1/8/2017 Comparisonofisofluraneandsevofluraneinanaesthesiafordaycaresurgeriesusingclassicallaryngealmaskairway

IndianJAnaesth.2011JulAug55(4):364369. PMCID:PMC3190510
doi:10.4103/00195049.84857

Comparisonofisofluraneandsevofluraneinanaesthesiafordaycare
surgeriesusingclassicallaryngealmaskairway
DineshKumarSahu,VincaKaul,andReenaParampill
DepartmentofAnaesthesiologyandAdvancedPainManagement,JagjivanramRailwayHospital,Mumbai,India
Addressforcorrespondence:Dr.DineshKumarSahu,C69,JagjivanramRailwayHospitalCampus,MumbaiCentral,Mumbai400008,India.E
mail:drdksahujrh@gmail.com

Copyright:IndianJournalofAnaesthesia

ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNoncommercialShareAlike3.0Unported,whichpermits
unrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

ThisarticlehasbeencitedbyotherarticlesinPMC.

Abstract Goto:

Background:
Inthepresentstudy,wecomparedisofluranewithsevofluraneindaycaresurgeriesinordertodeterminethe
suitabilityofeachagentforanaesthesiawithClassicallaryngealmaskairway(LMA).

Aims:
Theaimofthisstudyhasbeentocompareisofluraneandsevofluraneasmaintenanceanaestheticagentsindaycare
surgerieswithrespecttointraoperativehaemodynamics,recoveryprofile,timeoffirstpostoperativeanalgesiaand
painscore,adverseeffectswhenusedwithclassicalLMA.

SettingsandDesign:
Thisopenlevel,prospectiverandomizedstudywascarriedouton60patientswhowereadmittedonadaycare
basisforelectiveshortsurgicalprocedures.

Methods:
Thepatientswererandomlyassignedtooneofthetwostudygroupsof30patientseach.Firstgroupwas
maintainedonisofluraneandsecondonsevofluraneasinhalationalagent.

StatisticalAnalysis:
Theobservationsobtainedinboththegroupswererecordedandtabulated.Statisticalanalysiswascarriedoutusing
theStudentttest,Chisquaretest,MannWhitneytest.

Results:
EmergencefromSevofluranewassignificantlyquickerascomparedtoisoflurane.Sevofluranegroupalsoshowed
earlierdischargetimefromthepostanaesthesiacareunit(PACU)1ascomparedtoisofluranegroup,butdischarge
timewassamefromthePACU1.Isofluranehasmoreincidencesofmildairwayhyperreactivitywhencompared
tosevoflurane.

Conclusions:

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Itcanbeconcludedthatbothisofluraneandsevofluranearesuitablefordaycareanaesthesia.Sevofluranehaslittle
advantagesoflessairwayhyperreactivityandquickeremergenceanddischargefromPACU1.

Keywords:Anaesthesia,classicallaryngealmaskairway,daycaresurgery,isoflurane,sevoflurane

INTRODUCTION Goto:

Daycaresurgeryisaplannedsurgerywhereinthepatients,requiringearlyrecoveryanddischarge,areadmittedfor
shortstayforsurgeryonanonresidentbasis.Advancesinanaestheticinductionagentsandairwaymanagement
havecontributedtothesuccessofdaycaresurgeries.Anidealdaycareanaestheticagentshouldhaverapidsmooth
inductionprovideoptimumsurgicalconditionswithrapidrecoveryandminimalsideeffects.Oneshouldbeableto
rapidlyaltertheeffectsiteconcentration,allowingtheanaestheticdepthtobealteredeasily.Althoughnosingle
anaestheticagentcompletelysatisfiesalltheserequirements,pharmacologicaldevelopmentsoverthepastdecades
havebroughtusconsiderablycloser.[1]Inrecenttimes,inhalationalagentslikeisoflurane[2]andsevoflurane[1,3,4]
haveshownapromisingresult.Thisstudywasconductedtocompareisofluraneandsevoflurane,whenusedas
maintenanceanaestheticagentsforanaesthesiausingclassicalLaryngealmaskairway(LMA)indaycaresurgery.
Thestudywasdesignedtodetermineiftheseagentsofferedadvantagesintermsofintraoperativehaemodynamics,
cardiorespiratoryeffects,recoveryprofile,emergencetimesandadverseeffectsincludingseverityofairwayhyper
reactivityassociatedwithLMAremoval.

