Blood Concentrations of Enflurane Before, During, and After Hypothermic Cardiopulmonary Bypass

OBJECTIVE

The purpose of this study was to determine blood concentrations of enflurane delivered via a membrane oxygenator during hypothermic cardiopulmonary bypass (CPB) with changes in the input enflurane concentration and temperature and to characterize the pharmacokinetics of enflurane washout during and after CPB.

DESIGN

Blood enflurane concentrations were measured by gas chromatography before, during, and after CPB by using mean delivered enflurane concentrations of 0.5% v/v (group 1, n = 5), 0.8% (group 2, n = 7), and 1% (group 3, n = 14).

SETTING

The investigation was performed in a teaching hospital setting.

PARTICIPANTS

Twenty-six patients undergoing cardiac surgery requiring hypothermic CPB.

INTERVENTIONS

Variations in input enflurane concentration in different patients plus blood sampling from the arterial side of the circuit for enflurane assay.

MEASUREMENTS AND MAIN RESULTS

Median (25th and 75th percentiles) pre-CPB blood enflurane concentrations were 48 (25-50) mg/L, 52 (47-56) mg/L, and 115 (90-143) mg/L in groups 1 (0.5% v/v), 2 (0.8% v/v), and 3 (1% v/v), respectively. During hypothermia (28 degrees C) corresponding enflurane concentrations were 44 (31-53) mg/L, 56 (45-62) mg/L, and 145 (109-203) mg/L, respectively. For groups 1 and 2, there were no significant changes in blood enflurane compared with the corresponding pre-CPB value. However, for group 3, cooling resulted in a significant increase (p = 0.006) in blood enflurane. In all groups, enflurane concentrations after rewarming were similar to those in the pre-CPB period.

CONCLUSIONS

It is concluded that exposure to enflurane concentrations greater than 0.8% during CPB can result in high blood concentrations.

Existence of reverse second gas effect with enflurane

OBJECTIVE

To investigate the existence of 'reverse second gas effect' with enflurane and to find out any influence of the variables; age, gender, body weight and American society of anaesthesiologist (ASA) status of the patient over the existence of reverse second gas effect.

METHODS

This double blinded randomized control trial included forty eight adult ASA I and II patients divided in two groups 'A' and 'B'. The existence of reverse second gas effect was investigated in terms of rate of decline of exhaled concentration of enflurane with and without nitrous oxide. Collected data included age, weight, gender, ASA status, rate of decline of exhaled enflurane, heart rate & blood pressure of patients during the research protocol.

RESULTS

Independent 't' test was used to compare the rate of decline and exhaled concentration of enflurane with and without nitrous oxide (p = 0.22). 'T' test was also used (p = 0.45 & 0.97 respectively) to observe the influence of age and weight. For the influence of ASA status and gender, chi square test was applied (p = 0.99 and 0.77 respectively).

CONCLUSION

From the results of our study, we concluded that reverse second gas effect does not exist with enflurane. Furthermore, no influence of the variables age, gender, ASA status and body weight could be found on the existence of reverse second gas effect.

Determination of volatile anesthetics isoflurane and enflurane in mouse brain tissues using gas chromatography-mass spectrometry

INTRODUCTION

A method for determination of the volatile anesthetics, isoflurane, and enflurane in mouse brain tissues using headspace gas chromatography-mass spectrometry (GC-MS) is described.

METHODS

Halothane was used as internal standard (I.S.). Brain samples were completely homogenized in ice-cold water and isoflurane, enflurane, and I.S. were extracted with headspace. One milliliter of headspace gas was injected onto the GC-MS and separation was achieved by using porous layer open tubular (PLOT) capillary column with a solid stationary phase (GSC). As a result, isoflurane, enflurane, and halothane were cleanly separated.

RESULTS

The method demonstrated satisfactory recovery (72% and 76% for isoflurane and enflurane, respectively) and linear calibration ranges of 0.015-2.20 and 0.0152-3.94 microg/sample for isoflurane and enflurane, respectively. Reproducibility calculated as CV% was 3.3-3.9% for all intraday and interday determinations. The procedure was applied for quantitation of isoflurane and enflurane in about 300 mouse brain samples for genetic behavioral study.

DISCUSSION

The method was achieved and shown to be effective.

Caudal anesthesia reduces the minimum alveolar concentration of enflurane for laryngeal mask airway removal in boys

PURPOSE

To investigate the effects of caudal analgesia on the minimal alveolar concentration of enflurane for laryngeal mask airway (LMA) smooth extubation (MACex).

METHODS

We studied 50 nonpremedicated children, aged three to ten years, ASA physical status I, undergoing surgery for hypospadias repair. After a sevoflurane inhalation induction, children were randomized to receive LMA insertion with or without ropivacaine caudal analgesia. At the end of surgery, a predetermined end-tidal enflurane concentration was achieved, and the LMA was removed by an anesthesiologist blinded to group allocation. Each concentration at which LMA extubation was attempted was predetermined by the up-and-down method (with 0.1% as the step size). When LMA removal was accomplished without coughing, clenching teeth or gross purposeful muscular movements during or within one minute after removal, it was considered successful.

RESULTS

MACex of enflurane for LMA removal in the group without caudal anesthesia was 1.04% (95% confidence interval, 1.00-1.10) and the LMA MACex of enflurane in the group with caudal anesthesia was 0.74% (95% confidence interval, 0.63-0.81). Caudal analgesia significantly reduced enflurane requirements by 29% (95% confidence interval, 22-36%).

CONCLUSION

In conclusion, caudal analgesia significantly reduced the LMA MACex of enflurane by approximately 29%. Possible mechanisms may be related to the analgesic effect of caudal blockade or to the sedative properties of neuraxial anesthesia.

Fresh gas flow is not the only determinant of volatile agent consumption: a multi-centre study of low-flow anaesthesia

METHODS

Seven academic centres studied 302 patients, using desflurane, enflurane, halothane, or isoflurane using circle-systems and Dräger Julian anaesthetic machines, with fresh gas flows (V(F)) of 3, 1, and 0.5 litre min(-1). Volatile agent partial pressures in the breathing system were recorded and agent consumptions measured by weighing.

RESULTS

At these flows, desflurane consumption depended on V(F). In contrast, halothane consumption was not influenced by V(F). Isoflurane and enflurane showed differences in consumption between flows of 0.5 and 3 litre min(-1). Stepwise linear regression suggested that besides V(F), other factors influenced consumption of the more soluble agents (sex, age, weight, height, altitude, and temperature). The partial pressure ratios were independent of V(F) for desflurane (end-tidal to fresh gas=0.8), but the ratios of the more soluble agents varied with V(F) (end-tidal to fresh gas=0.3-0.7).

