Postoperative nausea and vomiting in arthroscopic day-case surgery: a comparison between desflurane and isoflurane

We compared the postoperative effects, in particular nausea and vomiting, of two commonly used anaesthetic agents, isoflurane and desflurane, in patients undergoing day-case arthroscopic surgery. We found a significantly higher incidence of postoperative nausea and vomiting in those patients receiving desflurane. In our study, desflurane was associated with a higher incidence of peroperative respiratory complications, including airway irritability and coughing.     

Postoperative nausea and vomiting. A comparison between intravenous and inhalation anaesthesia in breast surgery

Nausea and vomiting during the first 24 postoperative hours after breast surgery were studied. Ninety patients scheduled for elective breast surgery were randomly assigned to one of three anaesthetic methods: total intravenous anaesthesia with propofol, or propofol or thiopental for induction followed by isoflurane anaesthesia. All three groups received fentanyl for peroperative analgesia. A total of 46 (51%) patients experienced emetic sequelae: 19 (21%) complained about nausea and another 27 (30%) vomited once or more during the postoperative course. More than 50% of the patients with nausea and 70% with vomiting first suffered from these symptoms in the surgical wards after leaving the postoperative unit. Nausea and vomiting were seen in 18 (60%), 13 (43%) and 15 (50%) for the groups propofol–propofol, propofol–isoflurane and thiopental–isoflurane, respectively. In conclusion, every second patient experienced nausea or vomiting after breast surgery, the majority of these emetic symptoms occurring after leaving the postoperative unit. Propofol for induction or as a main anaesthetic did not make any major difference with regard to postoperative nausea or vomiting.     

Incidence of nausea and vomiting in children after strabismus surgery following desflurane anaesthesia

In a prospective, randomized parallel study, 60 ASA I-III children aged 1-17 years, scheduled for elective strabismus surgery, were anaesthetized with desflurane without prophylactic antiemetic medication. The objective of the study was to determine the incidence of postoperative nausea and vomiting after general anaesthesia with desflurane. To decide whether nitrous oxide further influences these symptoms, the patients were randomly assigned to two groups of 30 patients each. One group received desflurane in oxygen/air and a second group received desflurane in oxygen/nitrous oxide. In all children, after intravenous induction and tracheal intubation, anaesthesia was administered as minimal flow anaesthesia with oxygen and nitrous oxide or air according to the random plan. The patients were observed for 48 postoperative hours until their discharge from the ward. The overall incidence of nausea was found to be 37%, and vomiting was seen in 32% of all patients. No statistical correlation was found between the incidence of postoperative emesis and the administration of nitrous oxide or the duration of general anaesthesia. Instead, the incidence of vomiting was 2.5-fold higher when surgery was performed on both eyes compared with one eye. The relatively low incidence of postoperative nausea and vomiting, as well as the quick recovery from anaesthesia, permitting an early discharge from the postoperative care unit to the ward, show desflurane to be a suitable volatile anaesthetic in strabismus surgery in children.     

Pulmonary mechanics during isoflurane,sevoflurane and desflurane anaesthesia

This study was designed to investigate the effects of desflurane on bronchial smooth muscle tone, following intubation and to compare these effects with isoflurane and sevoflurane. Patients were randomly divided into three groups to receive, isoflurane (n = 22), sevoflurane (n = 23), or desflurane (n = 22). Peak inspiratory pressure (PIP), respiratory resistance (Rr) and dynamic compliance (Cdyn) measurements were recorded at three time points; After the beginning of ventilation and before inhalation agent was started, following 5 min of ventilation with 1 MAC (minimum alveolar concentration) inhalation agent and following 5 min of 2 MAC inhalation agent. We found that all inhalation agents caused a significant decrease in Peak Inspiratory Pressure (PIP) and respiratory resistance (Rr), and an increase in dynamic compliance (Cdyn) at 1 MAC concentrations. When the agent concentration was increased to 2 MAC, desflurane caused a significant increase in Rr and PIP and a decrease in Cdyn. We concluded that desflurane, like isoflurane and sevoflurane, exhibits a bronchodilator effect at 1 MAC concentration. However, increasing the concentration to 2 MAC caused an increase in airway resistance with desflurane, whilst sevoflurane and isoflurane continued to have a bronchodilator effect.     