METHODS Goto:

Approvalfromtheethicalcommitteeofthehospitalandinformedconsentfromeachpatientweretaken.Thestudy
wasanopenlevel,prospective,randomizedclinicaltrial.Thestudywasdoneon60patientsofAmericanSociety
ofAnaesthesiologist(ASA)gradeIorIIundergoingelectivedaycaresurgerieswithananticipatedlengthof
hospitalisationoflessthan24hpostanaesthesia.Thepatientswererandomlyselectedanddividedintotwogroup
of30patientstoreceiveeitherisofluraneorsevofluraneasamaintenanceagent.Thegroupswere:

GroupI:Patientswhoweremaintainedonisofluraneanaesthesia

GroupS:Patientswhoweremaintainedonsevofluraneanaesthesia

Uponarrivalintheoperationtheatre,thepatientsweremadetoliesupineontheoperatingtable,aperipheralvein
wascannulatedandanintravenousringerlactatedripwasstarted.Thepatientswereconnectedtononinvasive
syphgmomanometer,Electrocardiogram(ECG)monitorandpulseoximeter.

AuniformpremedicationwithInj.Glycopyrrolate0.2mg,Inj.Ondansetron4mgandInj.Fentanyl1.5mg/kg
intravenous(IV)wasgivenontheoperatingtable5minbeforeinductionofanaesthesia.Thepatientswerepre
oxygenatedwith100%oxygenfor3min.

InductionwasdonewithInj.Propofol2.5mg/kgivandclassicalLMAwasinserted.Anaesthesiawasmaintained
withoxygen(40%),nitrousoxide(60%)withisofluraneorsevofluraneonspontaneousventilationwithclosed
circuit.Thevolatileagentwasadministeredatapproximatelyoneminimalalveolarconcentration(MAC)for3
mini.e.1.2%forisofluraneand2%forsevoflurane.Thenitwascontinuedat0.75MACi.e.0.8%forisoflurane
and1.5%forsevoflurane,furtherincreasingordecreasingby0.5%forsevofluraneand0.2%forisoflurane(0.5
MAC)accordingtotheclinicalassessmentofthedepthofanaesthesiaandtomaintainbloodpressureat20%of
baselinevaluesinresponsetosurgicalstimulation.

Attheendofsurgery,administrationofisofluraneorsevofluranewasdiscontinuedwithouttaperingandthenafter
3minnitrousoxidewasdiscontinued.TheLMAwasremovedaftereyeopeningandmouthopeningtocommand.
Thehaemodynamicvariablesheartrate(HR),bloodpressures,saturationpercentageofoxygen(SpO2),respiratory
rate(RR)wasmonitoredinitiallyevery2minforthefirst10minandthenevery5minuptotheendofthesurgery.
Thenshiftedtopostanaesthesiacareunits(PACU)PACU1i.e.recoveryroomandthentoPACU2i.e.surgical
intensivecareunitinoursetup.Timeofemergencefromtheinhalationalanaesthetic(timeofstoppinginhalational
agenttotimeofextubation)andrecoverycriteria(modifiedAldretescore)[5,6]observed,thepatientisshiftedto
PACU1,whenthescoreis8ormore.Dischargecriteria[3]wereusedforassessmentanddischargefromPACU1
and2.TimeofdischargefromPACU1and2andthedurationfromextubationwerenoted.Airwayhyper
reactivityscore,[7]nauseascore,[2]visualanaloguescore(VAS)forpainandanyadverseeffectwerealsonoted.

