We sought to derive a sevoflurane FD sequence that maintains the end-expired sevoflurane concentration (FAsevo) at 1.3% using the fewest possible number of FD adjustments with a previously described O2-N2O FGF sequence that allows early FGF reduction to 0.7 l.min−1. In 18 ASA physical status I to II patients, FD was determined to maintain FAsevo at 1.3% with 2 l.min−1 O2 and 4 l.min−1 N2O FGF for three minutes, and with 0.3 and 0.4 l.min−1 thereafter. Using the same FGF sequence, the FD schedule that approached the 1.3% FAsevo pattern with the fewest possible adjustments was prospectively tested in another 18 patients. The following FD sequence approximated the FD course well: 2% from zero to three minutes, 2.6% from three to 15 minutes and 2.0% after 15 minutes. When prospectively tested, median (25th; 75th percentile) performance error was 0.8 (-2.9; 5.9)%, absolute performance error 6.7 (3.3; 10.6)%, divergence 18.2 (-5.6; 27.4)%.h−1 and wobble 4.4 (1.7; 8.1)%. In one patient, FGF had to be temporarily increased for four minutes. One O2/N2O rotameter FGF setting change from 6 to 0.7 l.min−1 at three minutes and two sevoflurane FD changes at three and 15 minutes maintained predictable anaesthetic gas concentrations during the first 45 minutes in all but one patient in our study.
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Affiliation(s)
- T. Van Zundert
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Onze Lieve Vrouw Hospital, Aalst, Belgium
- Research Fellow, Department of Anaesthesiology, Intensive Care and Pain Therapy and University of Maastricht, Maastricht, The Netherlands
| | - A. Brebels
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Onze Lieve Vrouw Hospital, Aalst, Belgium
| | - J. Hendrickx
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Onze Lieve Vrouw Hospital, Aalst, Belgium
- Consultant Anaesthesiologist, Department of Anaesthesiology, Intensive Care and Pain Therapy and Consulting Assistant Professor, Stanford University, Stanford, California, USA
| | - R. Carette
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Onze Lieve Vrouw Hospital, Aalst, Belgium
| | - S. De Cooman
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Onze Lieve Vrouw Hospital, Aalst, Belgium
- Consultant Anaesthesiologist, Department of Anaesthesiology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels
| | - S. Gatt
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Onze Lieve Vrouw Hospital, Aalst, Belgium
- Associate Professor, Head of Division and Director, Anaesthesia and Intensive Care, Prince of Wales and Sydney Children's Hospitals, University of New South Wales, Sydney, New South Wales
| | - A. De Wolf
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Onze Lieve Vrouw Hospital, Aalst, Belgium
- Professor, Department of Anaesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Scudder JD, Blystone RV, Pulliam DA. Control of anesthesia-induced hypothermia by ambient temperature regulation in rats. J Therm Biol 2009. [DOI: 10.1016/j.jtherbio.2008.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Lemmens HJM, Saidman LJ, Eger EI, Laster MJ. Obesity Modestly Affects Inhaled Anesthetic Kinetics in Humans. Anesth Analg 2008; 107:1864-70. [DOI: 10.1213/ane.0b013e3181888127] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Sakata DJ, Gopalakrishnan NA, Orr JA, White JL, Westenskow DR. Rapid Recovery from Sevoflurane and Desflurane with Hypercapnia and Hyperventilation. Anesth Analg 2007; 105:79-82. [PMID: 17578960 DOI: 10.1213/01.ane.0000265849.33203.60] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Hypercapnia with hyperventilation shortens the time between turning off the vaporizer (1 MAC) and when patients open their eyes after isoflurane anesthesia by 62%. METHODS In the present study we tested whether a proportional shortening occurs with sevoflurane and desflurane. RESULTS Consistent with a proportional shortening, we found that hypercapnia with hyperventilation decreased recovery times by 52% for sevoflurane and 64% for desflurane (when compared with normal ventilation with normocapnia). CONCLUSION Concurrent hyperventilation to rapidly remove the anesthetic from the lungs and rebreathing to induce hypercapnia can significantly shorten recovery times and produce the same proportionate decrease for anesthetics that differ in solubility.