Haemodynamic stability during moderate hypotensive anaesthesia for spinal surgery. A comparison between desflurane and isoflurane

BACKGROUND: The aim of this study was to compare desflurane and isoflurane for spinal procedures requiring moderate levels of controlled arterial hypotension, when these agents were administered via a semi-closed circuit at 1 l x min(-1) fresh gas flow. METHODS: After ethics committee approval and written informed consent, 20 ASA I or II patients were randomly allocated to receive either desflurane (n=10) or isoflurane (n=10), in O2/ N2O (1:1) for maintenance of anaesthesia. Induction of anaesthesia, fentanyl dosing and volume loading were standardized. Blood pressure was invasively monitored and maintained within a target systolic blood pressure (SBP) range of 80 to 100 mmHg during the study period. Results were presented as medians and interquartiles, and non-parametric statistical methods were used. RESULTS: Patient demographic data, SBP and heart rate prior to surgery, and duration of the procedure were similar between the two groups. During the study period, tighter arterial blood pressure control was maintained with desflurane as compared with isoflurane. SBP was 21.2% (9.5-41.7) of time outside the range 80-100 mmHg with isoflurane and 5.1% (0.6-10.3) with desflurane (P<0.01). CONCLUSIONS: Desflurane, administered via a semi-closed circuit at 1 l x min(-1) fresh gas flow, maintained better haemodynamic stability in spinal surgery requiring moderate arterial hypotension than isoflurane.     

Emergence and recovery in children after desflurane and isoflurane anaesthesia: effect of anaesthetic duration

Background. We hypothesized that increasing duration of inhalationanaesthesia is associated with slower emergence and recoveryin children, and that this effect would be less marked withdesflurane in comparison with isoflurane. Methods. Fifty-four infants and children assigned in groupsaccording to age and expected length of operation were prospectivelyrandomized to receive either isoflurane (I) or desflurane (D)for anaesthesia. After standard induction, the anaesthesia wasmaintained using an age-related 1.0 minimum alveolar concentration(MAC) equivalent for either agent in air and oxygen. Local analgesiawas used as appropriate. End-tidal volatile agent concentrationwas recorded until extubation. Clinical evaluation of recoverywas made by observers, blinded to group allocation. Results. For patients <4 yr of age, the median (95% CI) timesin minutes to first movement [5.27 (D), 9.22 (I)], eye opening[9.42(D), 13.3(I)] and extubation [7.18 (D), 12.5 (I)] weresignificantly shorter (P<0.05) for desflurane. In the group>4 yr of age, the median (95% CI) times in minutes to firstmovement [4.42 (D), 11.6 (I)], eye opening [8.55(D), 18.0(I)]and extubation [7.08 (D), 16.7 (I)] were significantly shorter(P<0.001) for desflurane. Times to leave recovery were notsignificantly different for the group <4 yr of age, but weresignificantly shorter for desflurane in the group >4 yr ofage (P<0.01). The isoflurane, but not desflurane, had a time-dependenteffect on arousal. There were no significant differences inincidence of airway irritation or emergence delirium betweenthe two agents. Conclusions. The rate of recovery in children after exposureto desflurane was faster than those patients receiving isoflurane;recovery from desflurane, but not isoflurane, was relativelyunaffected by the duration of anaesthesia.     

Comparison of recovery after intermediate duration of anaesthesia with sevoflurane and isoflurane