CONCLUSIONS

At V(F) that involves significant re-breathing, consumption of soluble agents depends only partially on V(F). These results can be explained using Mapleson's hydraulic analogue model.

Tissue solubility of four volatile anesthetics in fresh and frozen tissue specimens from swine

OBJECTIVE

To determine tissue solubilities of desflurane, sevoflurane, enflurane, and halothane in swine and to evaluate the effects of freezing specimens on tissue solubility,

SAMPLE POPULATION

Arterial blood samples and specimens of brain, heart, liver, kidney, muscle, and subcutaneous fat from 5 healthy female adult Chinese Meishan pigs.

PROCEDURE

Each tissue specimen was divided into 2 parts. One part was used to measure tissue-gas partition coefficients immediately after collection. The other part was frozen at -20 C for 6 days prior to determination of tissue-gas partition coefficients. Tissue-gas and blood-gas partition coefficients were measured by use of gas chromatography, and tissue-blood partition coefficients were calculated. Regression analysis was performed to determine whether fat-gas partition coefficients were correlated with lean tissue-gas partition coefficients.

RESULTS

Tissue-gas and blood-gas partition coefficients of halothane were greater than those of enflurane followed by coefficients of sevoflurane and desflurane. However, the order of anesthetic agents with the greatest to smallest tissue-blood partition coefficients was sevoflurane, halothane, enflurane, and desflurane. Muscle-gas partition coefficients of sevoflurane and enflurane, liver-gas partition coefficients of desflurane and halothane, and the kidney-gas partition coefficient of enflurane were significantly greater in frozen specimens, compared with fresh specimens. Lean tissue-gas partition coefficients of all 4 volatile anesthetics correlated directly with fat-gas partition coefficients.

CONCLUSIONS AND CLINICAL RELEVANCE

The fat content of lean tissue is an important factor in determining the tissue solubility of volatile anesthetics. Freezing specimens before determination of tissue-gas partition coefficients may result in a false increase in tissue solubility.

Predictive performance of a physiological model for enflurane closed-circuit anaesthesia: effects of continuous cardiac output measurements and age-related solubility data

BACKGROUND

The disposition of inhalation anaesthetics is governed by the factors described in the Fick principle.

METHODS

We have recalibrated a previously validated physiological model for enflurane closed-circuit inhalation anaesthesia, using individual continuous cardiac output measurements as well as age-related enflurane solubility coefficients as inputs to the model. Two model versions using 'calculated' (Brody's formula) or 'measured' (thoracic electrical bioimpedance) cardiac output values, and two versions with 'standard' (fixed) or 'age-related' solubility coefficients were formulated.

RESULTS

Data from 62 ophthalmic surgical patients were used to validate the predictive performance of the four model versions. The root mean squared errors (total error) and scatters (error variation) were similar with the extended model versions, but the group biases (systematic error component) were significantly less with the model versions that included age-related solubility compared with the versions using standard solubility coefficients (bias -0.76/-0.78% vs -3.44/-3.60%).

CONCLUSION

The inclusion of age-related solubility coefficients but not of continuous cardiac output measurements improves the predictive performance of the physiological model for closed-circuit inhalation anaesthetic conditions in routine clinical practice.

Pharmacodynamic interaction of nitrous oxide with sevoflurane, desflurane, isoflurane and enflurane in surgical patients: measurements by effects on EEG median power frequency

BACKGROUND AND OBJECTIVE

This study investigates the interaction of sevoflurane and nitrous oxide on EEG median power frequency of 2.5 Hz during surgery.

METHODS

Sevoflurane concentrations required for electroencephalographic median power frequency between 2 and 3 Hz were measured in 25 patients during gynaecological laparotomies. Nitrous oxide was randomly administered at 0, 20, 40, 60 and 75 vol%, subsequently two different concentrations in each patient. The data were analysed using isobolographic analysis together with previously published data on nitrous oxide-isoflurane, -enflurane, or -desflurane interaction.

RESULTS

The interaction is described by the equation: C volatile anaesthetic/C0 volatile anaesthetic + C N2O/C0 N2O=1 (C is the concentrations for a drug combination to achieve the desired effect; C0 is the concentration for single drug use). The parameters are C0 isoflurane=1.11 vol% (95% CI 1.03-1.19), C0 enflurane=1.64 (1.52-1.77), C0 desflurane=5.31 (4.92-5.73), C0 sevoflurane=2.12 (1.96-2.29), C0 N2O=174 (153-202). These parameters decrease by 6% (2.5-10) for every 10 years of patients' age > 40 years.

CONCLUSIONS

The interaction is compatible with additivity. The potency of nitrous oxide to substitute the volatile anaesthetics is less than anticipated from previously reported MAC values.

The minimum alveolar concentration of enflurane for laryngeal mask airway extubation in deeply anesthetized children

The end-tidal anesthetic gas concentration required to prevent the anesthetized patient from coughing or moving during or immediately after the laryngeal mask airway (LMA) extubation is not known. We sought to determine the minimum alveolar concentration of enflurane required for the removal of the LMA in children. We studied 21 nonpremedicated children between 4 and 11 yr of age, ASA physical status I, undergoing procedures below the umbilicus. General anesthesia was induced with a mask by using sevoflurane, nitrous oxide, and oxygen, and the LMA was inserted. Anesthesia was maintained with enflurane, nitrous oxide, and oxygen. At the end of surgery, a predetermined end-tidal enflurane concentration was achieved, and the LMA was removed. Each concentration at which the LMA extubation was attempted was predetermined by the up-and-down method (with 0.1% as a step size). When LMA removal was accomplished without coughing, clenching teeth, or gross purposeful muscular movements during or within 1 min after removal, it was considered a successful LMA removal. Removal was considered to be unsuccessful in patients who developed breath holding or laryngospasm during or immediately after LMA removal. The minimum alveolar concentration of enflurane at which 50% of children had a successful LMA removal was found to be 1.02% (95% CL, 0.95%-1.11%), and the 95% effective dose for successful extubation was 1.14% (95% CL, 1.07%-1.66%). In conclusion, the LMA removal may be accomplished without coughing or moving at 1.02% end-tidal enflurane concentration in 50% of anesthetized children aged 4-11 yr.

IMPLICATIONS

There may be fewer problems associated with the laryngeal mask airway extubation when patients are deeply anesthetized. The purpose of this study was to determine the minimum concentration of enflurane for successful removal of the laryngeal mask in children.