Recoverycriteria(modifiedAldretescore)
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Oxygenation SPO 2morethan92%onroomair2

SPO2morethan90%onroomair1

SPO2lessthan90%onoxygen0

Respiration Breathesdeeplyandcoughsfreely2

Dyspnoeic,shalloworlimitedbreathing1

Apnoea0

Circulation B.P20mmHgofnormal2

B.P20to50mmHgofnormal1

B.Pchangemorethan50mmHgofnormal0

Consciousness Fullyawake2

Arousableoncalling1

Notresponsive0

Activity Movesallextremities2

Movestwoextremities1

Nomovement0

Airwayhyperreactivityscore

Nauseascore

I.None0
II.Mild(nauseaandnovomiting)1
III.Moderate(nauseaandoccasionalvomiting)2
IV.Severe(nauseaandfrequentvomiting)3

Painscore
VASonascaleof1to10

DischargereadinessfromPACU1

1.Alertandorientedtotimeandplace
2.Conversantandcooperative
3.Stablevitalsignsforatleast0.5h
4.Abletositupwithoutnauseaandordizziness
5.Painistolerable
6.Aldretescoreis>/=8

Dischargereadiness(homereadiness)fromPACU2

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1.Stablevitalsignsforatleast1h
2.Paincontrollablebyoralanalgesics
3.Nauseaoremesismildifpresent
4.Abletowalkwithoutdizziness,andabletoretainoralfluids

Theobservationsobtainedinboththegroupswererecordedandtabulated.Afterthestudy,analysisofthedata
donebyChisquaretestandttestforparametricdataandMannWhitneyfornonparametricdata.Aprobability
value(Pvalue)of<0.05wasconsideredasstatisticallysignificant.Thesoftwareusedwasstat32(Systatsoftware,
inc.)

RESULTS Goto:

Thegroupswerecomparable(Pvalue>0.05)intermsofdemographicdata,ASAgrading,typeofsurgeriesand
durationofanaesthesia[Table1].

Table1
Demographicandrelevantdata

InourstudyafterLMAplacement,theinhalationalagent(isofluraneorsevoflurane)wasstartedat1MAC(i.e.2%
forsevofluraneand1.2forisoflurane)for3minandthenmaintainedbetween0.75MAC(i.e.1.5%for
sevofluraneand0.8forisoflurane)and0.5MAC(i.e.1.0%forsevofluraneand0.6forisoflurane)inboththe
groups.Themeanconcentrationagainsttimeintervalisplottedinthegraph[Figure1].

Figure1
Graphicalrepresentationofinhalationalagentconcentrationatvarious
intervalsinisofluraneandsevofluranegroups.LMA:Laryngealmask
airway

ThebloodpressuresbetweenthetwogroupswerecomparedbytheMannWhitneytest.Systolicbloodpressure
(SBP)revealslowervaluesinGroupSwhichwerestatisticallysignificanttoGroupI,fromstarttothefirst20min[
Figure2].Diastolicbloodpressures(DBP)betweenthetwogroupsreveallowervaluesintheGroupSwhichwere
statisticallysignificantwhencomparedtoGroupI,fromstarttothefirst40min[Figure2].Meanarterialpressures
(MAP)betweenthetwogroupsreveallowervaluesinGroupSwhichwerestatisticallysignificantwhencompared
toGroupI,fromstarttothefirst40min.Statisticalanalysisindicatedthatbothisofluraneandsevofluranedecrease
SBP,DBPandMAP,althoughthefallwassignificantlymoreinthesevofluranegroup.Howeverwehavereduced
theMACtokeepthesevalueswithin20%ofthebaselinevaluesinanygroup.HRandRRwerecomparablein
boththegroupsandalsodidnotchangefromthebaselinevaluesinanygroup.Therewerenoepisodesof
hypotension(SBPlessthan90mmHg)orbradycardia(HRlessthan60/min).

Figure2
GraphicalcomparisonofdiastolicBPandsystolicBPatvariousintervals.
(DBPIMeandiastolicBPofGroupI,DBPSMeandiastolicBPofGroup
S,SBPIMeansystolicBPofGroupI,SBPSMeansystolicBPofGroup
S)

Comparisonofrespiratoryratebetweenthetwogroupsdidnotrevealastatisticallysignificantdifferenceexceptfor
threeisolatedreadings.Comparisonofrespiratoryratesintherespectivegroupsalsodidnotrevealanysignificant
changefromthebaselinevalues,Pvalue>0.05.AllthepatientsinboththegroupsmaintainedSpO2above96%
throughout.