BACKGROUND: The purpose of this study was to compare recovery from anaesthesia after sevoflurane and isoflurane were administered to children for more than 90 min. METHODS: After parental informed consent and ethical committee approval, children aged between 2 months and 6 years, ASA I or II, were randomly allocated to sevoflurane (n=20) or isoflurane (n=20) groups. Halogenated agents were discontinued following skin closure and patients were ventilated mechanically with 100% oxygen until minimum alveolar concentration (MAC) values awake were obtained (endtidal concentrations 0.6 MAC for sevoflurane and 0.4 MAC for isoflurane). Effective perioperative analgesia was provided by a caudal block. RESULTS: The mean (+/- SD) duration of anaesthesia was 132 +/- 38 min and 139 +/- 49 min for sevoflurane and isoflurane, respectively. Early recovery occurred sooner in the isoflurane group (time to extubation was 16 +/- 7 min and 11 +/- 5 min, P<0.01; Aldrete's score at 0 min was 5.5 +/- 1.5 and 7.4 +/- 1.8, P<0.001, respectively). But the time to be fit for discharge from recovery room was similar at 136 +/- 18 min and 140 +/- 20 min, respectively. CONCLUSIONS: After intermediate duration of anaesthesia administered to children for up to 90 min, isoflurane and sevoflurane allow recovery after approximatively the same lapse of time.     

A review of recovery from sevoflurane anaesthesia: comparisons with isoflurane and propofol including meta-analysis

BACKGROUND: Sevoflurane has a lower blood:gas partition coefficient than isoflurane and thus should be associated with a more rapid recovery from anaesthesia. METHODS: A review and meta-analysis were employed to examine the recovery profiles of adult patients following anaesthesia, comparing sevoflurane to isoflurane and sevoflurane to propofol. RESULTS: There were significant differences in times to several recovery events that favoured sevoflurane to isoflurane anaesthesia, including time to emergence, response to commands, extubation, and orientation. Likewise, there were significant differences in times to the same recovery events following anaesthesia with sevoflurane versus propofol. There were no differences in time to recovery room discharge when comparing sevoflurane to isoflurane or propofol. CONCLUSION: The observed differences between sevoflurane and isoflurane or propofol anaesthesia support the postulate that the use of sevoflurane is associated with a more rapid recovery from anaesthesia than either isoflurane or propofol.     

Prophylaxis of postoperative nausea and vomiting in elective breast surgery

Study Objective

To evaluate strategies to treat postoperative nausea and vomiting (PONV) in patients undergoing elective breast surgery.

Design

Prospective, randomized, double-blinded, placebo-controlled trial.

Setting

University-affiliated hospital.

Patients

480 patients with risk factors for PONV.

Interventions

Patients were randomized to three groups to receive an antiemetic prophylactic combination of haloperidol and tropisetron (Group HT), dimenhydrinate and dexamethasone (Group DD), or no prophylaxis (Group P). Anesthesia was maintained with volatile anesthesia (desflurane or sevoflurane) and fentanyl or total intravenous anesthesia (TIVA).

Measurements

Incidence of nausea, emesis, or both in the early (0 - 2 hrs) and late (2 - 24 hrs) postoperative periods were recorded, as were the number of episodes and the time of each occurrence; and patient assessment of the PONV experience on a scale comparable to a numeric rating scale (NRS).

Main Results

Both antiemetic combinations significantly reduced PONV incidence. In patients who received no prophylaxis, PONV incidence was 48.2% in patients given volatile anesthetics and 43.8% in those who received TIVA. PONV incidence was 17.5% in the Group HT patients who received volatile anesthetics, and 25% in the Group HT patients who received TIVA. PONV incidence was 11.4% in Group DD patients given volatile anesthetics, and 15% in Group DD patients receiving TIVA. TIVA reduced the incidence of PONV in the early postoperative period (0-2 hrs), but increased PONV incidence in the late period (2-24 hrs). Patients given TIVA with propofol and remifentanil intraoperatively required more opioids postoperatively than patients given volatile anesthetics.

Conclusion

The frequency of PONV was reduced significantly with both antiemetic combinations.     

Power spectral analysis of the electroencephalogram during increasing end-expiratory concentrations of isoflurane, desflurane and sevoflurane

We studied the effects of increasing end-expiratory concentrations of isoflurane (0.3, 0.6, 0.9, 1.2 vol.%) ( n  = 12 patients), desflurane (1.5, 3.0, 4.5, 6.0 vol.%) ( n  = 12 patients) and sevoflurane (0.5, 1.0, 1.5, 2.0 vol.%) ( n  = 12 patients) on power spectral analysis of the electroencephalogram (EEG). Spectral edge frequency (SEF), total power (TP) and relative power in the delta, theta, alpha and beta band were calculated. EEG changes were very similar within the three groups. SEF decreased, TP and relative power in the delta and theta band increased, power in the beta band decreased in a dose-dependent fashion with comparable regression lines. This indicates that MAC equivalent administration of isoflurane, desflurane and sevoflurane in clinically applied dose ranges is associated with equipotent EEG suppression.     