The "second gas effect" is not a valid concept

To determine whether the "second gas effect" is valid, we determined the pharmacokinetics of 0.2% enflurane with or without 80% N2) (n = 7 each) under controlled constant volume ventilation in 14 young healthy male patients before their operations. The alveolar (end-tidal) concentration (FA) and inspired concentration (FI) at the mouthpiece and the arterial blood concentration of enflurane were measured, and the ratio of FA to FI was calculated. The FA/FI of enflurane increased rapidly during the first few minutes of administration and then increased slowly. No significant difference was found in the FA/FI between the two groups at any time point (P > 0.05). The arterial blood concentrations of enflurane increased progressively and were not significantly different between the two groups at any time point (P > 0.05). The results indicate that, at high concentrations, N2O neither facilitated the increase of FA nor enhanced the uptake of a companion gas. The second gas effect is a nonexistent phenomenon in clinical practice because the concentrating effect is very weak and the augmentation effect is nonexistent under controlled ventilation.

IMPLICATIONS

We studied the effects of N2O on the ratio of alveolar (end-tidal) concentration to inspired concentration of the second gas (enflurane) and on its blood concentration in humans. Nitrous oxide did not affect the alveolar or blood concentration of the second gas under controlled constant volume ventilation. The "second gas effect" is not a valid concept.

[The pharmacokinetic study of desflurane, sevoflurane, isoflurane and enflurane in general anesthesia]

OBJECTIVE

To compare pharmacokinetics of desflurane, sevoflurane, isoflurane and enflurane in general anesthesia.

METHODS

40 patients scheduled for abdominal hysterectomy under general anesthesia were randomly divided into desflurane(D), sevoflurane(S), isofluane(I) and enflurane(E) groups. After induction of anesthesia and endotracheal intubation, desired fraction (Fd) of desflurane(6%), sevoflurane(2%), isoflurane (1.15%) and enflurane(1.7%) in oxygen and nitrous oxide(1:2) were inhaled in D, S, I and E groups, respectively. The fractional end tidal alveolar concentration (Fa) was adjusted to 1MAC during the maintenance of anesthsia. Fa and the fractional inspired concentration of inhaled anesthetics (Fi) were monitored continuously. During operation, fentanyl was infused continuously and pancuronium was injected intermittently.

RESULTS

After the beginning of inhalational anesthesia, the time required for Fa/Fi = 1:2 and Fa = 1MAC in D and S groups was significantly shorter than that in E and I groups. The rates of Fa/Fi in D and S groups were significantly higher than those in E and I groups during the maintenance of anesthesia, so were those of Fa/Fd. After cessation of inhalational anesthesia, the time required for Fa equaled to 50% of Fa0(the last Fa during stoping administration of the inhalational anesthesia) in D group was significantly faster than that in the other three groups.

CONCLUSIONS

The rates of desflurane wash-in and wash-out are faster than those of other inhaled anesthetics. The depth of anesthesia is easy to control when desflurane is used in general anesthesia.

Factors influencing MAC reduction after cardiopulmonary bypass in dogs

BACKGROUND

Anaesthetic requirements may be reduced following surgery employing cardiopulmonary bypass (CPB). This study, in dogs, determined the role of a) volatile agents (enflurane [E] vs isoflurane [I]), b) oxygenator (bubble [B] vs membrane [M]), and c) presence [FL] vs absence [NoFL] of an in-line arterial filter in the bypass circuit in altering anaesthetic requirements following CPB.

METHODS

Male mongrel dogs were anaesthetized with either enflurane (n = 24) or isoflurane (n = 24). They were randomly assigned to one of eight groups (n = 6 per group); Group 1 (E/B/FL), Group 2 (E/M/FL), Group 3 (E/M/NoFL), Group 4 (E/B/NoFL), Group 5 (I/M/FL), Group 6 (I/B/FL), Group 7 (I/M/NoFL) or Group 8 (I/B/NoFL). MAC was determined using the tail-clamp method at hourly intervals, twice before and three times after a one hour normothermic perfusion using aortoatrial cannulation and CPB.

RESULTS

Prior to CPB, MAC was reproducible (enflurane: MAC1 2.17 +/- 0.29 vs MAC2 2.14 +/- 0.28%; isoflurane: MAC1 1.42 +/- 0.31 vs MAC2 1.41 +/- 0.33%) and differed among groups only for the volatile agent employed. Following CPB, MAC was reduced in all groups (P < 0.05 vs pre-CPB measurements) except Group 1 (E/B/FL). The degree of MAC reduction in other groups ranged from 39-64% and was not different based on type of agent employed, use of a membrane or bubble oxygenator, or presence or absence of an in-line arterial filter.

CONCLUSION

In dogs, MAC reduction following CPB was variable, not related to type of volatile agent employed, use of a membrane or bubble oxygenator, or presence or absence of an in-line arterial filter. The explanation for reductions in anaesthetic requirements following CPB in this model remains speculative.

Repeated enflurane anaesthetics and model predictions: a study of the variability in the predictive performance measures

We quantified the total variability (reproducibility) and the within-patient but between repeat anaesthetics variability (repeatability) in measures which are used to judge the predictive performance of our physiological model. We studied 14 patients who received enflurane closed-circuit anaesthesia on two occasions. The end-tidal concentrations measured and those predicted served to calculate the predictive performance measures of the model: root mean squared error (rmse = total error), bias (systematic error) and scatter (error around the bias). The overall results were: rmse 15 (7)%, bias 0 (14)% and scatter 9 (3)% (grand mean (total SD)). The within-patient SD values were smaller for the rmse (4%) and bias (10%), but not for scatter (3%). The repeat rmse values and biases were linked to the first results. This implies that these performance measures depended partly on the patient. As there was no association between the personal performance measures and age, sex, body weight, body surface area or body mass index, these characteristics cannot be used to further tune the model.

Context-sensitive half-times and other decrement times of inhaled anesthetics

The length of anesthetic administration influences the rate at which concentrations of anesthetics decrease after their discontinuation. This is true for both intravenous (I.V.) and inhaled anesthetics. This has been explored in detail for I.V. anesthetics using computer simulation to calculate context-sensitive half-times (the time needed for a 50% decrease in anesthetic concentration) and other decrement times (such as the times needed for 80% or 90% decreases in anesthetic concentration). However, decrement times have not been reported for inhaled anesthetics. In this report, published pharmacokinetic parameters and computer simulation were used to compare the context-sensitive half-times and the 80% and 90% decrement times of the expected central nervous system concentrations for enflurane, isoflurane, sevoflurane, and desflurane. The context-sensitive half-times for all four anesthetics are small (<5 min) and do not increase significantly with increasing duration of anesthesia. The 80% decrement times of both sevoflurane and desflurane are also small (<8 min) and do not increase significantly with duration of anesthesia. However, the 80% decrement times of isoflurane and enflurane increase significantly after approximately 60 min of anesthesia, reaching plateaus of approximately 30 and 35 min. The 90% decrement time of desflurane increased slightly from 5 min after 30 min of anesthesia to 14 min after 6 h of anesthesia. It remained significantly less than the 90% decrement times of sevoflurane, isoflurane, and enflurane, which reached values of 65 min, 86 min, and 100 min, respectively, after 6 h of anesthesia.