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Affiliation(s)
- Derek J Sakata
- Department of Anesthesiology, University of Utah, Salt Lake City, UT 84132, USA.
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Sakata DJ, Gopalakrishnan NA, Orr JA, White JL, Westenskow DR. Hypercapnic Hyperventilation Shortens Emergence Time from Isoflurane Anesthesia. Anesth Analg 2007; 104:587-91. [PMID: 17312214 DOI: 10.1213/01.ane.0000255074.96657.39] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND To shorten emergence time after a procedure using volatile anesthesia, 78% of anesthesiologists recently surveyed used hyperventilation to rapidly clear the anesthetic from the lungs. Hyperventilation has not been universally adapted into clinical practice because it also decreases the Paco2, which decreases cerebral bloodflow and depresses respiratory drive. Adding deadspace to the patient's airway may be a simple and safe method of maintaining a normal or slightly increased Paco2 during hyperventilation. METHODS We evaluated the differences in emergence time in 20 surgical patients undergoing 1 MAC of isoflurane under mild hypocapnia (ETco2 approximately 28 mmHg) and mild hypercapnia (ETco2 approximately 55 mmHg). The minute ventilation in half the patients was doubled during emergence, and hypercapnia was maintained by insertion of additional airway deadspace to keep the ETco2 close to 55 mmHg during hyperventilation. A charcoal canister adsorbed the volatile anesthetic from the deadspace. Fresh gas flows were increased to 10 L/min during emergence in all patients. RESULTS The time between turning off the vaporizer and the time when the patients opened their eyes and mouths, the time of tracheal extubation, and the time for normalized bispectral index to increase to 0.95 were faster whenever hypercapnic hyperventilation was maintained using rebreathing and anesthetic adsorption (P < 0.001). The time to tracheal extubation was shortened by an average of 59%. CONCLUSIONS The emergence time after isoflurane anesthesia can be shortened significantly by using hyperventilation to rapidly clear the anesthetic from the lungs and CO2 rebreathing to induce hypercapnia during hyperventilation. The device should be considered when it is important to provide a rapid emergence, especially after surgical procedures where a high concentration of the volatile anesthetic was maintained right up to the end of the procedure, or where surgery ends abruptly and without warning.
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Affiliation(s)
- Derek J Sakata
- Departmentof Anesthesiology, University of Utah, Salt Lake City, UT 84132, USA.
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Wüstneck N, Wüstneck R, Pison U, Möhwald H. On the dissolution of vapors and gases. LANGMUIR : THE ACS JOURNAL OF SURFACES AND COLLOIDS 2007; 23:1815-23. [PMID: 17279661 DOI: 10.1021/la0622931] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
The captive bubble technique in combination with axisymmetric drop shape analysis (ADSA-CB) and with micro gas chromatography is used to study the dynamics of dissolution of different gases and vapors in water in situ. The technique yields the changes in the interfacial tension and bubble volume and surface. As examples, the dissolution of methanol and hexane vapors, inhaled anesthetic vapors, and gases, that is, diethyl ether, chloroform, isoflurane, enflurane, sevoflurane, desflurane, N2O, and xenon, and as nonimmobilizers perfluoropentane and 1,1,2-trichloro-1,2,2-trifluoro-ethane (R113) were investigated. The examination of interfacial tension-time and bubble volume-time functions permits us to distinguish between water-soluble and -insoluble substances, gases, and vapors. Vapors and gases generally differ in terms of the strength of their intermolecular interactions. The main difference between dissolution processes of gases and vapors is that, during the entire process of gas dissolution, no surface tension change occurs. In contrast, during vapor dissolution the surface tension drops immediately and decreases continuously until it reaches the equilibrium surface tension of water at the end of dissolution. The results of this study show that it is possible to discriminate anesthetic vapors from anesthetic gases and nonimmobilizers by comparing their dissolution dynamics. The nonimmobilizers have extremely low or no solubility in water and change the surface tension only negligibly. By use of newly defined molecular dissolution/diffusion coefficients, a simple model for the determination of partition coefficients is developed.