Sevoflurane vs. isoflurane: a clinical comparison in day surgery

Discharge times after ambulatory surgery are determined by postoperative complications and in particular by the presence and severity of nausea and vomiting. Sevoflurane has become a popular agent for day-case surgery despite little evidence of clear advantages over current alternatives. We compared this agent with isoflurane in day-case patients undergoing knee arthroscopy in order to quantify the incidence of complications associated with each agent. One hundred and eighty patients received a standardised anaesthetic induction with propofol and fentanyl followed by maintenance with either isoflurane or sevoflurane. Standardised postoperative analgesic and anti-emetic drugs were prescribed. Any intra-operative cardiovascular or respiratory instability was recorded. After surgery, nausea, vomiting and pain were assessed. Almost all patients made an uneventful recovery and were discharged as scheduled. There was a significantly higher incidence of complications in the sevoflurane group. These included the presence of nausea and vomiting, and cardiovascular and respiratory complications. We found nothing to commend the routine use of sevoflurane rather than isoflurane in the context of day case anaesthesia.     

Recovery of elderly patients from two or more hours of desflurane or sevoflurane anaesthesia

Background. The solubility of desflurane compared with sevofluranesuggests more rapid recovery from desflurane anaesthesia. Thiscould be important after prolonged anaesthesia and fast recoverymay be advantageous in the elderly where slow recovery of mentalfunction is a concern. We compared emergence from desfluranevs sevoflurane in elderly patients undergoing two or more hoursof anaesthesia. Methods. Fifty ASA physical status I, II, or III patients, 65yr of age or older, undergoing anaesthesia expected to lasttwo or more hours were randomly assigned to receive desflurane/nitrousoxide or sevoflurane/nitrous oxide anaesthesia. Patients weregiven 1–2 µg kg^–1 fentanyl i.v. and anaesthesiawas induced with propofol 1.5–2.5 mg kg^–1 i.v. andmaintained with either desflurane 2–6% or sevoflurane0.6–1.75% with nitrous oxide 65% in oxygen. Inspired anaestheticconcentrations were adjusted to obtain adequate surgical anaesthesiaand to maintain mean arterial pressure within 20% of baselinevalues. Early and intermediate recovery times were recorded.Digit-Symbol Substitution Test (DSST) scores and Visual AnalogScale (VAS) scores for pain and nausea were recorded beforepre-medication and every 15 min in the Post Anaesthesia CareUnit (PACU) until patients were discharged. Results. Early recovery times are given as median, quartiles.The times to extubation (5 (4–9); 9 (5–13) min),eye opening (5 (3–5); 11 (8–16) min), squeezingfingers on command (7 (4–9); 12 (8–17) min); andorientation (7 (5–9); 16 (10–21) min) were significantlyless (P<0.05) for desflurane than for sevoflurane. Intermediaterecovery, as measured by the DSST and time to ready for dischargefrom the PACU (56 (35–81); 71 (61–81) min) was similarin the two groups. Conclusions. Early but not intermediate recovery times of elderlypatients undergoing a wide range of surgical procedures requiringtwo or more hours of anaesthesia is significantly (P     

Clinical evaluation of the Mapleson theoretical ideal fresh gas flow sequence at the start of low-flow anaesthesia with isoflurane, sevoflurane and desflurane

