Comparison of intraoperative brain condition, hemodynamics and postoperative recovery between desflurane and sevoflurane in patients undergoing supratentorial craniotomy

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.

Propofol versus Desflurane in Moyamoya Disease Patients-A Pilot Study

Objectives  The choice of inhalational or intravenous anesthetic agents is debatable in neurosurgical patients. Desflurane, a cerebral vasodilator, may be advantageous in ischemic cerebral pathologies. Hence, we planned to compare desflurane and propofol in patients with moyamoya disease (MMD) with the objective of comparing neurological outcomes. Materials and Methods  This prospective pilot trial was initiated after institutional ethics committee approval. Patients with MMD undergoing revascularization surgery were randomized into two groups receiving either desflurane or propofol intraoperatively. Neurological outcomes were assessed using a modified Rankin score (mRS) at discharge and an extended Glasgow outcome score (GOS-E) at 1 month. Intraoperative parameters, including hemodynamic parameters, end-tidal carbon dioxide, entropy, intraoperative brain relaxation scores (BRS), and rescue measures for brain relaxation, were compared. Statistical Analysis  The normality of quantitative data was checked using Kolmogorov-Smirnov tests of normality. Normally distributed data were compared using unpaired t -tests, skewed data using Mann-Whitney U tests, and categorical variables using chi-squared tests. Results  A total of 17 patients were randomized, 10 in the desflurane and 7 in the propofol group. mRS (1.3 ± 0.6 and 1.14 ± 0.4, p  = 0.450) and GOS-E (6.7 ± 0.6 and 6.85 ± 0.5, p  = 0.45) were comparable between desflurane and propofol groups, respectively. BRS was significantly higher in the desflurane group (3.6 ± 0.5) compared to the propofol group (2.1 ± 0.3, p  = 0.001), with a significant number of patients requiring rescue measures in the desflurane group (70%, p  < 0.001). Other outcome parameters were comparable ( p  > 0.05). Conclusion  We conclude that postoperative neurological outcomes were comparable with using either an anesthetic agent, desflurane, or propofol in MMD patients undergoing revascularization surgery. Maintenance of anesthesia with propofol had significantly superior surgical field conditions.

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.

Sevoflurane versus desflurane for early postoperative vomiting after general anesthesia in hospitalized adults: A systematic review and meta-analysis of randomized controlled trials

STUDY OBJECTIVE

This systematic review and meta-analysis aimed at assessing the effects of two commonly used anesthetics in general anesthesia (GA), sevoflurane and desflurane, on early postoperative vomiting (POV) in hospitalized adults.

DESIGN

Systematic review and meta-analysis of randomized controlled trials (RCTs).

SETTING

Early postoperative vomiting after GA.

PATIENTS

A total of 266 adult patients receiving inpatient surgeries under GA maintained with sevoflurane or desflurane.

INTERVENTIONS

We searched PubMed, Medline, Cochrane Central Register of Controlled Trials, ScienceDirect, and Embase for eligible RCTs comparing postoperative outcomes following sevoflurane- or desflurane-maintained anesthesia.

MEASUREMENTS

The primary outcome was early POV. Secondary outcomes included late POV, early and late postoperative nausea (PON), time to extubation, and emergence time.

MAIN RESULTS

Eight trials were included. There was no significant difference in the risk of early POV (risk ratio [RR] 1.03, 95% confidence interval [CI] 0.64-1.64, p = 0.91). No significant difference in early PON was observed (RR 1.09; 95% CI, 0.77-1.56; p = 0.62). Nevertheless, the incidence of late POV and late PON were significantly lower in the sevoflurane group than that in the desflurane group (RR 0.47, 95% CI 0.23-0.94, p = 0.03; RR 0.45, 95% CI 0.24-0.84, p = 0.01, respectively). The extubation time was longer in the sevoflurane group than in the desflurane group (standardized mean difference [SMD] 0.56, 95% CI 0.14-0.97, p = 0.009). The emergence time of patients in the sevoflurane group was longer than that in those receiving desflurane (SMD 0.76, 95% CI 0.1-1.42, p = 0.02).

CONCLUSIONS

Desflurane had the same effects on early POV and early PON as sevoflurane. However, the association between late POV and late PON with desflurane was stronger than that with sevoflurane if the effects of opioids were not considered. The desflurane group had shorter time to extubation and emergence time than the sevoflurane group. PROSPERO registration number: CRD42020218988.