IMPLICATIONS

The major differences in the rates at which desflurane, sevoflurane, isoflurane, and enflurane are eliminated occur in the final 20% of the elimination process.

Biotransformation of halothane, enflurane, isoflurane, and desflurane to trifluoroacetylated liver proteins: association between protein acylation and hepatic injury

In susceptible patients, halothane, enflurane, isoflurane, and desflurane can produce severe hepatic injury by an immune response directed against reactive anesthetic metabolites covalently bound to hepatic proteins. The incidence of hepatotoxicity appears to directly correlate with anesthetic metabolism catalyzed by cytochrome P450 2E1 to trifluoroacetylated hepatic proteins. In the present study, we examined whether the extent of acylation of hepatic proteins in rats by halothane, enflurane, isoflurane, and desflurane correlated with reported relative rates of metabolism. After pretreatment with the P450 2E1 inducer isoniazid, five groups of 10 rats breathed 1.25 minimum alveolar anesthetic concentration (MAC) of halothane, enflurane, isoflurane, or desflurane in oxygen, or oxygen alone, each for 8 h. Immunochemical analysis of livers harvested 18 h after anesthetic exposure showed tissue acylation (greatest to least) after exposure to halothane, enflurane, or isoflurane. Reactivity was not different between isoflurane as compared to desflurane or oxygen alone. An enzyme-linked immunosorbent assay showed halothane reactivity was significantly greater than that of enflurane, isoflurane, desflurane, or oxygen, and that enflurane reactivity was significantly greater than desflurane or oxygen. Sera from patients with a clinical diagnosis of halothane hepatitis showed antibody reactivity against hepatic proteins from rats exposed to halothane or enflurane. No reactivity was detected in rats exposed to isoflurane, desflurane, or oxygen alone. These results indicate that production of acylated proteins may be an important mediator of anesthetic-induced hepatotoxicity.

Minimum alveolar concentration of halothane and enflurane are decreased in early pregnancy

BACKGROUND

Minimum alveolar concentration (MAC) of isoflurane is decreased in early pregnancy but it is not known whether this occurs to the same extent with other inhalational anesthetics. The MAC of halothane and enflurane were compared in pregnant women undergoing elective termination of pregnancy and in nonpregnant women.

METHODS

We studied 16 pregnant women scheduled for termination of pregnancy at 8 to 13 weeks gestation and 16 non-pregnant patients undergoing laparoscopic sterilization. Eight patients in each group received halothane and the others received enflurane. After inhalational induction of anesthesia and tracheal intubation, MAC was determined in each patient by observing the motor response to a 10-s, 50-Hz, 80-mA transcutaneous electric tetanic stimulus to the ulnar nerve at varying concentrations of either halothane or enflurane. The end-tidal concentration of inhalational anesthetic was kept constant for at least 15 min before each stimulus and the concentration was varied ultimately in steps of 0.05 vol% (halothane) or 0.10 vol% (enflurane) until a sequence of three alternate responses (move, not move, move) or (not move, move, not move) was obtained. Minimum alveolar concentration for each person was taken as the mean of the two concentrations just permitting and just preventing movement, and MAC for the group was the median of individual MAC values. Confidence intervals were calculated for the percentage decrease in MAC for pregnant women compared with nonpregnant women.

RESULTS

The median (range) MAC of halothane, 0.58 vol% (0.53 to 0.58), and enflurane, 1.15 vol% (0.95-1.25), in the pregnant women were less than those in the nonpregnant women, 0.75 vol% (0.70 to 0.78), P = 0.0005 and 1.65 vol% (1.45 to 1.75), P = 0.0007, respectively. The percentage decrease (95% CI) in MAC for pregnant women was 27% (20 to 27%) for halothane and 30% (24 to 36%) for enflurane.

CONCLUSIONS

The MAC of halothane and enflurane were reduced by a similar degree in pregnant women at 8 to 13 weeks gestation compared with nonpregnant women.

The relationship between anaesthetic uptake and cardiac output

The hypothesis that anaesthetic uptake during maintenance of anaesthesia is related to cardiac output was tested on 21 patients undergoing cardiac surgery. Using a computer-controlled closed breathing system, enflurane was administered to maintain an end-expired concentration of 1%. Cardiac output was measured by thermodilution using a pulmonary artery catheter. A clear qualitative but not quantitative relationship was demonstrated. Changes in anaesthetic requirements at a constant end-expired concentration are a better guide to changes in cardiac output than changes in end-expired carbon dioxide with constant ventilation in patients undergoing cardiac surgery.

[Serum fluoride concentrations and exocrine kidney function with sevoflurane and enflurane. An open, randomized, comparative phase III study of patients with healthy kidneys]

Sevoflurane is a "new" volatile inhaled anaesthetic. Owing to its lower blood-gas solubility coefficient, emergence from anaesthesia is faster with sevoflurane than with isoflurane, enflurane, or halothane. Sevoflurane undergoes metabolic biodegradation, releasing inorganic fluoride ions that could produce nephrotoxicity. In this study, we compared serum inorganic fluoride concentrations (IFCs) in patients receiving either sevoflurane or enflurane. Furthermore, indices of renal function were evaluated until the 3rd postoperative day.

METHODS

Thirty patients with no history of renal or hepatic disease and with an anticipated duration of anaesthesia of at least 3 h were studied in an open, prospective, randomised clinical trial. Anaesthesia was induced with fentanyl, thiopentone, and vecuronium for facilitating endotracheal intubation. Anaesthesia was maintained with sevoflurane or enflurane, 60% nitrous oxide in oxygen, and additional doses of fentanyl. Blood samples for serum IFCs were obtained preoperatively and 2 and, if possible, 4 and 6 h after starting sevoflurane or enflurane, at the end of anaesthesia, and 1, 2, 4, 8, 12, 24, 48 and 72 h post-anaesthesia. Fluoride analysis was performed using an ion-selective electrode. Indices of renal function (serum sodium, osmolality, creatinine, urea, and uric acid, urine specific gravity, osmolality, and pH) were evaluated preoperatively, at the end of anaesthesia, and 24, 48, and 72 h post-anaesthesia.

RESULTS

The duration of anaesthetic exposure was approximately 1.65 MAC-h for both inhaled anaesthetics. Peak serum IFCs were higher with sevoflurane (34.5 mumol/l) than with enflurane (19.4 mumol/l). Fluoride levels decreased more rapidly with sevoflurane: 24 h post-anaesthesia there was no difference between sevoflurane and enflurane (Fig. 1). The area under the curve (AUC) was greater with sevoflurane (688 mumol/l.h) than with enflurane (591 mumol/l.h). For both groups correlation coefficients were higher for MAC-h and AUC than for MAC-h and peak serum IFC (Figs. 2 and 3). Indices of renal function did not change in either group.