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Affiliation(s)
- N Wüstneck
- Anaesthesiologie, Charité Campus Virchow-Klinikum, Humboldt-Universität Berlin, AugustenburgerPlatz 1, 13344 Berlin, Germany.
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Levitt DG. Heterogeneity of human adipose blood flow. BMC CLINICAL PHARMACOLOGY 2007; 7:1. [PMID: 17239252 PMCID: PMC1797001 DOI: 10.1186/1472-6904-7-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2006] [Accepted: 01/20/2007] [Indexed: 01/14/2023]
Abstract
BACKGROUND The long time pharmacokinetics of highly lipid soluble compounds is dominated by blood-adipose tissue exchange and depends on the magnitude and heterogeneity of adipose blood flow. Because the adipose tissue is an infinite sink at short times (hours), the kinetics must be followed for days in order to determine if the adipose perfusion is heterogeneous. The purpose of this paper is to quantitate human adipose blood flow heterogeneity and determine its importance for human pharmacokinetics. METHODS The heterogeneity was determined using a physiologically based pharmacokinetic model (PBPK) to describe the 6 day volatile anesthetic data previously published by Yasuda et. al. The analysis uses the freely available software PKQuest and incorporates perfusion-ventilation mismatch and time dependent parameters that varied from the anesthetized to the ambulatory period. This heterogeneous adipose perfusion PBPK model was then tested by applying it to the previously published cannabidiol data of Ohlsson et. al. and the cannabinol data of Johansson et. al. RESULTS The volatile anesthetic kinetics at early times have only a weak dependence on adipose blood flow while at long times the pharmacokinetics are dominated by the adipose flow and are independent of muscle blood flow. At least 2 adipose compartments with different perfusion rates (0.074 and 0.014 l/kg/min) were needed to describe the anesthetic data. This heterogeneous adipose PBPK model also provided a good fit to the cannabinol data. CONCLUSION Human adipose blood flow is markedly heterogeneous, varying by at least 5 fold. This heterogeneity significantly influences the long time pharmacokinetics of the volatile anesthetics and tetrahydrocannabinol. In contrast, using this same PBPK model it can be shown that the long time pharmacokinetics of the persistent lipophilic compounds (dioxins, PCBs) do not depend on adipose blood flow. The ability of the same PBPK model to describe both the anesthetic and cannabinol kinetics provides direct qualitative evidence that their kinetics are flow limited and that there is no significant adipose tissue diffusion limitation.
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Affiliation(s)
- David G Levitt
- Department of Integrative Biology and Physiology, University of Minnesota, 6-125 Jackson Hall, Minneapolis, MN 55455, USA.
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McGlinch BP, Que FG, Nelson JL, Wrobleski DM, Grant JE, Collazo-Clavell ML. Perioperative care of patients undergoing bariatric surgery. Mayo Clin Proc 2006; 81:S25-33. [PMID: 17036576 DOI: 10.1016/s0025-6196(11)61178-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The epidemic of obesity in developed countries has resulted in patients with extreme (class III) obesity undergoing the full breadth of medical and surgical procedures. The popularity of bariatric surgery in the treatment of extreme obesity has raised awareness of the unique considerations in the care of this patient population. Minimizing the risk of perioperative complications that contribute to morbidity and mortality requires input from several clinical disciplines and begins with the preoperative assessment of the patient. Airway management, intravenous fluid administration, physiologic responses to pneumoperitoneum during laparoscopic procedures, and the risk of thrombotic complications and peripheral nerve injuries in extremely obese patients are among the factors that present special intraoperative challenges that affect postoperative recovery of the bariatric patient. Early recognition of perioperative complications and education of the patient regarding postoperative issues, including nutrition and vitamin supplementation therapy, can improve patient outcomes. A suitable physical environment and appropriate nursing and dietetic support provide a safe and dignified hospital experience. This article reviews the multidisciplinary management of extremely obese patients who undergo bariatric surgery at the Mayo Clinic.
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Affiliation(s)
- Brian P McGlinch
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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