Mapleson used a computer spreadsheet model to predict the theoretical ideal fresh gas flow sequence at the start of low-flow anaesthesia. The aim was to increase the end-expired partial pressure of inhalational agent (PE'an) to one minimum alveolar concentration (MAC) as quickly as practicable and then to keep it constant. Ninety adult patients undergoing elective tonsillectomy under general anaesthesia were randomly allocated to one of three groups (n = 30) to receive isoflurane, sevoflurane or desflurane in oxygen. Fresh gas flow and vaporiser settings as specified by Mapleson were followed in all cases except that the maximum setting for desflurane was 18% (2.7 MAC instead of 3 MAC). Recordings of PE'an were made at 1, 2, 3, 4, 5, 7, 10, 15 and 20 min. Mean values of PE'an exceeded 1 MAC by 2 min in all three groups and remained above this value throughout. Each group's PE'an measurements were divided by their respective 1-MAC value. A simple two-level model (with patients at level 2 and time at level 1), with measurements at 1 min excluded, showed that the fitted value at 2 min and the time-weighted mean for 2-20 min for PE'iso (1.042 [95% CI 0.980-1.104] and 1.044 [0.984-1.104], respectively) were not significantly different from its 1-MAC value, whereas those of the PE'sevo (1.169 [1.119-1.219] and 1.143 [1.119-1.219]) and PE'des (1.305 [1.261-1.349] and 1.140 [1.098-1.182]) were significantly higher than their respective 1-MAC values. The Mapleson concept of an initial high fresh gas flow and high vaporiser settings, followed first by reduced high fresh gas flow, as followed in this clinical study, results in PE'an values close to or slightly higher than predicted in the spreadsheet model.     

Granisetron reduces incidence of nausea and vomiting after breast surgery

Background: Postoperative nausea and vomiting (PONV) remains a troublesome problem. This study was performed to evaluate the antiemetic efficacy of prophylactic granisetron, a selective 5-hydroxytryptamine type 3 receptor antagonist, on the incidence of PONV in patients undergoing general anaesthesia for breast surgery.
Methods: In a randomized, placebo-controlled, double-blind study, 50 female patients, 45–68 years, were given a single dose of either placebo (saline, n=25) or granisetron (40 ug kg^-1, n= 25) intravenously over 2–5 min immediately before the induction of anaesthesia. Postoperatively, during the first 24 hours after anaesthesia, the incidence of PONV and adverse events was recorded.
Results: The treatment groups were similar for patient demographics, types of surgery, anaesthetic and postoperative management. Postoperatively, the incidence of PONV was 48% and 16% after administration of placebo and granisetron, respectively ( P < 0.05). No differences in the incidence of other adverse events were observed between the two groups.
Conclusion: Granisetron is an effective antiemetic for preventing PONV in patients undergoing general anaesthesia for breast surgery.     

Dolasetron decreases postoperative nausea and vomiting after breast surgery

In a randomized, placebo-controlled, double-blind trial, we compared the efficacy of dolasetron, dexamethasone, and metoclopramide in a preventing postoperative nausea and vomiting in women undergoing breast surgery. Patients were allocated randomly to one of four groups (20 patients each): group A received 12.5 mg dolasetron, group B received 8 mg dexamethasone, group C received 20 mg metoclopramide, and group D received placebo intravenously. If patients complained of retching or vomiting or if patients demanded an antiemetic, 1.25 mg droperidol was administered intravenously. To quantify postoperative nausea and vomiting, the following score was used: 0 = no nausea, 1 = nausea, 2 = retching, 3 = single vomiting, 4 = multiple vomiting. Dolasetron and dexamethasone reduced the postoperative nausea and vomiting score significantly (p < 0.02 versus metoclopramide; p < 0.0001 versus placebo). Metoclopramide also reduced the postoperative nausea and vomiting score (p < 0.02 versus placebo). Fisher's exact test showed a significant reduction of vomiting in the dolasetron and dexamethasone groups compared with metoclopramide-treated patients (p < 0.007) and placebo-treated patients (p < 0.000006) and a significantly lower rate of nausea in comparison to the placebo group (p < 0.009). There were no significant differences between the metoclopramide and the placebo groups (using Fisher's exact test). The use of postoperative droperidol was significantly lower in both the dolasetron group (p < 0.04 versus metoclopramide; p < 0.0001 versus placebo) and dexamethasone group (p < 0.04 versus metoclopramide; p < 0.0001 versus placebo), as well as in the metoclopramide group (p < 0.02 versus placebo). Intravenous dolasetron and dexamethasone were equally effective and both are more effective than metoclopramide for preventing vomiting after breast surgery. Also both were significantly superior to either metoclopramide or placebo for postoperative nausea and vomiting and the need for droperidol rescue.     