DISCUSSION

In our study 1.69 MAC-h sevoflurane produced peak serum IFCs of 34.5 mumol/l. This is in accordance with the investigation of Frink et al. [4], who reported approximately 30 mumol/l after 1.4 MAC-h sevoflurane. Peak serum IFCs with sevoflurane were twice those with enflurane. Within the first 24 h post-anaesthesia, fluoride levels decreased more rapidly after sevoflurane. AUC may be more important than peak serum IFC in evaluating patients who are at risk for renal concentrating defects. In our study there was no evidence of renal dysfunction in either group.

Isomerism and anaesthetic drugs

Isomers are two or more different substances with the same molecular formula (i.e., the same number of different types of atoms). There are two main types of isomerism: 1) structural isomerism, and 2) steroisomerism. Structural isomers (e.g., enflurane and isoflurane) have different molecular structures, and usually behave like different drugs. Occasionally, structural isomers are interconvertible (i.e., they are tautomers or dynamic isomers); this occurs with the barbiturates and midazolam. Steroisomers have identical structures, but a different configuration or spatial arrangement. Stereiosomerism in drugs is often due to chirality or "handedness"; i.e., the presence of right-handed (R)- and left-handed (S)- forms of drugs which are nonsuperimposable mirror images ("enantiomers"). Approximately 60% of anaesthetic agents are chiral drugs; some of these are administered as single enantiomers. However, many synthetic chiral drugs are equal mixtures of (R)- and (S)-isomers, and there are often important differences in their activity and pharmacokinetics. Halothane, enflurane, and isoflurane are chiral drugs with different anaesthetic potencies. Similar differences occur with intravenous anaesthetics; thus, (S) (+)-ketamine causes fewer psychotic emergence reactions, less agitated behaviour, and better intraoperative amnesia and analgesia than its enantiomer. Some local anaesthetics are administered as chiral mixtures; the (S)-isomers have a longer action because of enhanced vasoconstriction. (S)-prilocaine is more slowly metabolized than its enantiomer, while (S)-bupivacaine may produce less cardiotoxicity than (R)-bupivacaine. These differences suggest that some anaesthetic drugs (particularly ketamine and chiral local anaesthetics) should be administered as single enantiomers. In recent years, their synthesis has been greatly simplified, and almost all new drugs may soon be introduced in this form.(ABSTRACT TRUNCATED AT 250 WORDS)

[Rates of awakening, circulatory parameters and side-effects with sevoflurane and enflurane. An open, randomized, comparative phase III study]

OBJECTIVE

Sevoflurane is a "new" volatile inhaled anaesthetic currently undergoing phase III clinical trials in Europe and USA. Owing to the low blood solubility, rapid induction of anaesthesia and emergence from anaesthesia would be expected. In this study, we compared emergence times and haemodynamics in patients receiving either sevoflurane or enflurane. Furthermore, all adverse experiences were recorded, and the relationship to the drug administered was rated.

METHODS

Thirty ASA physical status I and II patients were studied in an open, prospective and randomised clinical trial. Anaesthesia was induced with fentanyl, thiopentone and vecuronium for facilitating endotracheal intubation. Anaesthesia was maintained with sevoflurane or enflurane, 60% nitrous oxide in oxygen and additional doses of fentanyl (1-2 micrograms/kg/h). ECG, blood pressure (non-invasive), inspiratory and end-tidal concentrations of sevoflurane or enflurane were monitored continuously. At the end of surgery, administration of sevoflurane or enflurane and nitrous oxide stopped without tapering and emergence times were recorded. All adverse experiences which occurred until the third postoperative day were recorded and the relationship to the inhaled anaesthetic was rated as "none", "unlikely", "possible", "probable" or "highly probable".

RESULTS

With the exception of the end-tidal concentration at the end of surgery and the mean inspiratory and end-tidal concentrations, which were higher for sevoflurane, the two patient groups were comparable. Pulmonary elimination was significantly faster and emergence time was significantly shorter (5 vs. 9 minutes) with sevoflurane. Emergence time did not correlate with the duration of anaesthetic exposure (MAC hours) for sevoflurane. There was no difference in the time courses of heart rate and mean arterial blood pressure between sevoflurane and enflurane. No adverse experiences with a "probable" or "highly probable" relationship to the inhaled anaesthetic were observed.

CONCLUSION

Emergence time after inhalation anaesthesia depends on (alveolar) ventilation, blood-gas solubility coefficient and, at least for enflurane and isoflurane, on the dose applied (MAC hours). There is no positive correlation between emergence time and dose applied for sevoflurane. Due to the lower blood-gas solubility coefficient (0.6-0.7 for sevoflurane vs. 1.8 for enflurane) pulmonary elimination is faster and emergence time is shorter with sevoflurane. Supplementing inhalation anaesthesia with fentanyl, there is no difference in the time courses of heart rate and mean arterial blood pressure between sevoflurane and enflurane.

The uptake of enflurane during anaesthesia

The uptake of enflurane at a constant end-expired concentration of 2% in oxygen was studied in 38 patients, ASA 1 or 2, undergoing elective orthopaedic procedures. The anaesthetic was administered using a computer-controlled closed circle system. Following an initial 4 min period during which the expired concentration of enflurane was established, the rate of uptake of enflurane showed a triexponential decline. The mean cumulative use of enflurane after 60 min was 10.7 ml, and after 120 min was 18.4 ml.

[Narcotic gas burden of personnel in pediatric anesthesia]

METHODS

To assess the occupational exposure of the anaesthetist to anaesthetic gases, a total of 1 German and 25 Swiss hospitals were investigated. A Brüel & Kjaer Type 1302 multi-gas monitor was used to measure concentrations of nitrous oxide and halogenated anaesthetic agents in the anaesthetist's breathing zone. Measurements were performed during 114 general anaesthetic, 55 of which were in patients under 11 years of age. In these 55 patients, the influence of various factors on the exposure (time-weighted average concentrations) was estimated by comparing different data groups. The efficiency of the applied scavenging equipment was examined by surveying the exhalation valve with a leak detector (type TIF 5600, TIF Instruments, Miami).