Analysisrevealsquickerextubationinthesevofluranegroupascomparedtoisofluranegroup.Median(inter
quarantilerange[IQR])inGroupSwas4(1.25)minadthatinGroupIitwas10(1)min,withPvalues=2.22E11
asanalysedbytheMannWhitneytest,whichissignificant.DischargefromthePACU1wassignificantlyearlyin
sevofluraneanaesthesiaascomparedtoisofluraneanaesthesia,medianIQRinGroupIwas477.25minandthat
inGroupSwas353min.MannWhitneytestrevealedaPvalue=1.351010,whichissignificant.Therewasa
minordifferenceinthedischargetimesfromPACU2betweentheisofluraneandsevofluranegroups,medianIQR
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inGroupIwas136.0020.50whileinGroupSitwas132.0021.25,thisdifferenceisnotstatisticallysignificant
asanalysedbytheMannWhitneytest(Pvalue=0.08).

Inourstudy,thetimeofrequirementoffirstpostopanalgesiaafterextubationissimilarinboththesevofluraneand
isofluranegroupsmedianIQRinGroupIwas53.019minwhileinGroupSitwas54.515min.Analysisby
theMannWhitneytestrevealedaPvalue=0.094whichisnotsignificant.

Inthepresentstudy,onlyonepatientinthesevofluranegroupandfivepatientsintheisofluranegroupcomplained
ofmildnauseainthePACU1.ComparisonbyMannWhitneytestrevealedaPvalueof0.08whichisstatistically
notsignificanthencetheincidenceofnauseawascomparableinthetwogroups.Noneofthepatientsineither
groupcomplainedofnauseainPACU2.Therewasnoepisodeofemesisinanypatient.Airwayhypersensitivity
scorewashigherinGroupIinPACU1(Pvalue=0.001).Nootheradverseeffectswereseeninthetwogroups.

DISCUSSION Goto:

InourstudyafterLMAplacement,theinhalationalagent(isofluraneorsevoflurane)wasstartedat1MACfor3
minandthenmaintainedbetween0.75MACand0.5MACinboththegroups.Ourstudycannotdrawany
conclusionsregardingequianaestheticconcentrationeffectsoftheanaestheticsasourclinicalprotocollikemost
otherclinicalprotocolsallowedustotitratetheanaestheticconcentrationtomaintainstablebloodpressurewithin
20%ofbaselinevaluesduringthesurgicalcaseandfluidadministrationwasnotacontrolledvariable.Moreover,
theuseofotheranaestheticadjuvantswasincludedasapartoftheroutinemanagementofthesepatientslike
narcoticsandnitrousoxide(N2O).Therefore,measurementofactualdifferencesinbloodpressurebetweenthetwo
groupscouldbedifficulttodetectduetoroutineclinicalmanagementthatwasguidedbybloodpressure.Smithet
al.,[8]reportedthattheendtidalconcentrationofsevofluranerequiredtomaintainastablelevelofanaesthesia,as
indicatedbyclinicalandhaemodynamicsignswas0.860.35MACandthatofisofluranewas0.690.17MAC,
whichiscorrelatingtoourstudy.

Inourstudy,wefoundthattheSBP,DBP,MAPwerealllowerinthesevofluranegroupwhencomparedto
isofluranegroup.WithingroupcomparisonsalsorevealedasignificantfallintheSBP,DBPandMAPinboththe
groupswhenthesewerecomparedtothebaselinevalues.However,inboththegroups,SBP,DBPaswellasMAP
didnotchangemorethan20%fromthebaselinevalues.Noepisodesofhypotension,bradycardia,orarrythmias
wererecorded.

Frinketal.,[9]intheircomparisonofsevofluraneandisofluraneinhealthysubjectsfoundthatcomparedto
baselinevalues,sevofluraneanaesthesiadecreasedsystolicanddiastolicarterialbloodpressures35minbefore
surgicalincision,whereasintheisofluranegroup,systolicanddiastolicarterialbloodpressuresdidnotdifferfrom
baselinevaluesatthistime.Arterialbloodpressuresdidnotdifferfrombaselinevaluesafterincisionorduring
maintainanceanaesthesiawithsevofluraneandisofluranebutincreasedinbothgroupsduringemergencefrom
anaesthesia.