A clinical assessment of desflurane anaesthesia and comparison with isoflurane

In 48 randomly assigned ASA I adult patients undergoing elective orthopaedic procedures, we compared the pharmacodynamics of desflurane (DF) and isoflurane (IF), and their pharmacokinetics during rapid induction of deep anaesthesia (via face mask, to 1.5–2 MAC, after thiopentone), maintenance of anaesthesia at 1.25 MAC, and emergence therefrom. During induction, laryngeal reactions ranging from mild crowing to laryngospasm occurred more frequently with DF than with IF (15/24 DF, 5/24 IF; P < 0.05) and was more severe (9/ 24 DF, 1/24 IF, excluding the mildest form, P < 0.05). As a result, induction of anaesthesia was not accomplished faster with DF, in spite of a faster equilibration between exhaled and inhaled concentrations. Emergence from DF was more rapid and less complicated by delirium. Pharmacokinetically, the exhaled concentration of DF reached 90% of the inhaled concentration within five minutes of induction, whereas that of IF lagged behind and remained 25% below the inhaled concentration (1 vs 1.34 ± 0.05) even one hour after induction. Premature ventricular contractions did not occur in any patient even during periods of difficulty with the airway and oxygen desaturation. It is concluded that DF is a safe anaesthetic, pharmacokinetically superior to IF but clinically inferior for induction of anaesthesia via a face mask. Because of the fast equilibration, the exhaled concentration of DF can be controlled more precisely by the dial setting of the vaporiser.     

Nitrous oxide does not increase nausea and vomiting following gynaecological laparoscopy

The effect of three different anaesthetic techniques on the incidence and severity of postoperative emesis (nausea, retching and vomiting) was studied in 150 patients undergoing gynaecological laparoscopy. Patients were anaesthetized with isoflurane in nitrous oxide and oxygen (Group A), enflurane in nitrous oxide and oxygen (Group B) or with isoflurane in air and oxygen (Group C). Groups had been predetermined by date of birth. During the first 24 hours after the operation no difference was found at any time in the incidence or severity of emesis among the groups. The overall incidence of emesis during the first 24 hours postoperatively was 54, 48 and 52 per cent, in groups A, B and C, respectively. It is concluded that nitrous oxide does not increase the incidence of emesis after isoflurane anaesthesia and that isoflurane and enflurane anaesthesia are associated with similar incidences of nausea and vomiting after gynaecological laparoscopy.     

Effective dose of granisetron in the reduction of nausea and vomiting after breast surgery

Background: Prophylactic use of granisetron, a selective Shydroxytryptamine type 3 receptor antagonist, reduces the incidence of nausea and vomiting after breast surgery. This study was undertaken to determine the minimum effective dose of granisetron in the reduction of postoperative nausea and vomiting (PONV) in patients undergoing general anaesthesia for breast surgery.
Methods: In a randomized, double-blind manner, 120 female patients aged 42–66 years were assigned to receive either placebo (saline) or granisetron in a dose of 20 μg · kg^-1, 40 μg · kg^-1 and 80 μg · kg^-1 i.v. immediately before the induction of anaesthesia. A standard general anaesthetic technique was employed throughout. The POW and safety assessments were performed continuously during the first 24 h after anaesthesia.
Results: There were no significant differences among the groups with regard to patient demographics, surgical procedures, anaesthetics administered and analgesics given. The incidence of PONV was 47%, 43%, 17% and 17% after administration of placebo and granisetron 20 μg -kg^-1, 40 μg kg^-1 and 80 μg kg^-1, respectively. Granisetron 40 μg kg^-1 was as effective as 80 μ g - kg^-1 and both resulted in significant reductions of the incidence of PONV compared with placebo and granisetron 20 μg kg^-1 ( P < 0.05). No differences in the incidence of adverse events were observed among the groups.
Conclusion: Granisetron 40 μg · kg^-1 appears to be the minimum effective dose for reducing POW in patients undergoing general anaesthesia for breast surgery.