RESULTS

Sessions with patients under 11 years of age revealed much higher anaesthetic gas exposures compared to older patients. The concentrations of nitrous oxide were on average threefold (Fig. 1), those of the halogenated anaesthetics fivefold higher (Fig. 2) for the younger patients. In 11- to 16-year-old patients the exposure level was the same as in adult patients. The measurements showed a reduction of 85% in exposure if an efficient scavenging system (i.e., no waste gas discharge to room air through the exhalation valve) or lower fresh gas flow were used (Fig. 4); 42% of the inspected scavengers were inefficient, and reduced the exposure on average by only 30%. In operating theatres with a ventilation rate of at least ten air changes per h, the measured concentrations of anaesthetic gases in the inhalation zone of the anaesthetists were reduced more than 50% compared to poorly ventilated rooms (Figs. 4 and 5). The use of tracheal intubation or laryngeal mask airway (LMA) anaesthesia resulted in a reduction of 80% in exposure compared to standard face masks if efficient scavenging was used. The exposures during sessions with inefficiently scavenged Bain coaxial systems or unscavenged semi-open delivery systems of the Jackson-Rees type were tenfold higher than with scavenged rebreathing circuit systems (Fig. 6). During anaesthesia with IV or double-mask induction, the average levels of inhalation anaesthetics were reduced by about 80% compared to inhalational induction with standard masks (Fig. 7). The anaesthetist's working technique is a very important factor that strongly influences the concentrations. Poor work practices, like lifting off the face mask with anaesthetic gas flow turned on, increased the exposure of the anaesthetist and other operating room personnel drastically, even if the other conditions (scavenger and room ventilation) were good.

DISCUSSION

The exposure levels of anaesthetic gases are generally higher during anaesthesia in children up to 10 years of age than in older patients. Nevertheless, the measurements showed that exposure during paediatric anaesthesia can be kept below the recommended limit (8-h TWA in Switzerland) of 100 ppm nitrous oxide and 5 ppm halothane or 10 ppm enflurane or isoflurane. Causes of high exposures were particularly high fresh gas flows often applied without scavenging or together with inefficient scavenging devices and the high part of mask anaesthesia and inhalation induction with a loosely held mask. To achieve an effective reduction of occupational exposure, well-adjusted and maintained scavenging systems and low-leakage work practices are of primary importance. As leakage can never be completely avoided, a ventilation rate of at least ten air changes per h should be maintained in operating rooms and rooms where anaesthesia is induced to keep down concentrations of waste anaesthetic gases. High exposure during mask anaesthesia and inhalation induction can be prevented by further measures. Using a LMA instead of a standard mask reduces the exposure to the same level as endotracheal intubation.

Simulation of inhalational anaesthetic uptake using a lung model with charcoal

A physical lung model for simulation of volatile anaesthetic uptake is described. Two communicating water-filled chambers simulate pulmonary mechanics allowing adjustment of functional residual capacity, resistance and compliance. The uptake of the volatile anaesthetics is reproduced by pumping gas from the lung chamber through a charcoal absorber at different rates; using a second pump for a bypass an arterial to end-tidal gradient can be generated. Changes of cardiac output are simulated by adjusting pump speed and of alveolar ventilation by adapting the ventilator setting. The results are reproducible and correspond with patient studies and computer stimulation, not necessitating empirical correction factors as in a previously described oil-based lung model. The model can serve as a teaching instrument, for the comparison and testing of anaesthetic equipment and the development of feedback systems.

The impact of streptozotocin-induced diabetes on the minimum alveolar anesthetic concentration (MAC) of inhaled anesthetics in the rat

We designed experiments to examine the effects of insulin-dependent diabetes mellitus on the anesthetic requirements for volatile anesthetics. A standard tail-clamp technique was used to determine minimum alveolar anesthetic concentrations for halothane, enflurane, and isoflurane in spontaneously breathing rats. Three groups of animals were used: 1) diabetic rats (12 wk after induction of diabetes with streptozotocin, 50 mg/kg, single dose, intravenously), 2) insulin-treated (7 U extended insulin zinc suspension per day, subcutaneously, beginning 5 wk after streptozotocin treatment) diabetic rats, and 3) control rats. The minimum alveolar anesthetic concentration values of the control animals were 1.16 +/- 0.02 vol% for halothane, 2.25 +/- 0.05 vol% for enflurane, and 1.42 +/- 0.04 vol% for isoflurane. Minimum alveolar anesthetic concentration was reduced by 23% for halothane (0.90 +/- 0.06 vol%), by 18% for enflurane (1.85 +/- 0.07 vol%), and by 17% for isoflurane (1.18 +/- 0.04 vol%) in diabetic rats. Insulin treatment restored the anesthetic requirement to control levels for all three anesthetics. These data from the rat model indicate that uncontrolled diabetes lowers anesthetic requirements significantly.

[Serum inorganic fluoride concentrations and their urinary excretion during and after sevoflurane, isoflurane, or enflurane anesthesia in man]

Serum inorganic fluoride concentrations and their urinary excretion were examined during and after sevoflurane, isoflurane, or enflurane anesthesia in man. Duration of anesthesia was 3 hours in sevoflurane and enflurane groups (S3 group: n = 10, E3 group: n = 5), and 3 or 5 hours in isoflurane groups (I3 group: n = 5, I5 group: n = 5). Serum inorganic fluoride concentration of the S3 and E3 groups increased immediately following induction, and reached the maximum concentration of 21.8 +/- 9.3 (M +/- SD) mumol.l-1 (S3), 13.6 +/- 6.2 mumol.l-1 (E3) at 1 hour after anesthesia. Serum inorganic fluoride decreased after the peak concentrations, and returned to the pre-anesthesia level at 96 hours (S3) and 144 hours (E3) after anesthesia. On the other hand, serum inorganic fluoride of the I3 and I5 groups scarcely changed from the pre-anesthesia level, and maximum concentrations of these two groups were one tenth of the S3 group. Urinary excretion of inorganic fluoride of the S3 and E3 group began to increase from 2 hours after anesthesia, and showed plateau of 60-90 mmol.h-1 from 12 hours to 24 hours after anesthesia. The change of serum inorganic fluoride sharply contrasted with urinary excretion. Our results suggest that fluoride excretion is largely carried out by the kidney. Therefore sevoflurane or enflurane anesthesia should be avoided in patients with renal dysfunction.

Uptake of enflurane and isoflurane during spontaneous and controlled ventilation

The uptake of enflurane and of isoflurane were studied in forty patients during anaesthesia with nitrous oxide using either spontaneous or controlled ventilation. A Douglas bag method was used in combination with low fresh gas flows to a circle system and constant end-tidal anaesthetic concentration. The mean enflurane uptake rates were between 24 and 14 ml.70kg-1.min-1 between 10 and 60 minutes. Corresponding isoflurane uptake rates were between 15 and 8 ml. 70 kg-1.min-1. The initial uptake rates were lower than expected from "the square root of time concept". During spontaneous ventilation, the anaesthetic uptake rates were similar or even higher than corresponding rates during controlled ventilation in spite of lower minute ventilation volumes.

