Early postoperative recovery after intracranial surgical procedures. Comparison of the effects of sevoflurane and desflurane

Clinical Effects and Adverse Events Associated With Desflurane Use in Adult Patients Undergoing Supratentorial Craniotomy: A Systematic Review

Desflurane is an inhalational anesthetic agent with an appealing recovery profile. The present systematic review investigates the clinical effects and adverse events associated with desflurane use during supratentorial craniotomy for brain tumor resection in adults in comparison with other inhalational and intravenous anesthetic agents. A literature search was conducted across the MEDLINE, Library of Congress and LISTA (EBSCO) databases from January 2001 to January 2021. Twelve studies published between 2003 and 2020 were included in this systematic review. Desflurane was compared with either isoflurane, sevoflurane, or propofol for anesthesia maintenance. Brain relaxation scores showed no statistically significant difference between desflurane and the other anesthetic agents. Recovery timepoints, such as time to recovery, time to eye opening, time to extubation, time to follow commands, and time to reach a modified Aldrete score ≥9 were significantly shorter with desflurane in the majority of studies. Systemic hemodynamic variables (mean arterial pressure and heart rate) and cerebral hemodynamics (intracranial pressure and cerebrospinal fluid pressure) were comparable between desflurane and other anesthetic agents in each study. The results of this systematic review demonstrate that desflurane is associated with few adverse events when used for anesthesia maintenance in adult patients undergoing supratentorial brain tumor surgery. Large, prospective, comprehensive studies, utilizing standardized parameter evaluation could provide higher levels of evidence to support these findings.

Systematic review with meta-analysis of relative risk of prolonged times to tracheal extubation with desflurane versus sevoflurane or isoflurane

The objective of this systematic review was to estimate the relative risk of prolonged times to tracheal extubation with desflurane versus sevoflurane or isoflurane. Prolonged times are defined as ≥15 min from end of surgery (or anesthetic discontinuation) to extubation in the operating room. They are associated with reintubations, naloxone and flumazenil administration, longer times from procedure end to operating room exit, greater differences between actual and scheduled operating room times, longer times from operating room exit to next case start, longer durations of the workday, and more operating room personnel idle while waiting for extubation. Published randomized clinical trials of humans were included. Generalized pivotal methods were used to estimate the relative risk of prolonged extubation for each study from reported means and standard deviations of extubation times. The relative risks were combined using DerSimonian-Laird random effects meta-analysis with Knapp-Hartung adjustment. From 67 papers, there were 78 two-drug comparisons, including 5167 patients. Studies were of high quality (23/78) or moderate quality (55/78), the latter due to lack of blinding of observers to group assignment and/or patient attrition because patients were extubated after operating room exit. Desflurane resulted in a 65% relative reduction in the incidence of prolonged extubation compared with sevoflurane (95% confidence interval 49% to 76%, P < .0001) and in a 78% relative reduction compared with isoflurane (58% to 89%, P = .0001). There were no significant associations between studies' relative risks and quality, industry funding, or year of publication (all six meta-regressions P ≥ .35). In conclusion, when emergence from general anesthesia with different drugs are compared with sevoflurane or isoflurane, suitable benchmarks quantifying rapidity of emergence are reductions in the incidence of prolonged extubation achieved by desflurane, approximately 65% and 78%, respectively. These estimates give realistic context for interpretation of results of future studies that compare new anesthetic agents to current anesthetics.

Neurosurgical Anesthesia: Optimizing Outcomes with Agent Selection

Anesthesia in neurosurgery embodies a vital element in the development of neurosurgical intervention. This undisputed interest has offered surgeons and anesthesiologists an array of anesthetic selections to utilize, though with this allowance comes the equally essential requirement of implementing a maximally appropriate agent. To date, there remains a lack of consensus and official guidance on optimizing anesthetic choice based on operating priorities including hemodynamic parameters (e.g., CPP, ICP, MAP) in addition to the route of procedure and pathology. In this review, the authors detail the development of neuroanesthesia, summarize the advantages and drawbacks of various anesthetic classes and agents, while lastly cohesively organizing the current literature of randomized trials on neuroanesthesia across various procedures.