BachaniandKothari[10]intheircomparisonofsevofluraneandisofluraneinpaediatricpatientsobservedthat
complicationslikebradycardiaandhypotensionweremorewithsevoflurane.

Therewasnoepisodeofoxygendesaturationnoranydifferencesinrespiratoryrate.Sevofluraneandisoflurane
maintainedadequatedepthofanaesthesiainthespontaneouslybreathingpatientsinourstudy.

Inourstudy,thetimefromthestoppingofinhalationalagenttothetimeofextubationwasrecordedanditwas
foundtobesignificantlylessinthesevofluranegroupascomparedtoisofluranegroup.SmithIetal.[8]inthe
comparisonbetweensevofluraneandisofluranefoundthatforoperationslasting14h(withameanof135min),
sevofluranepermittedemergencewithin4.12.2minaftertheendofanaesthesiacomparedwith6.72.2minwith
isoflurane.

InourstudythereisastatisticallysignificantdifferenceinthedischargetimefromPACU1betweentheisoflurane
andsevofluranegroupswithearlierdischargefromPACU1inthesevofluranegroupcomparedtoisoflurane
group,However,thisearlierdischargefromPACU1didnottranslateintoearlierdischargefromPACU2(home
readiness)forthesevofluranegroup.Guptaetal.[11]concludedthatrecoverywasfasterwithsevoflurane
comparedtoisoflurane.Theyfoundaminordifferenceof5mininhomereadinessbetweensevofluraneand
isoflurane.

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ThetimeofrequirementoffirstpostoperativeanalgesiawassimilarinthetwogroupshoweverpatientsinGroupI
hadhigherpainscore(VASscore)thanGroupSinPACU1(Pvalue=0.03).Theairwayhypersensitivityscores
werehigherintheisofluranegrouphoweveronlymildcoughingorbuckingwasseen,therewerenocritical
airwayevents.Airwayhyperreactivityduringmaintainenceandemergencefromanaesthesiacanbeattributedto
severalfactorsasthedepthofanaesthesia,thechoiceofvolatileanaestheticdrug,useofopioidanalgesics,and
historyofupperrespiratoryinfection.Tospecificallyexaminetheimpactofchoiceofvolatileanaestheticagenton
airwayhyperreactivity,thisstudyattemptedtocontrolseveralfactorsthatcouldcontributetoairwayhyperreactivity
duringmaintainenceandemergencefromanaesthesia.

Pappasetal.[7]intheirstudyfoundthatthedepthofanaesthesiaduringLMAremovaldoesnotappeartoaffectthe
incidenceorseverityofairwayhyperreactivitywhensevofluraneisthemaintainenceanaesthetic.AwakeLMA
removalduringisofluraneanaesthesiahoweverresultedinahigherincidenceofadverseeventsandcarriedahigh
riskofsevereairwayhyperreactivityandcriticalevents.Soalthoughourstudyshowedahigherincidenceof
airwayhyperreactivityintheisofluranegroupascorroboratedbytheabovediscussedstudiesaswell,noadverse
airwayeventswereseeninourstudy,onlymildtomoderatecoughorbuckingwasreportedintheisofluranegroup
atemergence.

Theincidenceofnauseawaslowandcomparable(Pvalue=0.08)inthepresentstudy.FrinkEJetal.[9]intheir
clinicalcomparisonofsevofluraneandisofluraneinhealthypatientsreportedthattheincidenceofpostoperative
nauseadidnotdifferbetweenthesevofluraneandisofluranegroups,withanincidenceof10and12%respectively,
occurringinthePACUimmediatelyafteranaesthesia.

CONCLUSION Goto:

Henceitcanbeconcludedthatbothsevofluraneandisofluranearesuitablefordaycareanaesthesia.Sevoflurane
hasadvantagesofquickeremergence,earlydischargefromPACUIandlessairwayhypersensitivity.Isofluranehas
moreincidenceofairwayhyperreactivitythoughmilderlevel,whencomparedtosevoflurane.Incidenceofnausea
andvomitingandrequirementofpostoperativeanalgesiaarecomparableinboththegroups.Isofluraneislesscostly
incomparisontosevoflurane.

Footnotes Goto:

SourceofSupport:Nil

ConflictofInterest:Nonedeclared

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