Haemodynamic effects and uptake of enflurane in patients undergoing cardiac surgery: good versus poor myocardial function

We measured haemodynamic effects and uptake of enflurane in patients undergoing cardiac surgery utilizing a standard anaesthetic technique of fentanyl 15 mcg/kg nitrous oxide 50%/enflurane 1%. We divided 22 patients preoperatively into two groups according to standard criteria: good and poor myocardial function. Regression lines could be drawn illustrating the relationship of cardiac output and uptake (at 1 minute: r = -0.56, P less than 0.01; at 5 minutes: r = -0.43, P less than 0.05; at 30 minutes: r = -0.31, P = 0.08). Although patients with poor myocardial function had decreased uptake of enflurance (approximately 10-20%), this did not reach statistical significance. Fentanyl/nitrous oxide/enflurane anaesthesia provided stable haemodynamics, even in patients with poor myocardial function. Both groups had a shunt fraction of approximately 10% and an arterial: end-tidal carbon dioxide difference of approximately 3-4 mmHg.

Age affects the pharmacokinetics of inhaled anesthetics in humans

To define the effect of aging on the pharmacokinetics of volatile anesthetics, we determined the end-tidal and mixed expired anesthetic concentrations of isoflurane, enflurane, halothane, and methoxyflurane during 30 min of simultaneous administration and for 5-12 days of elimination in seven healthy young patients (31 +/- 1.8 yr [mean +/- SEM]) and in 11 healthy aged patients (73.2 +/- 3.1 yr [mean +/- SEM]). A five-compartment mammillary function was fit to the end-tidal and mixed expired anesthetic elimination data simultaneously using ordinary least-squares analysis. We assumed the compartments to represent the following tissue groups: lungs and pulmonary capillary blood (V1), vessel-rich tissues (i.e., liver, heart, kidneys, and brain) muscle, an unidentified fourth compartment, perhaps fat adjacent to well-perfused tissues, and fat tissues. The tissue volumes and perfusions estimated for these compartments approximated values from the literature. In general, the volume of the fourth and fifth compartments increased with age, and perfusion to the second and fifth compartments decreased with age. Aging delayed anesthetic elimination and increased the apparent volume of distribution at steady state. These observations are compatible with decreased tissue perfusion and an increase in the ratio of fat/lean body weight in the elderly. Our mammillary analysis described the behavior of less soluble anesthetics such as isoflurane well, but that of highly soluble anesthetics such as methoxyflurane less well.

Study of biodistribution of enflurane in rats with in vivo 19F MRI

In vivo 19F magnetic resonance imaging (MRI) of anesthetized rats enabled us to visualize the biodistribution of fluorinated anesthetics and to document the changes in MR signals in the body during the induction and the elimination phase of anesthesia. The authors examined in vivo 19F MRI in rats anesthetized with concentrations of 1.75-2.0% enflurane and demonstrated its in vivo distribution with concomitant 1H and 13C MRI to verify the anatomical correlation. Distinct 19F MR signals were acquired predominantly from the systemic adipose tissue and the liver. Additionally, the temporal changes in the tissue during and after anesthesia were characterized with in vivo 19F MRI in 6.4 min of the acquisition time. The 19F MR signals increased with time after anesthesia; however, the signals from the adipose tissue were apparently stronger than those from the liver. Following the discontinuation of inhalation, the MR signals in the liver decreased far more rapidly than those from the adipose tissue. When the animal woke up and began to move, the MR signals were still visible in the adipose tissue. These results confirmed the fact that enflurane dissolves preferentially in the adipose tissue and remains when the anesthetic effect disappears. Additionally, 19F MR signals of the liver during the elimination phase might reflect the concentration of enflurane in the blood.

Uptake and biotransformation of sevoflurane in humans: a comparative study of sevoflurane with halothane, enflurane, and isoflurane

STUDY OBJECTIVE

To compare the volatile anesthetic sevoflurane with halothane, enflurane, and isoflurane on the uptake and biotransformation in humans.

DESIGN

Prospective pharmacokinetic study of sevoflurane administration in human subjects.

SETTING

Inpatient surgery clinic at a university medical center.

PATIENTS

Thirty-two Japanese patients, free of systemic diseases, undergoing minor elective surgery with endotracheal general anesthesia.

INTERVENTIONS

The patients were assigned randomly to one of four groups: halothane, enflurane, isoflurane, or sevoflurane. One of the four volatile anesthetics being investigated [equivalent to 1.1 minimum alveolar concentration (MAC): halothane, 0.85%; enflurane, 1.85%; isoflurane, 1.27%; and sevoflurane, 1.88%; in inspired concentrations throughout the first hour of anesthesia] was administered for 60 minutes.

MEASUREMENTS AND MAIN RESULTS

In all patients, serum and urinary fluoride concentrations were measured. The concentrations of all gases were measured separately with a mass spectrometer. The cumulative uptake of each anesthetic agent during a certain period was calculated as an integration of the uptake rate per minute. The results for one-hour inhalation of sevoflurane (1.1 MAC) showed an uptake (corrected for body surface area and MAC) of 490 ml/m2/MAC and estimated degradation rate of 3.3%. For purposes of comparison, similar studies of halothane (uptake, 653 ml/m2/MAC; degradation rate 15.7%), enflurane (1150 ml/m2/MAC; 1.3%), and isoflurane (439 ml/m2/MAC; 0.6%) were also conducted. Sevoflurane had a peak serum inorganic fluoride concentration of 19.3 mumol/L, and no abnormality in hepatic or renal functions was observed in any of the subjects during the two weeks postoperatively.

CONCLUSIONS

Accurate determinations of uptake and degradation rate for sevoflurane and three other volatile anesthetics in Japanese patients were obtained. These findings have established that, despite its relatively large MAC (1.71%), sevoflurane has a small uptake due to its low solubility. However, the degradation rate was shown to be as high as 3.3%, resulting in a higher serum fluoride concentration than seen after administration of isoflurane, halothane, and (possibly) enflurane.

[The predictability of inspiratory and endexpiratory concentrations of isoflurane and enflurane using pharmacokinetic models and interindividual variability]

The predictability of the inspiratory and endexpiratory concentrations of the volatile anaesthetics isoflurane and enflurane by pharmacokinetic models was investigated. 67 patients of ASA-classes 1-2 that underwent minor surgical procedures were studied. The pharmacokinetic model consisted of two parts, a model of the anaesthesia machine and a model of the patient. The mean values of the predicted/measured concentrations of isoflurane had an amount of 1.01 +/- 0.13 (inspiratory) and 0.97 +/- 0.13 (endexpiratory), the mean values of enflurane showed a value of 1.00 +/- 0.11 (inspiratory) and 0.97 +/- 0.13 (endexpiratory). The interindividual variances amounted to between 10% and 40% of the variance of all patients. This corresponded to a standard deviation of about 6% (inspiratory) while the endexpiratory concentrations showed a standard deviation about 8% for the average values of every patient.