Propofol But Not Desflurane Maintains Rat Cerebral Arteriolar Responses to Acetylcholine During Acute Hyperglycemia

BACKGROUND

Acute hyperglycemia causes vascular endothelial dysfunction in various organs including the cerebral vessels. It is associated with increased mortality and morbidity in the perioperative period. The impact of anesthetic agents on cerebral vasodilatory responses during hyperglycemia remains unclear. We investigated endothelial function in rat cerebral arterioles during acute hyperglycemia, under propofol or desflurane anesthesia.

MATERIALS AND METHODS

A closed cranial window preparation was used to measure changes in pial arteriole diameter induced by topical application of acetylcholine (ACh), an endothelium-dependent vasodilator, in rats anesthetized with propofol or desflurane. Pial arteriole responses to ACh were measured during normoglycemia and hyperglycemia. We then investigated whether the response of cerebral arterioles to acute hyperglycemia under propofol anesthesia were related to propofol or its vehicle, intralipid.

RESULTS

ACh resulted in a dose-dependent dilation of cerebral arterioles during propofol and desflurane anesthesia under normoglycemic conditions. The vasodilatory effects of ACh were also maintained under hyperglycemic conditions during propofol anesthesia, but the vasodilator response to ACh was significantly impaired during hyperglycemia compared with normoglycemia with desflurane anesthesia. The vasodilatory effects of ACh were maintained during normoglycemia and hyperglycemia in rats receiving propofol or intralipid.

CONCLUSIONS

Rat pial arteriole responses to ACh are maintained during conditions of acute hyperglycemia with propofol anesthesia but suppressed compared with normoglycemia with desflurane anesthesia.

Desflurane anesthesia compared with total intravenous anesthesia on anesthesia-controlled operating room time in ambulatory surgery following strabotomy: a randomized controlled study

BACKGROUND

Ophthalmic ambulatory surgery is preferred to be performed under general anesthesia either by total intravenous anesthesia (TIVA) or by inhalational anesthesia to increase the patient comfort. However, anesthesia-controlled time (ACT) can cause increased non-operative operating room (OR) time which may adversely affect the ORs efficiency. This study was aimed to compare the ACT of desflurane with that of propofol-remifentanil in strabismus ambulatory surgery.

METHODS

From November 2016 to December 2017, a total of 200 strabismus patients (aged 18-60 years old, and scheduled for elective ambulatory surgery at Zhongshan Ophthalmic Center) were randomly assigned to receive either propofol-based TIVA (group TIVA) or desflurane anesthesia (group DES) for maintenance of anesthesia. The primary outcome was the extubation time. Secondary outcomes included surgical time, anesthetic time, OR exit time, and Phase I and II recovery time. The intraoperative incidences of hypotension, bradycardia and oculocardiac reflex (OCR), and the incidences of any post-operative complications were recorded. Mann-Whitney U test and Chi-square or Fisher exact tests were used to compare the two groups.

RESULTS

We found that the extubation time (5.5 [3.9-7.0] vs. 9.7 [8.5-11.4] min, P < 0.001) and the incidence of prolonged time to extubation (0 vs. 6%, P = 0.029) in the DES group were significantly decreased compared with those in the TIVA group. The patients in the DES group displayed shorter OR exit time as compared with that in the TIVA group (7.3 [5.5-8.7] vs. 10.8 [9.3-12.3] min, P < 0.001). The patients using desflurane exhibited more stable hemodynamics during surgery than the patients using propofol-based TIVA, as demonstrated by lower incidences of hypotension (1% vs. 22%, P < 0.001), bradycardia (2% vs. 13%, P = 0.002), and OCR (17% vs. 44%, P < 0.001).

CONCLUSION

DES enhanced the ophthalmic OR efficiency by reducing the extubation time and OR exit time, and provided more stable hemodynamics intra-operatively than TIVA in patients undergoing strabismus ambulatory surgery.

TRIAL REGISTRATION

ClinicalTrials.gov, No. NCT02922660; https://clinicaltrials.gov/ct2/show/NCT02922660?id=NCT02922660&draw=2&rank=1.

Randomized Trial to Compare Plasma Glucose Trends in Patients Undergoing Surgery for Supratentorial Gliomas under Maintenance of Sevoflurane, Desflurane, and Propofol

Background

Anesthetic agents influence the glycemic response by affecting the neuroendocrine surgical response or directly modifying pancreatic insulin release. Due to chances of neuronal damage, intraoperative hyperglycemia and hypoglycemia both are detrimental for patients undergoing neurosurgeries. Inhalational (sevoflurane and desflurane) and intravenous (propofol) agents have been found to raise intraoperative glucose levels in nonneurological surgeries.