Interaction of ethanol with enflurane metabolism and toxicity: role of P450IIE1

Administration of enflurane (EF), a widely-used anesthetic agent, sometimes results in occult liver injury. As hepatic cytochromes P450 oxidize EF to a reactive intermediate, we assessed whether one such microsomal enzyme, ethanol-inducible P450IIE1, plays an obligatory role in EF metabolic activation and hepatotoxicity. Liver microsomes from rats fed ethanol (36% of total calories for 14 days) oxidized 1 mM EF (measured by its defluorination) at rates nearly 10-fold greater than those from control rats, reflecting the markedly enhanced content of immunoreactive microsomal P450IIE1 in the former animals. P450IIE1 involvement in hepatic EF oxidation was further suggested by the pronounced inhibition of microsomal defluorination noted with P450IIE1 antibodies and with ethanol, a specific substrate for this enzyme. EF administration to rats treated chronically with ethanol caused significant elevations in plasma levels of aspartate and alanine aminotransferases and glutamate dehydrogenase, indicative of hepatic injury, whereas concurrent treatment of naive rats with EF and ethanol failed to produce the same effect. Our results imply that ethanol-inducible P450IIE1 is the primary catalyst of hepatic EF bioactivation and that the increased bioactivation occurring in vivo secondary to chronic ethanol consumption is attendant with an increased incidence of EF hepatotoxicity.

Anaesthetic concentrations of enflurane and methoxyflurane in rat brain in-vivo and in-vitro

We measured concentrations of enflurane and methoxyflurane in brains of anaesthetized rats and established conditions for reproducing these concentrations in brain tissue in-vitro. Despite a 12-fold difference in inspired potency, brain concentrations resulting in anaesthesia were similar for both compounds. However, substantially lower concentrations in the equilibrating gas were necessary to achieve similar tissue concentrations in-vitro, probably because anaesthetic-induced respiratory depression or changes in cardiac output causes incomplete equilibration in-vivo. These studies provide direct evidence that brain concentrations associated with anaesthesia are similar for anaesthetics with different inspired potencies. They also suggest that lower concentrations in the equilibrating gas should be used in-vitro to reproduce clinically relevant tissue concentrations that are necessary to cause anaesthesia in-vivo.

A comparison of enflurane with alfentanil anaesthesia for gynaecological surgery

Forty patients undergoing gynaecological surgery were randomly assigned to receive either alfentanil and thiopentone for induction of anaesthesia, followed by alfentanil-N2O/O2 (60%/40%) for maintenance of anaesthesia, or low-dose fentanyl and thiopentone, followed by enflurane-N2O/O2 (60%/40%). More patients given enflurane developed a tachycardia (P less than 0.03) and 20% decreases in systolic and diastolic blood pressure. Times to recovery were significantly shorter after alfentanil than after enflurane. Plasma concentrations of alfentanil during induction suggested that haemodynamic and catecholamine responses were either less than, or did not differ from, baseline levels when the plasma concentration of the drug exceeded 150 ng ml-1. At extubation and the beginning of spontaneous breathing, the plasma concentration was 278 +/- 129 ng ml-1. Values for pharmacokinetic parameters of alfentanil were as follows: clearance, 5.2 +/- 2.0 ml kg-1 min-1; volume of distribution, 0.63 +/- 0.20 1 kg-1; and elimination half-life, 96.9 +/- 52.5 min. Two patients who had extended surgery had significantly lower plasma clearance of alfentanil and increased half-life. The authors conclude that the alfentanil technique was preferable to maintenance with enflurane.

Pretreatment with paracetamol inhibits metabolism of enflurane in rats

We studied the interaction between paracetamol (acetaminophen U.S.P.) and enflurane. Sixteen rats were assigned to four groups (n = 4) to receive: paracetamol 7.5 mg/100 g body weight; paracetamol plus 1% enflurane; 1% enflurane alone, or no treatment (controls). Animals were killed 6 h later. A second series of 16 were treated identically, but were killed after 24 h. Measurements were made of fluoride concentrations in serum, liver and urine (indicators of biotransformation of enflurane), paracetamol concentrations in urine, pathological changes in liver samples, and concentrations of the enzymes aspartate aminotransferase (AST) and alanine aminotransferase (ALT) in serum. Pretreatment with paracetamol significantly decreased urinary fluoride at 6 and 24 h after exposure to enflurane, but decreased fluoride concentrations in serum and liver only at 6 h after exposure to enflurane. Paracetamol concentrations in urine did not change after exposure to enflurane. Exposure to paracetamol alone increased AST and ALT. At 24 h after exposure to enflurane, serum concentrations of enzymes in rats pretreated with paracetamol were similar to those of control rats. Pretreatment with paracetamol may therefore inhibit metabolism of enflurane. Although no hepatic damage was observed, the increased in AST and ALT suggested subclinical liver damage in rats given only paracetamol.

The pharmacokinetics of volatile anesthetic agent elimination: a theoretical study

The theoretical groundwork for a rate constant formulation of inhaled anesthetic elimination kinetics is discussed. In an effort to simulate recent experimental results a linear flow-limited five-compartment model was used comprising lung, vessel-rich tissue, muscle, nonvisceral fat, and an additional compartment, marrow-visceral fat whose functional existence recently has been experimentally demonstrated. Hypothetical but plausible parameters for the marrow-visceral fat compartment were used. The theoretically predicted values were in good agreement with experimental results suggesting that this model is appropriate for the elimination kinetics of agents that are not metabolized to any significant degree. Simple approximate expressions for the rate constants were also derived and were in reasonable agreement with experimental results. The model was also employed to clarify the effect of anesthetic duration on subsequent elimination kinetics.

Thioethers, mutagens, and D-glucaric acid in urine of operating room personnel exposed to anesthetics

Mutagenic hazards related to occupational exposure to nitrous oxide and enflurane was studied in the personnel of five operating rooms using a coupled environmental and biological monitoring approach. The environmental monitoring revealed air concentrations of the two anesthetics exceedings the TLVs by 10-15-fold. These values were correlated individually with the concentrations of the two anesthetics in the expired air of the exposed subjects. The biological monitoring was carried out by determining two parameters associated with mutagen exposure (urinary mutagenicity and thioethers) and a parameter associated with the enzymatic induction (D-glucaric acid) in the urine of exposed and unexposed subjects (N = 64 and N = 37, respectively). The results showed no difference in the two groups for urine mutagenicity and D-glucaric acid, but urine thioethers were significantly increased among highly exposed subjects.