Aim

We aimed to compare the intraoperative glucose levels in supratentorial glioma surgeries under the maintenance of three anesthetic agents such as sevoflurane, desflurane, and propofol.

Materials and Methods

This randomized trial was conducted with 90 nondiabetic adults with supratentorial glioma. Thirty patients were allocated randomly to the three groups receiving sevoflurane, desflurane, and propofol. Baseline and hourly plasma glucose levels were recorded. Postoperatively, the time required to achieve an Aldrete score of 9 and complications were assessed.

Results

Baseline plasma glucose levels were 111.23 ± 11.67, 109.47 ± 19.75, and 111.7 ± 13.88 mg/dL (P = 0.84) in sevoflurance, desflurane, and propofol group, respectively. All of them showed an elevation of plasma glucose in relation to the time of surgery with variable trends. In the 4^th and 5^th h, the elevations in the inhalational groups (sevoflurane and desflurane) were significantly higher than the propofol group (P = 0.003 and 0.002, respectively). The time for achieving Aldrete's score of 9 was higher in the propofol group (P < 0.0001). No differences were observed in the duration of hospital stay or complications.

Conclusions

Maintenance of anesthesia in nondiabetic patients showed clinically modest rise of plasma glucose which is higher in patients under sevoflurane and desflurane than under propofol. However, the immediate recovery was faster with inhalational agents compared to propofol-based anesthesia.

Inhaled anesthesia in neurosurgery: Still a role?

In patients undergoing craniotomy, general anesthesia should be addressed to warrant good hypnosis, immobility, and analgesia, to ensure systemic and cerebral physiological status and provide the best possible surgical field. Regarding craniotomies, it is unclear if there are substantial differences in providing general anesthesia using total intravenous anesthesia (TIVA) or balanced anesthesia (BA) accomplished using the third generation halogenates. New evidence highlighted that the last generation of halogenated agents has possible advantages compared with intravenous drugs: rapid induction, minimal absorption and metabolization, reproducible pharmacokinetic, faster recovery, cardioprotective effect, and opioid spare analgesia. This review aims to report evidence related to the use of the latest halogenated agents in patients undergoing craniotomy and to present available clinical evidence on their effects: cerebral and systemic hemodynamic, neurophysiological monitoring, and timing and quality of recovery after anesthesia.

Early postoperative recovery in operating room after desflurane anesthesia combined with Bispectral index (BIS) monitoring and warming in lengthy abdominal surgery: a randomized controlled study

BACKGROUND

This study aimed to determine whether the use of desflurane (DES) anesthesia combined with bispectral index (BIS) monitoring and warming is effective in reducing anesthesia-controlled operating room time (ACT) in patients undergoing lengthy abdominal surgery.

METHODS

Seventy patients, 40 years of age or older, undergoing abdominal surgery expected to last three to five hours were randomly assigned to the DES group (n = 35) or the control group (n = 35). Patients in the DES group were maintained with desflurane anesthesia and received BIS monitoring and warming. Patients in the control group were given non-desflurane anesthesia for maintenance, and the usage of BIS monitoring and warming were not mandatory and determined by anesthesia care providers. Early postoperative recovery times were recorded.

RESULTS

The times to extubation (8.8 ± 8.5 vs 14.7 ± 13.7 min, P = 0.035), eye opening (8.4 ± 8.6 vs 14.4 ± 13.4 min, P = 0.028), responds on command (8.2 ± 8.5 vs 14.4 ± 13.0 min, P = 0.022), and the ACT (23.8 ± 11.4 vs 32.7 ± 15.4 min, P = 0.009) were significantly less in the DES group than that in the control group. The postanesthesia care unit (PACU) length of stay, incidence of prolonged extubation, and surgeon and anesthesiologist satisfaction were similar in two groups. Also, the result of multivariable linear regressions showed that patients who were younger, female, lower BMI and non-DES anesthesia regimen resulted in prolonged extubation.

CONCLUSIONS

Desflurane anesthesia combined with BIS monitoring and warming is associated with early postoperative recovery in lengthy abdominal surgery.

TRIAL REGISTRATION

ChiCTR-INR-17013333 . Date of registration: November 11, 2017.